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Published in final edited form as: Int J Drug Policy. 2026 Feb 3;150:105178. doi: 10.1016/j.drugpo.2026.105178 Search in PMC Search in PubMed View in NLM Catalog Add to search Urban–Rural Disparities in Oral Nicotine Pouch Sales and Flavors in the United States Lei Xu Lei Xu 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA Find articles by Lei Xu 1 , Saber Feizy Saber Feizy 2 Center for Health, Engagement, & Transformation (CHET), College of Medicine, University of Kentucky, Lexington, Kentucky, USA Find articles by Saber Feizy 2 , Megan E Roberts Megan E Roberts 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA 3 College of Public Health, The Ohio State University, Columbus, Ohio, USA Find articles by Megan E Roberts 1, 3 , Ce Shang Ce Shang 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA 4 Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA Find articles by Ce Shang 1, 4 , Brittney Keller-Hamilton Brittney Keller-Hamilton 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA 4 Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA Find articles by Brittney Keller-Hamilton 1, 4 , Darren Mays Darren Mays 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA 4 Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA Find articles by Darren Mays 1, 4 , Shyanika W Rose Shyanika W Rose 2 Center for Health, Engagement, & Transformation (CHET), College of Medicine, University of Kentucky, Lexington, Kentucky, USA Find articles by Shyanika W Rose 2 , Yanyun He Yanyun He 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA Find articles by Yanyun He 1 Author information Article notes Copyright and License information 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA 2 Center for Health, Engagement, & Transformation (CHET), College of Medicine, University of Kentucky, Lexington, Kentucky, USA 3 College of Public Health, The Ohio State University, Columbus, Ohio, USA 4 Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA ✉ Corresponding author: Yanyun He, PhD, Center for Tobacco Research, The Ohio State University Wexner Medical Center, Current address: 3650 Olentangy River Rd, Columbus, OH 43214, [email protected] Issue date 2026 Apr. PMC Copyright notice PMCID: PMC13089354 NIHMSID: NIHMS2156758 PMID: 41637991 The publisher's version of this article is available at Int J Drug Policy Abstract 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 1,000 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. Keywords: oral nicotine pouch, sales disparity, flavor, urban-rural classification, price elasticity 1. Introduction Oral nicotine pouches (ONPs), a category of smokeless, tobacco-free products that deliver nicotine without combustion or tobacco leaf, have rapidly gained ground in the United States (US) nicotine product market ( He et al., 2025 ). Since their market entry in the mid-2010s, ONP sales have increased exponentially in the US, rising from 163,000 units sold in 2016 to 46 million units in 2020 ( Marynak et al., 2021 ). According to a recent analysis, ONP sales in the US have expanded from 327 million units sold in July 2021 to over 1 billion by May 2024 ( He et al., 2025 ). As ONP sales continue to grow, their use has also become more prevalent. In 2023, 3.34% of adults in the US reported ever using ONPs, and 1.58% reported past-year use ( Palmer et al., 2025 ). Among high school students, ONP use has risen significantly, from 1.1% in 2021 to 1.4% in 2022 to 2.4% in 2024 ( Birdsey, 2023 ; Gentzke, 2022 ; Park-Lee et al., 2022 , 2024 ). In contrast, during the same period, e-cigarette use among high school students dropped from 11.3% in 2021 to 7.8% in 2024 ( Park-Lee et al., 2024 ). Similar increases in ONP use have been observed internationally. In 2024, approximately 5% of youth in Canada, the US, and New Zealand, and 10% in England, reported ever using ONPs, while ever use among young adults ranged from 9.1% in Canada to 18.7% in England ( Reid et al., 2025 ). Together, these trends raise concerns about the growing popularity of ONPs among youth and young adults, highlighting the urgent need for regulatory action by state and local agencies. Although a growing body of research suggests that ONP use is disproportionately concentrated among younger and middle-aged males, non-Hispanic White individuals, and those with lower income and education levels ( Han et al., 2025 ; Harlow et al., 2022 ; Patel et al., 2023 ), major gaps remain in understanding how these patterns play out across geographic settings. In the general population, smokeless tobacco use is more common among males, non-Hispanic White individuals, and those with lower income and education (Pesko & Robarts, 2017; Sinha et al., 2018 ), and has consistently shown significantly higher prevalence in rural compared to urban areas ( Roberts et al., 2016 ). This rural–urban disparity is also reflected in smokeless