Jessica Liu

Use of oral nicotine pouches, and specifically the brand Zyn, has increased among all age groups in the United States (U.S.), and these products have a wide advertising and social media presence. The purpose of our study was to identify prevalence and correlates of oral nicotine pouch use, Zyn use, and Zyn susceptibility in the U.S. and identify sources of advertising exposure for Zyn. We conducted a cross-sectional survey. We conducted an online national survey in the U. S, through Qualtrics, from March-June 2025. Participants were 13-40-year-olds (N = 5733), with a 1:1:1 ratio of people ages 13-17, 18-20, and 21-40; 66.1% were female. We asked participants about lifetime and past 30-day oral nicotine pouch use, Zyn use in particular, susceptibility to use Zyn, use of Zyn flavors, detailed patterns of Zyn use, and exposure to Zyn advertising, overall and stratified by age group. Among our sample, lifetime use of any nicotine pouch and Zyn specifically were 11.5% and 9.3%, respectively; past 30-day use of any nicotine pouch and Zyn specifically were 5.0% and 3.9%, respectively. Lifetime use and past 30-day use increased across age groups. Among those who had never used any nicotine pouch, 27.6% were susceptible to Zyn use. Using logistic regressions, we identified correlates to oral nicotine pouch use and Zyn susceptibility, including covariates for age group, sex, race/ethnicity, financial comfort, e-cigarette use, and cigarette use. Increasing age group and e-cigarette and cigarette use were associated with any oral nicotine pouch use and Zyn susceptibility. The most popular Zyn flavors ever used were mint (n = 388) and drinks (n = 190). On average, participants with past 30-day Zyn use reported a median of using 4.0 (interquartile range [IQR]: 4.0) pouches per day; a median of placing 2.0 (IQR: 3.0) pouches in their mouth at once; and a median of using 2.0 (IQR: 2.0) cans of Zyn per week. TikTok (18.2%, n = 1044), YouTube (17.8%, n = 1021), and Instagram (16.3%, n = 935) were the top platforms participants reported ever seeing a Zyn advertisement or promotion. A United States national survey found substantial rates of use, susceptibility to use, and exposure to marketing for Zyn and other oral nicotine pouches. Mint and drinks were the most commonly used Zyn flavors.

Introduction: In 2019, Massachusetts enacted the nation’s first comprehensive statewide restriction on flavored tobacco sales and expanded tobacco cessation coverage. This study assessed the policy’s sustained effectiveness by examining trends and factors associated with tobacco use during the maintenance phase of the policy. Methods: We conducted monthly cross-sectional surveys (April 2021 to July 2022) to assess trends of past 30-day use of cigarettes, e-cigarettes, and other tobacco products of youth (ages 13-17, N = 1858) and adults (ages 18+, past 30-day tobacco use, N = 1548), including quit attempts among adults. We compared trends in Massachusetts to four neighboring states that did not have similar statewide restrictions using generalized linear models, modeling each outcome as a function of time (1-month increments), state (Massachusetts vs. four neighboring states), and an interaction between month and state, and adjusted for demographic covariates. Results: Analyses identified no significant differences in tobacco use trends between residents of Massachusetts and comparison states. While Massachusetts youth showed stable cigarette use and slower increases in e-cigarette use compared to steeper rises in neighboring states, these differences were not statistically significant. Among adults who currently use tobacco, monthly trends of their tobacco use and past-year quit attempts were also comparable across states. Conclusions: Findings highlight the need for comprehensive approaches combining sales restrictions with enhanced cessation support and prevention programs to achieve sustained effects on reducing population tobacco use. We found no unintended increase in trends of cigarette use among youth or adults in response to the Massachusetts flavor restrictions versus comparison states. Implications: This study aimed to compare trends in tobacco use for youth and adults, and quit attempts for adults in Massachusetts with those in neighboring states over a 16-month period in the maintenance period of implementation (in 2021 and 2022) of the statewide Massachusetts flavored tobacco sales restriction. We found no unintended increase in trends of cigarette use among youth or adults, and findings highlight the need for comprehensive approaches to achieve sustained effects on reducing population tobacco use. Given the focused New England population of this study, additional evaluation of the sustained impact of flavored tobacco sales restrictions is needed.

Background: Given the high prevalence of cannabis use among young adults, it is important to identify and develop appealing messaging strategies that will engage young adults when presented with cannabis health information. The purpose of this study was to identify appealing image features from a cannabis prevention campaign. Methods: We conducted a cross-sectional survey among N = 303 US young adults (ages 18-30) during February 2024. Consented participants reported their cannabis use and were randomly assigned to view 2 (of 6) selected images from California’s “Mind over Marijuana” cannabis prevention campaign. Participants were prompted to select the 3 most appealing regions of the image and report perceived message effectiveness (PME). Two-sample t -tests were used to compare differences between participants’ cannabis use status (any past-30-day use, no past-30-day use) and selected image regions. We used linear regressions to assess associations between sociodemographic factors and PME for each image. Results: Participants indicated that people’s faces (19.6%-66.3%) and anti-cannabis text (29.0%-83.6%) were the most appealing. The appeal of specific regions differed for 1 image (people who currently used cannabis found text in a unique format more appealing, and people with no past-30-day use found a person holding a phone more appealing). Depending on the image, race, and sexual orientation dictated PME scores. Non-Hispanic Black race (vs Non-Hispanic White) was associated with higher PME for 3 of the 6 images, and Multiple/Other races were associated with higher PME for 1 image. Identifying as LGBTQ+ (vs heterosexual) was associated with lower PME for 1 image. Conclusion: Future cannabis prevention campaigns for young adults may continue using creative and bold text as well as people when designing images.

