Nicotine Pouch: Awareness, Beliefs, Use, and Susceptibility among Current Tobacco Users in the United States, 2021

A comprehensive review on oral nicotine pouches: Available scientific evidence and future research needs

Oral nicotine pouches (ONPs) are an emergent class of tobacco products that, unlike conventional oral smokeless tobacco products, contain a nicotine powder instead of tobacco leaves. This review synthesizes available data on ONPs in key research domains including survey studies, marketing/advertising studies, chemical characterization and in vitro studies, and clinical studies. Research findings relevant for ONP regulations are summarized, including who uses these products and why, how marketing tactics influence appeal and use intentions, what harmful and potentially harmful constituents they contain, and what acute effects they have on humans. Taken together, the current data suggest that ONPs likely produce less harm to individual users than conventional tobacco products (e.g., moist snuff, cigarettes) and can acutely suppress nicotine/tobacco withdrawal symptoms among current cigarette smokers. Thus, ONPs may be a viable harm reduction option for individuals who switch completely to using them from conventional products. However, randomized controlled trials are needed to determine if established tobacco users would use ONPs long term, and more independent academic research is needed given that most ONP studies to date are tobacco industry-funded. Additionally, ONPs have qualities (e.g., flavors, marketing claims of "tobacco free") that could increase appeal among youth and young adults, and these products can deliver nicotine at levels sufficient to cause dependence; widespread adoption of ONPs among otherwise nicotine-naive individuals may reduce their net public health benefit. This review concludes by suggesting future research directions necessary to increase scientific understanding of ONPs and inform regulations for these increasingly popular products. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

The Potential Impact of Oral Nicotine Pouches on Public Health: A Scoping Review

INTRODUCTION

Oral nicotine pouches (ONPs) are a new class of nicotine products. This scoping review summarizes evidence on ONPs and explores their potential public health impact.

AIMS AND METHODS

We conducted a structured literature search for empirical studies across three electronic databases through January 10, 2024. Outcomes included ONP product characteristics, use patterns, beliefs and perceptions, toxicity, and marketing and sales.

RESULTS

Sixty-two studies were included, 17 were industry-funded. Most studies were from the United States. While large variations across studies were observed in ONP youth prevalence estimates, nationally representative U.S. studies find current use at 1.5% and lifetime use below 2.5% through 2023. Between 35% and 42% of U.S. adolescents and young adults have heard of ONPs, and 9-21% of tobacco-naïve youth were susceptible to trying them. U.S. adult-use estimates varied widely (0.8%-3% current; 3%-16% lifetime use) and were limited to populations with a history of tobacco use. The chemical composition of ONPs suggests fewer harmful/potentially harmful compounds at lower levels than cigarettes and smokeless tobacco (SLT), except formaldehyde. Industry-funded studies find substantially less cytotoxicity compared to cigarettes and suggest that higher nicotine-strength ONPs can deliver nicotine at levels comparable to or higher than SLT or cigarettes, although with slower nicotine release than cigarettes. Evidence on the cytotoxicity of ONPs relative to SLT is mixed.

CONCLUSIONS

ONPs appear to be less toxic than cigarettes and deliver comparable nicotine, presenting an alternative for combustible product users, although key data are mainly available from industry-funded studies. Data from independent research is critically needed. Industry marketing of ONPs may encourage initiation in youth and situational and dual use in adults.

IMPLICATIONS

The review provides an initial assessment of the potential role of ONPs in harm reduction and aims to determine unintended consequences of their use (youth uptake and dual-use) and identify populations that disproportionately use the product. This information is essential for tobacco regulatory bodies in determining the net public health impact of nicotine pouches.

Nicotine Pouch Use and Adolescents' and Children's Grades in School, National Youth Tobacco Survey 2022-23

BACKGROUND

The prefrontal cortex is not fully developed in middle/high school students, therefore many substances, including nicotine, have the potential to affect it, impair learning, and hinder academic performance. Nicotine in pouches is an emerging, heavily marketed, explicit public health concern. Adolescents may not know of the risks associated with nicotine pouches, especially with social media and marketing claims that they help with weight loss, athletic abilities, mood, and focus. The purpose of this study is to examine the relationship between nicotine pouches and poor academic performance in middle/high school students.

