Oral Nicotine Pouch Continuity Programs and US College Students’ Intention to Use

INTRODUCTION

Oral nicotine pouches (ONPs) have gained recent popularity in the US, with sales more than tripling between 2021 and 2024 to as high as 1,046 million units per month in 2024.¹ Recent research suggests there have been increases in youth and young adult use of these products.^2-5 In particular, a recent study from a college campus in the Midwest found 15.4% of undergraduate and 11.4% of graduate students had ever used ONPs,⁴ and ONP use doubled among college students in California from 2022 to 2024.⁵ Although two of the leading brands of ONPs, ZYN and on! Plus, have been authorized by the FDA to be lawfully sold and marketed in the US,⁶ use of ONPs among youth and young adults is a public health concern due to the effects that nicotine may have on brain development and the potential for nicotine addiction.^7,8

ONPs are being promoted on social media platforms, such as TikTok and Instagram,^9-12 that are popular among young audiences – 68% of 13-17-year-olds report using TikTok.¹³ ONP advertisements describe these products as convenient to use, smoke-free, tobacco-free, and available in a wide variety of flavors.¹¹ In a content analysis of paid ONP advertisements from 2021 to 2023, 7.6% were found to promote coupons or discounts.¹¹ Discounts and coupons are associated with ONP use among adults¹⁴; however, to date, research has not examined associations between marketing strategies used for ONPs and young adults’ intention to use these novel products.

One marketing strategy promoted on social media for ONPs is continuity programs—also referred to as loyalty programs, or rewards programs—which encourages repeated purchases by providing members with points that can be redeemed for prizes.¹⁰ Prizes include technology (e.g., Apple products), outdoor gear (e.g., grills, tents, tools), and experiences such as all exclusive concerts.¹⁵ Continuity programs are used to build brand loyalty with a wide range of products and commodities by appealing to social identities and comparisons (e.g., gold level, elite status) that provide more rewards or perks.¹⁶ However, they have been vastly understudied for emerging nicotine and tobacco products, with most research about continuity programs dating to cigarette product promotion in the 1990s.^17-20 Further, no research has examined the relationship between awareness of continuity programs and intention to use or ever use.

It has been thirty years since research has explored the relationship between engagement with continuity programs and intention to and use of a nicotine or traditional tobacco product (i.e., cigarettes and smokeless tobacco).¹⁸ With evidence that tobacco companies that sell ONP products are using continuity programs to promote their products, there is a need to understand if young adults are aware of continuity programs and if awareness of these programs is motivating them to use these products. Therefore, the purpose of the current study was to examine if there was an association between awareness of ONP continuity programs and US college students’ intention to use and ever use of ONPs.

METHODS

Undergraduate and graduate students from a large southern university in the US were recruited from September to November 2025 to complete a cross-sectional survey. This sample was collected by sending a recruitment email, that included a link to the survey, to student listservs. Eligibility to participate included being 18 years of age or older and enrollment at the university from where data were collected. The first page of the survey was a consent form. The median completion time was 6.9 minutes (IQR = 5.5 - 9.0 minutes). All procedures were approved by the University IRB (# 2024C0166).

RESULTS

A total of 887 participants completed the online survey. The final analytic sample included 764 students aged 18-30 years (M = 20.6, SD = 2.8). Most participants were female (60.7%, n = 464), heterosexual or straight (75.9%, n = 580), non-Hispanic whites (78.3%, n = 598). Among our sample, 29.8% (n = 227) were first-year undergraduates, 17.1% (n = 130) were second-year undergraduates, 18.4% (n = 140) were third-year undergraduates, 17.5% (n = 133) were fourth-year or higher undergraduates, and 17.3% (n = 132) were graduate students. A fifth (22.6%, n = 173) of participants were a member of a social fraternity or sorority, 21.7% (n = 166) were first generation college students, and 50.9% (n = 389) of participants reported middle socioeconomic status.

