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.