tobacco sales patterns ( Roberts et al., 2016 ), suggesting that ONPs, which share the same oral delivery mode, may similarly be more acceptable among rural populations. However, there is a lack of empirical evidence on whether ONPs also have the same rural vs. urban difference. This represents a critical gap in the context of persistent tobacco-related disparities in rural areas, where noncombustible product use may contribute to ongoing health inequities ( Dai et al., 2021 ; Doogan et al., 2017 ; Hilts et al., 2022 ; Roberts et al., 2016 ). In addition, there is a lack of empirical evidence on whether ONP sales by product attributes (e.g., price, flavor) vary across urbanicity/rurality. ONPs come in a variety of flavors, and some flavor chemicals used in ONPs may cause systemic and local toxicological responses during chronic usage ( Shaikh et al., 2022 ). Research has further shown that the availability of preferred flavors is a key ONP use motivation ( Dowd et al., 2024a ). Local flavored tobacco sales restrictions also vary in whether they include or exclude ONPs ( Shaikh et al., 2023 ), which may impact geographic patterns in use. However, evidence remains limited on how flavored versus implicitly flavored ONPs are associated with sales levels. In particular, little is known about whether sales patterns differ by flavor type across retail markets. Previous studies have shown that individuals with lower socioeconomic status (SES), as well as those living in rural areas, are more responsive to price increases ( Chaloupka et al., 2012 ; Choi, 2016 ; Nargis et al., 2019 ). This greater price sensitivity has important public health implications, as price-based policies, such as taxes, may be particularly effective in reducing tobacco use among these populations. However, to date, no empirical evidence has examined whether the association between price and ONP sales differs by urban-rural classification and SES. To address these gaps, it is crucial to conduct comprehensive market surveillance of ONP sales and product attributes. Our objective was to evaluate how ONP sales are associated with product attributes (prices and flavors) and sales locations (rural vs. urban), and whether the associations between sales and product attributes differ by urban/rural status. The findings have direct implications for Food and Drug Administration regulatory efforts, state- and county-level policy design, and ongoing public health initiatives aimed at addressing tobacco-related health inequities. 2. Method 2.1. Data ONP Sales, price, and flavors Data on ONP sales, price, and flavors were obtained from the 2021 NielsenIQ Retail Scanner Data (NRSD), one of the most widely used commercial datasets to provide national estimates of tobacco product sales. The NRSD captures approximately 84% of taxable cigarette sales in the States, and ONPs ( Liber et al., 2024 ), dominated by large tobacco manufacturers and sold primarily through traditional retail channels, are likely similarly well represented. The NRSD includes store location information for each ONP sales record, allowing us to identify the corresponding county and link the sales data with other county-level covariates. Urban–Rural Classification The National Center for Health Statistics assigned each county to one of six urban–rural categories based primarily on population size and degree of urbanization in 2023: large central metro, large fringe metro, medium metro, small metro, micropolitan, and noncore ( National Center for Health Statistics, 2024 ). Because this urban-rural classifications was last provided in 2013 and did not release updated classifications between 2013 and 2023, we used the most recent version available, the 2023 classification. Population Numbers and SES factors The Economic Research Service provides county-level population counts and SES data for 2021. The SES variables include: (1) educational attainment; (2) the unemployment rate; and (3) median household income. This study utilizes data from the NRSD and publicly available datasets that do not involve human subjects and is therefore exempt from ethical compliance requirements. 2.2. Measures The outcome variable in this study was monthly ONP sales volume (i.e., number of cans) per 1,000 population, calculated by dividing the total county-level sales volume by the county population sourced from the Economic Research Service and multiplying the result by 1,000. To improve model interpretability and address skewness in sales distribution, the outcome variable was log-transformed prior to regression analysis. ONP prices were measured as dollars per can. We log-transformed the ONP prices in the regression model. Thus, the estimated coefficient of ONP prices can be interpreted as the price elasticity of demand for ONPs. Given the wide variety of ONP flavors listed in the NRSD, we created a four-level categorical variable, flavor group, to facilitate