Overall, 229 participants (30.0%) reported having heard of ONP continuity programs. Participants who had heard of continuity programs were slightly older than those who had not (M = 20.9, SD = 2.7 vs. M = 20.4, SD = 2.8), t(762) = 2.26, p = .024. Awareness did not significantly differ by gender, χ²(2) = 4.78, p = .091, or by sexual orientation, χ²(2) = 3.96, p = .138. Awareness differed by year in school, χ²(4) = 12.33, p = .015, with 31.8% of graduate students indicating they had heard of continuity programs, and 25.1% of 1^st year students reporting this; those with more years of college completed had greater awareness of continuity programs. Further, awareness was more common among fraternity/sorority members than non-members, χ²(1) = 24.55, p < .001. Awareness did not differ by first-generation college student status, χ²(1) = 0.51, p = .474. Race/ethnicity was associated with awareness; non-Hispanic whites (33.8%) and American Indian or Alaskan Natives (30%) were most aware, and those identifying as Black or African American were least aware (12.5%). Socioeconomic status showed a non-significant trend with those of higher income (35.6%) reporting greater awareness than those of lower income (25%), χ²(1) = 5.25, p = .073. Awareness was also associated with both ever use of oral ONPs, χ²(1) = 77.76, p < .001, and intention to use ONPs, χ²(1) = 54.27, p < .001, such that awareness was more common among students who had ever used ONPs and among those who reported intention to use. Table 1 presents descriptive statistics and bivariate tests by awareness of continuity programs.

DISCUSSION

Young adult college students are becoming aware of ONP continuity programs, and awareness of these continuity programs is associated with intention to use and ever use of ONPs. Particularly, college males, who are members of a social fraternity and are aware of ONP continuity programs have greater odds of intention to use and ever use of ONPs. While use of ONPs appears to increase exposure to continuity programs marketing, it is possible that causality may also occur in the opposite direction, such that awareness of ONP continuity programs also increases intentions and use of these products. While it is well established that exposure to tobacco-related content (e.g., promotion on social media or retail advertisements) increases susceptibility to tobacco products^21-23 and use of ONPs,²⁴ this is the first study to find an association between exposure to ONP continuity programs – a specific marketing strategy – and intention to use. Argued by the tobacco industry as a brand loyalty strategy, continuity programs reward and reinforce nicotine use beyond the addictive properties of these products.²⁵ Further, similar to sales reports that ZYN remains the leading brand of ONPs¹ and research finding 9.7% of ZYN-related advertisements mentioned their continuity program,²⁶ we found ZYN Rewards was the most recognized continuity program (27.7%) among the different brands.

First used in the 1990s for traditional tobacco products (e.g., Marlboro Miles, Camel Cash),¹⁷ continuity programs are a recycled tobacco industry strategy used today to promote ONPs and combustible tobacco products (e.g., cigarettes and cigars), rewarding and reinforcing continued use of these nicotine products.^10,20 Although initially restricted in the US for traditional tobacco products in the 2009 Family Smoking and Tobacco Control Act (Tobacco Control Act), continuity programs were deemed legal for all tobacco products in 2012 when the Sixth Circuit Court of Appeals found there to be insufficient scientific evidence that continuity programs increased susceptibility and use among those under the minimum legal sales age (MLSA), at the time 18 (Discount Tobacco City & Lottery, 674 F.3d 509 (6th Cir. 2012)). In the court’s opinion, they cited that only one article and one Gallup poll had found these programs to be associated with increased susceptibility of using tobacco products, and this literature was nearly 20 years old when presented to the court.^18,28 This stark gap in research, juxtaposed the thousands of studies cited for other marketing restrictions, did not provide the necessary rational to restrict this marketing strategy to protect youth. Therefore, the appellant court determined that this law – passed by congress – was unconstitutional because it violated the tobacco companies’ First Amendment rights. However, should researchers find that continuity programs increase susceptibility and use among those under the MLSA, which is now 21 years of age in the US, the FDA could restrict this marketing strategy via an informal rulemaking procedure in an effort to protect youth from nicotine and tobacco marketing that increases intention and use of these products. Although the FDA limited it marketing regulatory authority of covered tobacco products in the 2016 Deeming Rule to only prohibiting the distribution of free samples,²⁹ it can “invoke its other authorities under the Tobacco Control Act” under section 906(d) of the Food Drug and Cosmetic Act (21 U.S.C. 387f(d)) which allow it regulate the access to and advertisement and promotion of all tobacco products if it is “appropriate for the protection of public health” (21 U.S.C. 387f(d)).

