Urban-rural disparities in oral nicotine pouch sales and flavors in the United States.

BACKGROUND

As oral nicotine pouches (ONPs) gain popularity in the United States, the extent to which product attributes, such as price and flavor, affect sales remains unclear. Examining urban-rural differences is particularly important given longstanding disparities in smokeless tobacco use and tobacco-related health outcomes across these settings, yet little is known about whether ONP sales and attribute preferences differ between urban and rural areas.

OBJECTIVES

This study aims to examine how ONP sales are associated with product attributes and sales locations (rural vs. urban), and whether the associations between sales and attributes differ by urban/rural locations.

METHODS

We linked 2021 NielsenIQ retail sales data with the National Center for Health Statistics county-level urban/rural classifications. Flavors were grouped as implicit (marketed without explicit flavor names), mint/menthol, fruity, or other. Multivariable linear regression models were used by regressing ONP sales on product attributes, rural/urban status, and their interactions.

RESULTS

In 2021, 88% of total ONP sales occurred in urban areas, compared with 12% in rural areas. ONP sales per 1000 population were 16% higher in rural than urban areas (p < 0.001). Compared to the sales of implicitly flavored ONPs, sales of mint/menthol, fruit, and other flavors were approximately 23-fold, 4-fold, and 7-fold higher, respectively. These flavor-related differences were less pronounced in rural counties than in urban counties. The price elasticity of demand was -0.66 (p < 0.001) in urban areas and -0.33 (p < 0.001) in rural areas.

CONCLUSIONS

ONP sales exhibit significant urban-rural disparities, with rural areas showing higher per capita sales overall, but urban areas showing stronger preferences for flavored products and greater price responsiveness. As a result, regulatory measures targeting flavors or pricing may have a greater impact in urban areas compared to rural ones.