regression analysis: (1) implicit flavor (e.g., chill, original, smooth, etc.), which are marketed without explicit flavor names but often contain additives that enhance sensory appeal; (2) mint or menthol (e.g., mint, wintergreen, spearmint, peppermint, menthol, etc.); (3) fruit (e.g., black cherry, citrus, apple, etc.); and (4) other flavors (e.g., coffee, cinnamon, etc.). The first four categories of NCHS classification are classified as metropolitan or urban counties, while the latter two are considered nonmetropolitan or rural. Based on this classification, we constructed a binary variable, rural, coded as 1 for rural (nonmetropolitan) counties and 0 for urban (metropolitan) counties. Educational attainment was measured using four categories: the percentage of adults with less than a high school diploma, a high school diploma, an associate degree, and a bachelor’s degree or higher (reference group). Because median household income is reported as a continuous variable, we created a categorical variable, income group, by dividing counties into tertiles: high-income (top third, reference group), middle-income (middle third), and low-income (bottom third). All SES factors are structured at the county level. 2.3. Study Sample The original Nielsen sales dataset was structured at the product-week level. To facilitate analysis, we aggregated the data to the county-month–flavor group level and merged it with county-level urban/rural classifications and SES factors. The final analytic sample comprises 83,796 observations from 2021. 2.4. Statistical Analysis We first conducted descriptive analyses for the full analytical sample and separately for urban and rural areas ( Table 1 ). Differences between urban and rural counties were assessed using two-sample t tests for continuous variables and chi-square tests for categorical variables. Then we employed multivariable linear regression models to examine the association of ONP sales with product attributes and urban/rural classification. The benchmark model (Model 1) is specified as follows: l o g ( S a l e s i c t ) = β 0 + β 1 l o g ( P r i c e i c t ) + β 2 F l a v o r i + β 3 R u r a l c + β 4 X c + ϵ i c t (1) Table 1. Summary statistics of oral nicotine pouch (ONP) sales per capita, product attributes, sales locations, and control variables, county-level, 2021 (n=83,796) Panel A. Continuous Variables All Sample Mean (SD) Rural Areas Urban Areas P values ONP sales per 1,000 population (# of cans) 4.648 (12.037) 5.231 (14.887) 4.066 (8.227) <0.001 Average ONP prices ($/can) 3.865 (1.011) 3.791 (1.126) 3.940 (0.874) <0.001 Unemployment rate 0.048 (0.015) 0.049 (0.015) 0.048 (0.015) <0.001 Education Below high school 0.114 (0.053) 0.127 (0.056) 0.101 (0.046) <0.001 High school diploma 0.327 (0.077) 0.359 (0.065) 0.295 (0.074) <0.001 Associate degree 0.305 (0.047) 0.307 (0.050) 0.303 (0.044) <0.001 Bachelor's degree or higher 0.254 (0.107) 0.207 (0.078) 0.300 (0.112) <0.001 Panel B. Categorical Variables Frequency (%) Rural Areas Urban Areas P values Flavor Groups implicitly flavored 12,550 (14.98%) 5,261 (41.92%) 7,289 (58.08%) <0.001 Mint/menthol 24,640 (29.40%) 12,905 (52.37%) 11,735 (47.63%) <0.001 Fruit 23,052 (27.51%) 11,684 (50.69%) 11,368 (49.31%) <0.001 Others 23,554 (28.11%) 11,988 (50.90%) 11,566 (49.10%) <0.001 Urbanization Code 1 Urban 41,958 (50.07%) Rural 41,838 (49.93%) Income Groups Low income 31,577 (37.68%) 23,661 (74.93%) 7,916 (25.07%) <0.001 Medium income 27,542 (32.87%) 13,679 (49.67%) 13,863 (50.33%) <0.001 High income 24,677 (29.45%) 4,498 (18.23%) 20,179 (81.77%) <0.001 Open in a new tab Notes: 1 The dataset includes 995 urban counties and 1,129 rural counties. P-values are derived from two-sample t-tests or chi-square tests comparing rural and urban counties. Where S a l e s i c t denotes the ONP sales volume per 1,000 population for flavor group i in county c and month t ; P r i c e i c t represents the average price per can of ONPs for flavor group i in county c and month t ; F l a v o r i is a set of dummy indicators of flavor group, with implicitly flavored ONPs as the reference group; R u r a l c is a dummy indicator for whether county c is classified as rural. X c is a vector of county-level SES factors, including dummy indicators for educational attainment, unemployment rate, and income group. ϵ i c t is the idiosyncratic error term. Building on Model (1), Model (2) introduces an interaction between flavor group and the rural indicator to examine whether the association between flavors and ONP sales differs between urban and rural areas. Model (3) further includes an interaction between ONP prices and the rural indicator to assess whether the price elasticity of demand for ONPs varies by urban/rural classifications. Finally, Model (4) adds interactions between ONP price and SES indicators (income group and unemployment rate) to assess heterogeneity in price elasticity by SES. All analyses were conducted using Stata 18 (StataCorp LLC, College Station, TX). 