Although not considered in the aforementioned court opinion, past research found a small group of youth (15-16-year-olds) had participated in continuity programs, and awareness of and engagement with these programs was associated with ever and current use of cigarettes.²⁵ Similarly, we found only a small portion of college students had participated in continuity programs; however, over one fourth of our sample was aware of this marketing strategy, and word of mouth and social media influencers were the most common communication channels from where college students first learned about ONP continuity programs. Despite research that only 13.1% of ZYN-related content on TikTok was posted by influencers,¹² this is a concern given their large following, ability to reach a broad audience, and recognition as a trusted source of information for many young social media users.³⁰ Further, influencers may market or promote unhealthy products for commercial benefit.³¹ The FDA, in collaboration with the Federal Trade Commission (FTC), has warned influencers in the past about promoting vaping without providing required disclosures that they are brand representatives (e.g., hashtags such as #ad or #sponsored).³² Such consumer protections prevent deceptive and unfair business practices, which are also regulated by many state agencies through their consumer protection laws. While research has found sponsorship disclosures are necessary, it has also been noted that they are not sufficient to protect youth and young adults from the impact of exposure to influencer content that depicts emerging nicotine products on social media.³³ Therefore, while social media platforms remain largely self-regulated,³⁴ better regulation by platforms, as well as government action at the federal and state levels is needed to prevent influencers from exposing youth and young adults to tobacco marketing that may increase susceptibility and use of these novel nicotine products. Notably, a small but meaningful portion of our sample indicated that they communicated with ONP companies via social media direct messages (a communication forum between individuals provided by social media platforms), which does not restrict communication by age and involves private communication between a potential minor and these companies that sell age-restricted products. While more qualitative research is needed to learn more about these private messages, false or misleading information shared via private messages could subject these tobacco companies to regulatory review by state or federal agencies.

This study was subject to limitations. First, convenience sampling with a high-education sample and a cross-sectional study design do not allow for broad generalizations or causality claims. Further, some demographic categories (e.g., gender, racial groups) included small samples which raise caution for interpretation of odds ratios of association with intention and ever use. As with all self-reported measures, self-reported bias and recall bias may have affected participants response. It is also unclear whether reward program engagement (for any commodity) is common among this age group, which may have impacted awareness and participation with these programs. Despite these limitations, strengths of the study include the sample size and the identification of a specific marketing strategy rather than a blanket marketing item that groups several marketing strategies.

Although only a small portion of our sample had participated in an ONP continuity program, this study provides initial evidence that US college students are aware of and participate with this marketing strategy. Notably, 30% of our sample was aware of ONP continuity programs. Further, exposure to this rewards-based marketing strategy was associated with greater odds of intention to use and ever use of ONPs. While more research is needed, such as experimental assessments and longitudinal surveillance of those under the MLSA to evaluate impact on ONP initiation and continued use, this study provides evidence that this marketing strategy is reaching a young audience. This is particularly concerning because many companies that sell ONPs also sell other traditional tobacco products, such as cigarettes and moist snuff, and continuity programs give these parent companies access to information regarding purchasing behaviors among a young, price-sensitive audience. Therefore, policy efforts may be warranted to prohibit marketing strategies that increase susceptibility and use among those under the MLSA for tobacco in the US.