Prevalence and risk perceptions of nicotine pouch use: A systematic review of population-based studies.

Abstract

Oral nicotine pouches (NPs) are a new class of non-combustible nicotine products that have gained rapid popularity. Despite rising sales and marketing, evidence of their prevalence and risk perceptions remains limited. This systematic review aimed to synthesize the available global evidence on the prevalence and patterns of nicotine pouch use and to summarize reported risk perceptions from population-based studies. Four electronic databases (Scopus, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials [CENTRAL]) were searched in March 2024 and searches were updated in September 2025. Observational studies reporting the prevalence of NPs use among general populations were selected. Study quality was assessed using an adapted Newcastle-Ottawa Scale, and findings were synthesized narratively. From 6752 records, 16 studies met the inclusion criteria and were included in this systematic review. The studies conducted surveys on NPs use in the United States, United Kingdom, Canada, Switzerland, the Netherlands, Finland, Poland, and Saudi Arabia (overall sample size = 184 497). Reported ever (defined as lifetime use) and current use (defined as use within the past 30 days) varied by country and demographic group. In the US, ever use ranged from 0.6% to 17.9%, while current use ranged from 0.8% to 12.0%; most studies were conducted among youth (<18 years) and young adults (18-29 years). In Europe, current use ranged from 0.06% in a population aged ≥13 years in the Netherlands to 3.7% among adults in Finland and 4.3% among adults in Poland, while lower rates were observed among adults in the United Kingdom and youth in Switzerland with 0.2% and 3.0%, respectively. In Canada, current use among secondary-school students was 2.6%, and in Saudi Arabia, 11.9% of medical university students reported ever use. Across studies, use was higher among adults aged 18-40 years compared with youth and older age adults and was also higher among males than females. NPs were frequently used concurrently with cigarettes, e-cigarettes, and smokeless tobacco. Perceptions generally indicated lower harm, lower addictiveness, and greater social acceptability than cigarettes. Marketing emphasizing flavors or cessation benefits increased appeal and intentions to use, particularly among youth perceiving low risk. Current global prevalence of oral nicotine pouch use remains low but varies by country and population group, with higher use reported among younger adults and males. Nicotine pouches are commonly used concurrently with other nicotine products and are generally perceived as less harmful and more socially acceptable than cigarettes.