Introduction: Accurate measurement is critical for understanding the population health impact of nicotine pouches, yet precise, standardized measures of nicotine pouch use are lacking, possibly driving disparate prevalence estimates across studies. We implemented a split sample survey experiment to assess the impact of including a product image when asking about nicotine pouches.
Methods: We randomized an online sample of US adults ages 18-45 (N=2,130) recruited through the February 2023 wave of the Rutgers Omnibus Study to view either a text-only or text-plus-image description of oral nicotine pouches before being asked about awareness of the products. Participants who endorsed awareness were then asked about their use and brands they had tried. We calculated prevalence of awareness, ever, and current use of nicotine pouches and used chi-square tests to assess differences in responses to each question by survey condition.
Results: Participants in the image condition were more likely than those in the text condition to report awareness (40.6% vs 31.5%, P<.001) and ever use (7.2% vs 5.2%, P=.044). Among those reporting nicotine pouch use, 5.9% in the text-only condition, compared to 0% in the image condition, listed a smokeless tobacco brand as one they tried, suggesting they were misclassified by the text-only question.
Conclusion: Inclusion of product imagery can improve nicotine pouch measurement accuracy in surveys, while text-only measures may misestimate prevalence of awareness and use. Differences in nicotine pouch prevalence estimates may be explained in part by differences in survey measures, highlighting a need to harmonize measures across studies.
Implications: In this first study to evaluate nicotine pouch measurement methods, findings suggest that existing surveillance and research efforts may be undermined by misclassification. Text-only measures of nicotine pouch awareness and use may produce biased prevalence estimates, and inclusion of product imagery can improve nicotine pouch measurement accuracy in surveys.
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