A qualitative assessment of oral nicotine pouch use topography.

INTRODUCTION: Oral nicotine pouch (ONP) sales are growing in the U.S., yet little is known about how they are used (e.g., use topography). To inform assessments of ONPs' abuse liability, toxicity, and health effects, we examined typical ONP use behaviors and topographies among adults who use ONPs. METHODS: We conducted 16 virtual focus groups (2-9 participants each) with 44 adults who reported using ONPs at least some days per week: 16 adults with no history of cigarette smoking or smokeless tobacco (SLT) use and 28 adults with a history of cigarette smoking or SLT use. Participants completed an online survey and semi-structured focus group interview. Quantitative data were summarized descriptively, and qualitative transcripts underwent thematic analysis with a comparative approach. RESULTS: Participants were 33 (SD=11) years old on average, had used ONPs for 1.7 (SD=1.5) years on average, 18% were women, and 82% used ONPs daily. Topography behaviors varied, with participants describing differing preferences for upper versus lower lip placement, frequent ONP movement around the mouth versus static "parking," use of multiple ONPs simultaneously, and consecutive ONP additions without removal, i.e., "stacking." Participants described strategies to titrate nicotine delivery through placement techniques, use duration, and stacking. CONCLUSIONS: ONP use patterns vary among established users. Future evaluations of abuse liability, toxicity, and health effects should consider effects across different use topographies.