Prevalence & Characteristics of E-Cigarette and Nicotine Pouch Use Among United States Military Veteran Smokers

Introduction The recent growth of Alternative Nicotine Products (ANP), such as e-cigarettes and Nicotine Pouches (NPs), raises concerns for groups with heightened health-risks from tobacco/nicotine products, like U.S. military veterans. Considering, and given the limited available data on veteran ANP use, we explored the prevalence, perceptions, and use characteristics of two ANP types (e-cigarettes and NPs) in this population. Materials and Methods In the context of a larger, ongoing study examining veteran beliefs, awareness, and use of nicotine products, we conducted an anonymous, cross-sectional, paper-and-pencil survey examining ANP use/perceptions at a large Veterans Health Administration (VHA) hospital in the northeast U.S. Veterans self-describing as current smokers (i.e., responding affirmatively to research assistant inquiry of “are you a current smoker?”) were provided a 42 closed-ended item survey inquiring about demographic, psychiatric, and medical information, as well as use habits and motivations for use of cigarettes and ANPs. Veteran data was stratified into “cigarette only” vs. “dual users” (cigarettes and ANP), as well as sub-stratified by ANP type (e-cigarette vs. NP). Frequencies were tabulated per group and ANP product type. χ2/Fisher’s Exact tests were used to explore potential differences between “cigarette only” and “dual users”. Results Of 100 veterans who initiated surveys, seven did not return surveys to researchers. Thus, our analytic sample consisted of N = 93 veterans who were primarily male (n = 83/93; 89.25%), >50 years old (n = 62/93; 66.67%), and Non-Hispanic and White (n = 38/93; 40.86%) or Black/African US (n = 31/93; 33.33%). Roughly half of participants reported only past-month cigarette use (n = 52/93, 52.91%) or dual cigarette and ANP use (n = 41/93; 44.09%). No significant differences in rates of mental health/substance use disorders were identified between cigarette vs. cigarette + ANP user groups, χ2(3) = 0.87, P = .833. Compared to those smoking cigarettes only in the past month, dual users had a smaller proportion reporting past-year quit attempts, χ2(1)=4.59, P = .032, and more frequently reported smoking 0.5 packs-per-day (versus greater/less than 0.5 packs-per-day), χ2(2)=6.94, P = .031. Among ANP users, past-month use of both NPs and e-cigarettes was most common (n = 21/41; 51.22%), followed by e-cigarette use only (n = 17/41; 41.46%), and NP use only (n = 3/41; 7.32%). ANPs were generally described to be as addictive as combustible cigarettes (NP users: n = 13/24, 54.17%; E-cigarette users: n = 32/38, 84.21%). Across ANP products, motivations for use emphasized saving money (NP users: n = 8/24, 33.33%; e-cigarette users: n = 6/38, 15.79%) and convenience when cigarettes cannot be used (NP users: n = 6/24, 25.00%; e-cigarette users: n = 6/38, 15.79%). Compared to combustible cigarettes, NP users more frequently endorsed perceptions that pouches were better for their health (n = 5/24; 20.83%), although e-cigarette users emphasized reduced harms to—or setting a better example for—others (n = 5/38; 13.16% per reason). Conclusions Our findings indicate a high level of ANP use among U.S. military veterans, who also describe ANP products to be as addictive as combustible cigarettes. Results also suggest convenience and cost are prominent motivations for ANP use. Larger epidemiological and experimental investigations are needed to verify the current estimates and evaluate patterns of influence between cigarette and ANP use among veterans.