3. Results Table 1 presents summary statistics for the analytic sample, which is described in the supplementary files . In 2021, total ONP sales reached 40.8 million cans in urban areas (88%) and 5.8 million cans in rural areas (12%, see Figure 1 ). When adjusted for population, rural areas had slightly higher per capita sales, 0.19 cans, compared to 0.17 cans in urban areas ( Figure 2 ). Figure 3 further breaks down ONP sales by flavor group across urban and rural areas. Mint/menthol flavors were the most popular in both areas, with rural counties reporting slightly higher average sales per 1,000 population (121.38 vs. 111.29). Sales of fruit-flavored ONPs (29.25 vs. 24.84) and other flavors (41.85 vs. 31.98) were also higher in rural areas. Implicitly flavored ONPs had the lowest average sales in both settings, though rural counties still showed slightly greater sales (6.78 vs. 5.44). Figure 1. Open in a new tab Total Oral Nicotine Pouch Sales by Urban and Rural Classification, U.S., 2021 Figure 2. Open in a new tab Per Capita Oral Nicotine Pouch Sales by Urban and Rural Classification, U.S., 2021 Figure 3. Open in a new tab Average Oral Nicotine Pouch Sales per 1,000 Population by Flavor and Urban–Rural Classification, U.S., 2021 Table 2 presents regression estimates from three multivariable OLS models. In Model 1, the log of ONP sales per 1,000 population was 0.146 units higher in rural counties compared to urban ones, indicating that ONP sales per 1,000 population were approximately 16% (calculated as e β - 1 ) higher in rural areas, holding other factors constant. Across all models, average ONP prices were negatively associated with sales. The estimated price elasticity of demand was −0.44, suggesting that a 10% increase in ONP prices was associated with a 4.4% decrease in ONP sales per 1,000 population. Flavored ONPs were significantly associated with higher sales compared to implicitly flavored products. 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. Table 2. Linear regression models of how oral nicotine pouch (ONP) sales per capita are associated with product attributes and sales locations, county level, 2021 (n=83,796) Independent Variables Log (ONP Sales Per Capita ×1,000) Model (1) Model (2) Model (3) Model (4) Urban/rural classification (base: Urban) Rural 0.146 *** (0.012) 0.530 *** (0.026) 0.120 * (0.051) 0.028 (0.056) Log (Average ONP prices) −0.437 *** (0.017) −0.441 *** (0.017) −0.660 *** (0.029) −0.639 *** (0.058) Flavor Group (base: Implicitly flavored) Mint/menthol 3.186 *** (0.016) 3.426 *** (0.021) 3.456 *** (0.022) 3.455 *** (0.022) Fruit 1.672 *** (0.016) 1.836 *** (0.021) 1.834 *** (0.021) 1.832 *** (0.021) Others 1.968 *** (0.016) 2.147 *** (0.021) 2.176 *** (0.022) 2.174 *** (0.022) Interaction – Flavor group and urban/rural classification Mint/menthol × Rural −0.532 *** (0.031) −0.576 *** (0.032) −0.576 *** (0.032) Fruit × Rural −0.388 *** (0.032) −0.378 *** (0.032) −0.377 *** (0.032) Others × Rural −0.418 *** (0.032) −0.454 *** (0.032) −0.453 *** (0.032) Interaction – Price and urban/rural classification Price × Rural 0.328 *** (0.035) 0.396 *** (0.039) Unemployment rate −0.050 *** (0.003) −0.050 *** (0.003) −0.047 *** (0.003) −0.067 *** (0.014) Interaction – Price and unemployment rate Price × unemployment rate 0.015 (0.010) Income Group (base: High income) Low income −0.170 *** (0.017) −0.170 *** (0.017) −0.174 *** (0.017) 0.091 (0.068) Medium income −0.077 ** (0.014) −0.077 *** (0.014) −0.084 *** (0.014) 0.121 (0.066) Interaction – Price and income group Price × Low income −0.197 *** (0.049) Price × Medium income −0.150 ** (0.048) Education (base: Bachelor's degree or higher) Below high school −0.004 ** (0.001) −0.004 ** (0.001) −0.004 ** (0.001) −0.004 ** (0.001) High school diploma −0.028 *** (0.001) −0.028 *** (0.001) −0.029 *** (0.001) −0.029 *** (0.001) Associate degree 0.027 *** (0.001) 0.027 *** (0.001) 0.026 *** (0.001) 0.027 *** (0.001) Constant −0.744 *** (0.055) −0.885 *** (0.055) −0.584 *** (0.064) −0.627 *** (0.095) Observations 83,796 83,796 83,796 83,796 R-squared 0.346 0.348 0.349 0.349 Open in a new tab Note: Standard errors in parentheses. *** p<0.001 ** p<0.01 * p<0.05 Although explicitly flavored ONPs had higher sales than implicitly flavored products in both urban and rural areas, the influence of flavor was weaker in rural counties. In Model (2), the interaction terms between flavor and rural status were all negative, indicating that the sales boost associated with flavored ONPs was significantly attenuated in rural areas. Specifically, in urban areas, sales of mint/menthol, fruit, and other flavored ONPs were approximately 30, 5, and 8 times higher, respectively, than those of implicitly flavored ONPs. In rural areas, the differences were somewhat smaller, with flavored ONPs selling about 17, 3, and 5 times more than implicitly