Latent profile analysis reveals diverse perceptions of tobacco product risks among youth.

With more than a billion units sold per month in 2024, oral nicotine pouch (ONP) products have rapidly gained popularity, prevalence, and tobacco-marketplace share in the United States of America (USA). Sales in the USA have increased from 163,000 units upon market introduction in 2016 to 9.5 billion units in 2023, with higher prevalence seen in younger and middle-aged men compared to older men and women across all ages. In high-school adolescents, a continuous increase in ONP use is seen over the past years, increasing from 1.1% to 2.4% from 2021 to 2024. Analyzing a 2021 cohort of Southern California high-school adolescents and 2024 NYTS data, ONPs were demonstrated to be the 2 most prevalent nicotine product, after e-cigarettes. Evidence also indicates that awareness and favorable perceptions of ONPs are high among young adults. ONPs use among youth was also associated with use of other tobacco products, with current use more prevalent among Hispanics, Non-Hispanic Blacks, and those with lower education and annual incomes. ONPs are available in several youth-appealing flavors, with fruit (berry, citrus) and mint/menthol (peppermint, spearmint, wintergreen) being the most commonly used and preferred flavors. Starting in 2021, ice-flavored ONPs containing cooling agents have been introduced, including ZYN products, where coolants like Wilkinson Sword-3 (WS-3) are added either to provide more intense cooling notes to flavored ONPs or to circumvent “characterizing flavor” definitions included in the local and statewide restrictions and regulations on flavored tobacco and nicotine products. These synthetic cooling agents, similar to menthol, elicit robust cooling sensations through activation of the cold/menthol receptor TRPM8 expressed in the trigeminal neurons innervating the buccal and oral cavities. However, unlike menthol, these cooling agents lack the characteristic minty odor and are much less irritating than menthol due to their reduced activity at the sensory-irritant receptor TRPA1. This combination of properties eliciting cooling sensations with little to no sensory irritation has made these synthetic cooling agents a popular substitution of menthol in a wide variety of tobacco products, including e-cigarettes, ONPs and even combustible cigarettes. California’s 2022 flavor ban prohibited the sale of flavored tobacco products (with exceptions to hookah, premium cigars, and looseleaf pipe tobacco) to reduce youth appeal, initiation, and tobacco-related health disparities. The legislation defined “characterizing flavors” as any natural or artificial taste or aroma beyond tobacco and nicotine. Still, some tobacco companies appear to circumvent flavor restrictions by marketing products with ambiguous names (e.g., “clear,” “non-menthol”) and color-coded packaging to suggest cooling sensations without overtly signaling flavor. These tactics highlight the challenges of enforcing a comprehensive flavor ban and underscore the need for research on how modifications in chemical composition, sensory attributes, and marketing affect product appeal.