Objectives: Massachusetts signed into law An Act Modernizing Tobacco Control (hereinafter, the Act) in 2019, which restricted retail sales of flavored tobacco products, including menthol cigarettes. This study assessed differences in advertising exposure to flavored tobacco products among adolescents in Massachusetts compared with adolescents in 4 neighboring states after passage of the Act. Methods: We collected monthly cross-sectional survey data from April 2021 through August 2022 among a convenience sample of adolescents (aged 13-17 y) in Massachusetts and 4 control states: Connecticut, New Hampshire, Rhode Island, and Vermont. We measured self-reported past-30-day exposure to advertising for flavored electronic cigarette (e-cigarette) products and flavored cigarettes or other tobacco products across 9 channels. Results: After implementation of the Act, adolescents in Massachusetts, compared with adolescents in the 4 control states, reported significantly lower levels of exposure to advertisements for flavored e-cigarettes (convenience store: adjusted odds ratio [AOR] = 0.80 [95% CI, 0.66-0.96]; supermarket/grocery store: AOR = 0.66 [95% CI, 0.52-0.84]; gas station: AOR = 0.61 [95% CI, 0.51-0.75]) and flavored cigarette/other tobacco products (convenience store: AOR = 0.69 [95% CI, 0.57-0.83]; supermarket/grocery store: AOR = 0.63 [95% CI, 0.49-0.79]; gas station: AOR = 0.55 [95% CI, 0.45-0.66]) in retail channels, which were the intended targets of the Act. We found no significant differences in flavored tobacco product advertising exposure for non–retail channels (television, radio, posters/billboards, newspapers/magazines, social media, and streaming services/movies in a theater). Conclusions: Future research should further examine the effects of statewide flavored tobacco sales restrictions on the availability of and exposure to advertisements for flavored tobacco products.

The purpose of this study was to identify more detailed use behaviors and motivations for same-day co-use of tobacco and cannabis among U.S. young adults, compared to previous literature on co-use. We conducted an online cross-sectional survey among N = 303 U.S. young adults (ages 18-30, mean 25.9) during February 2024 through Prolific. The questions included co-use behaviors of tobacco and cannabis within the same day, and motivations for tobacco, cannabis, and their co-use. Using R, paired two-sample t-tests were used to compare mean differences of separate motivations to use measures for cannabis and tobacco among participants with same day co-use. Among participants who reported past-30-day co-use of tobacco and cannabis (n = 176), a majority (94%; n = 160) reported same-day co-use. Participants who engaged in same-day co-use (n = 160) reported craving nicotine (60%), craving cannabis (54%), and feeling stressed (49%) as reasons for co-use. Among participants who engaged in same-day co-use, motivations for using cannabis (vs. tobacco) were higher for the level of effect, satisfying feeling, control over how much used, time to feel the effect, liking, purity, price, variety of product, amount to feel the effect, feeling less judged (p's < 0.024), and motivations for using tobacco (vs. cannabis) were higher for convenience, when feeling angry, and when feeling uncomfortable or upset (p's < 0.044). Findings show that young adults may be co-using tobacco and cannabis on the same day due to cravings for both substances and stress and yet have different motivations for using cannabis and tobacco.

The Massachusetts legislature passed An Act Modernizing Tobacco Control in November 2019 to restrict retail sales of flavored commercially manufactured tobacco products including menthol products, increase penalties for violating the law’s provisions, and provide health insurance coverage for tobacco treatment. This study explores key informants’ perceptions of intended and unintended impacts of implementation of the 2019 Massachusetts statewide law through a health equity and racial justice lens. We conducted in-depth interviews with 25 key informants from three key informant groups (public health officials and advocates, clinicians, and school staff) between March 2021 and April 2022. Using deductive codes on unintended impacts of the implementation of the law’s policies, we conducted a focused analysis to identify impacts that were perceived and observed by informants from different key informant groups. Perceived or observed impacts of the law were identified across multiple levels by key informants and included concerns related to three broad themes: 1) intended impacts on health equity and racial justice, 2) ongoing availability of restricted products undermining the intended impact of the law, and 3) inequitable targeting by the policies and enforcement among communities of color. Future evaluation is needed to assess the intended and unintended impacts of implementation of the Massachusetts law to maximize the potential of the policies to reduce tobacco-related health disparities. We discuss implications and recommendations for achieving a national policy and equitable enforcement of flavored tobacco sales restrictions. This qualitative study among 25 key informants including public health and tobacco control advocates, clinicians, and school staff obtained perspectives of intended and unintended health equity and racial justice impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control. Findings and recommendations from this study can inform monitoring efforts to assess the law’s impacts in Massachusetts and the adoption of similar flavored tobacco sales restrictions and other tobacco control policies in other states to maximize the health equity benefits and minimize unintended impacts.