flavored ONPs, respectively. In Model (3), the interaction between ONP prices and rural status was positive, indicating that the negative effect of price on ONP sales was weaker in rural areas. The estimated price elasticity of demand was −0.66 (p<0.001) in urban areas and −0.33 (p<0.001) in rural areas, suggesting that ONP sales in rural counties were less sensitive to price changes than those in urban counties. In Model (4), the interactions between ONP price and income group were consistently negative. The estimated price elasticity of demand for ONPs was −0.37, −0.52, and −0.57 in high-, medium-, and low-income counties, respectively (all p<0.001), indicating greater price responsiveness in low- and medium-income counties compared with high-income counties. Holding other factors constant, counties with a higher proportion of residents holding a high school diploma or less were associated with lower ONP sales, whereas a higher proportion of residents with associate degrees was linked to higher ONP sales. In addition, higher unemployment rates were associated with lower ONP sales. Counties classified as low- or medium-income reported lower ONP sales compared to high-income counties. 4. Discussion In this study, we found that ONP sales per capita were higher in rural areas, when products are priced lower, and when products have explicit instead of implicit flavors. In addition, the associations between product attributes and sales are less pronounced in rural areas compared to urban areas. This study contributes to the growing body of literature on disparities in nicotine and tobacco product use. Our finding that rural counties had higher ONP sales per capita aligns with previous research showing greater tobacco use prevalence, especially smokeless tobacco use, in more rural areas ( Agaku et al., 2020 ; Cardarelli et al., 2021 ). While some studies suggest that rural populations are more resistant to adopting novel tobacco products such as e-cigarettes ( Tattan-Birch et al., 2022 ), the delivery mode of ONPs which is similar to smokeless tobacco, may have appeal among rural populations. Indeed, we found higher per capita ONP sales in rural areas. Our findings are consistent with previous research demonstrating that flavored nicotine products are associated with higher consumption and greadowdter consumer appeal ( Dowd et al., 2024b ; Shaikh et al., 2023 ). This underscores flavor as a key driver of ONP sales. Moreover, we found that the association between flavor and ONP sales was stronger in urban areas than in rural areas. This disparity may reflect differences in marketing exposure, retail availability, or underlying consumer preferences across geographic settings. We also found that the demand for ONPs was price inelastic (−0.44), falling within the elasticity range for combustible cigarettes (typically −0.2~−0.6) ( Chaloupka et al., 2011 ; Tauras et al., 2016 ). This implies that increasing ONP prices through taxation would lead to modest reductions in consumption, while still generating increased tax revenues. Specifically, because the estimated price elasticity of demand for ONPs is −0.44 (inelastic), a 10% increase in price would reduce consumption by only 4.4%. In other words, the decline in sales volume is proportionally smaller than the increase in price, so the total revenue generated from ONP taxes would rise despite the reduction in quantity sold. Additionally, we observed that urban consumers (−0.66) were more price-sensitive than rural consumers (−0.33), a pattern somewhat contrary to the existing literature, which generally finds that lower-income individuals, who are disproportionately located in rural areas, tend to be more price-sensitive ( Chaloupka et al., 2012 ; Choi, 2016 ; Franks et al., 2007; Townsend et al., 1994). Several factors may help explain this urban–rural difference. First, ONP prices were lower in rural areas (mean: $3.79, 95% CI: 3.78–3.80) than in urban areas (mean: $3.94, 95% CI: 3.93–3.95), which may reduce price salience, making consumers seem less price sensitive, as small changes are less likely to affect behavior than in higher-price urban markets. Second, urban consumers likely have greater access to alternative nicotine products such as e-cigarettes and other ONP brands, making them more responsive to price changes. In contrast, rural consumers may face limited retail access and product variety, reducing their ability to switch or adjust usage in response to price fluctuations. Third, ONP use may be more recreational or experimental in urban areas, where users treat these products as one option among many. As a result, they may be more willing to reduce consumption or switch to alternatives when prices rise. In rural areas, by contrast, ONP use might be more habitual or constrained by fewer available substitutes, resulting in lower price sensitivity. We further found that ONP price responsiveness was greater in low- and medium-income counties than in high-income counties. This suggests that, conditional on income, lower-income populations may still be more responsive to ONP price changes, even though rural areas overall exhibited lower price sensitivity. Together, these findings indicate that urban–rural and socioeconomic gradients capture distinct dimensions of heterogeneity in ONP demand. Finally, while prior research shows that cigarette smoking is more prevalent among lower-income and less-educated populations ( Mills et al., 2020 ; Nguyen et al., 2023 ), our study found higher ONP sales in counties with higher income levels and greater proportions of residents with higher educational attainment when controlling for rurality and other factors. This reversal in the socioeconomic gradient of use suggests that ONPs may follow different behavioral and market dynamics than traditional tobacco products, which could influence price responsiveness. Taken together, these findings suggest that price-based policies, such as excise taxes or minimum price laws, may have a more pronounced impact on reducing ONP sales in urban and low-income counties. Our results have several policy implications. If sales are mostly driven by individuals who never used other forms of tobacco and reducing sales through regulation is the goal, then flavor restrictions and excise taxes may help moderate ONP sales. However, given the relatively inelastic demand for ONPs, excise taxes are likely to produce modest reductions in consumption. Moreover, because urban sales are more responsive to these policies than rural sales, these policies could increase urban-rural disparities in ONP sales instead of reducing gaps. To avoid this, policymakers could consider complementary strategies specifically targeted to rural populations. For example, tailored public health campaigns, enhanced retail licensing and enforcement in rural areas, and support for local prevention programs. In addition, our study did not examine nicotine strength or cooling chemicals to determine whether limits on nicotine concentrations or on additives may have a differential impact by geography ( Tackett et al., 2023 , Majmundar et al., 2022 ). Conversely, if ONP sales are mostly driven by individuals who use tobacco and are using these products to quit, then maintaining the availability and affordability of ONPs could support harm reduction goals. In this context, ONP taxation, alongside taxation of other tobacco products, should reflect the relative harm of these products, so as not to inadvertently encourage substitution toward more harmful combustible cigarettes if ONP prices increase. Our findings suggest that rural ONP sales are less sensitive to flavor restrictions and price increases, which may indicate that rural smokers are more likely to continue accessing ONPs even under tighter regulation. From a practice perspective, this resilience underscores the need to pair regulatory efforts with expanded cessation support in rural areas, ensuring that individuals who wish to quit have access to both effective treatments and accurate information about lower-risk products. This study is not without limitations. First, our analysis used the NielsenIQ retail sales data, which may not capture all sales channels, such as online purchases or specialty tobacco shops. Second, we used the 2023 NCHS Urban-Rural Classification scheme, which does not perfectly align with the 2021 NielsenIQ sales data. However, because NCHS did not release classifications for 2021, and we expect minimal changes in county urban/rural status between 2021 and 2023, we consider this mismatch unlikely to bias our findings. Third, the outcome variable, ONP sales, is measured by volume and does not account for nicotine concentration. This approach is consistent with prior literature on e-cigarette and ONP sales ( Cotti et al., 2022 ; Diaz et al., 2025 ; He et al., 2025 ), which similarly measure units sold without adjusting for nicotine strength due to product variability. We acknowledge that differences in nicotine concentration may affect product comparisons. Lastly, our analysis is limited to a single year (2021), which coincided with the COVID-19 pandemic. During this period, retail purchasing patterns shifted substantially and may have differentially affected rural and urban communities and retail environments. As the ONP market continues to evolve and local regulations (e.g., flavor restrictions) change, our findings may not be generalizable to other time periods. 5. Conclusion This study provides timely surveillance evidence on ONP sales dynamics and geographic disparities. 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. Future research should investigate individual-level ONP use patterns, explore the impact of evolving state and local policies, and assess ONP health outcomes longitudinally. 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