METHODS

Data for this cross-sectional study were from the 2022 and 2023 U.S. National Students Tobacco Survey (n = 39,575) of students in grades 6-12 (mean age, 14.7 years). Current nicotine pouch use was defined as self-reporting its use for ≥1 day in the past thirty days. School grades were the self-reported grades in school during the past 12 months with two categories (A/B and C/D/F). Covariates included sex, race/ethnicity, English/not English language spoken at home, social media use, and depression.

RESULTS

Current nicotine pouch use was 0.9%. Middle/high school students' nicotine pouch use was associated with C/D/F grades (unadjusted odds ratio: 2.50 [95% confidence interval: 1.49, 4.27], p = 0.0007; adjusted odds ratio: 2.07 [95% confidence interval 1.17, 3.69], p = 0.0132).

CONCLUSION

Lower academic performance (mostly C/D/F grades) was associated with middle/high school students' use of nicotine pouches. Longitudinal research is needed in this new area of tobacco-derived product development.

Impact of Smokeless Oral Nicotine Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment: A Policy Statement From the American Heart Association

Smokeless oral nicotine products are addictive, and their use has potential adverse effects on some but not all biomarkers of cardiovascular risk. The use of some types of these products, for instance, is associated with an increased mortality risk in those with ischemic heart or cerebrovascular disease. Similarly, smokeless tobacco has the potential to increase the risk of oral cancer, but the risks depend on the chemical composition of the product. The market of smokeless oral nicotine products has transformed since the last American Heart Association smokeless tobacco policy statement. Several varieties of tobacco-free oral nicotine products-including oral nicotine pouches; nontherapeutic nicotine gums, lozenges, and tablets; and nicotine gummies-have rapidly proliferated. The sales of oral nicotine pouches, in particular, have increased substantially; however, no data are available on their cardiovascular or health risks. In addition, synthetic (compared with tobacco-derived) nicotine has been used in some brands of oral nicotine products, but its cardiovascular and health effects have been inadequately studied. Robust public policy levers are identified to support ending addiction to all commercial tobacco products. Critical components and policy initiatives include clinicians emphasizing the prevention of tobacco product initiation and supporting cessation with established pharmacological and behavioral tobacco dependence treatment therapies as primary goals for achieving an end to commercial tobacco and nicotine addiction.

'It'll save your lungs': early insights into nicotine pouch use and perceptions among young Australians

Flavoured oral nicotine pouches, manufactured and marketed by global tobacco companies, such as Philip Morris International (PMI) and British American Tobacco, entered the Australian market in 2024. Despite it being illegal for Australian retailers to sell nicotine pouches, the products have been seized in government enforcement raids of Australian retailers, and have also been promoted to young people by Australian social media influencers. The Australian Federal Government has recognized and expressed concern about the rising profile of nicotine pouches in Australia and the promotion of these products as unproven vaping and smoking cessation aids. Yet to date, there has been no published research on nicotine pouches in Australia. Using focus group and interview data collected in early 2024 as part of Generation Vape, an ongoing Australian national study into adolescent and young adult vaping and smoking, we explored their attitudes to and perceptions of nicotine pouches, including first-hand experiences and drivers of use. The participants perceived an increase in the use and popularity of oral nicotine pouches, including PMI's Zyn brand, for reasons including claimed sport performance enhancement, vaping cessation and as part of partying and clubbing culture. Some participants perceived nicotine pouches to be a 'healthier' alternative to smoking or vaping. It is critical that research on nicotine pouches is collected now to inform public health policy and to prevent the proliferation of a new class of addictive recreational nicotine products in Australia.

Cancer treatments as paradoxical catalysts of tumor awakening in the lung

Much of the fatality of tumors is linked to the growth of metastases, which can emerge months to years after apparently successful treatment of primary tumors. Metastases arise from disseminated tumor cells (DTCs), which disperse through the body in a dormant state to seed distant sites. While some DTCs lodge in pre-metastatic niches (PMNs) and rapidly develop into metastases, other DTCs settle in distinct microenvironments that maintain them in a dormant state. Subsequent awakening, induced by changes in the microenvironment of the DTC, causes outgrowth of metastases. Hence, there has been extensive investigation of the factors causing survival and subsequent awakening of DTCs, with the goal of disrupting these processes to decrease cancer lethality. We here provide a detailed overview of recent developments in understanding of the factors controlling dormancy and awakening in the lung, a common site of metastasis for many solid tumors. These factors include dynamic interactions between DTCs and diverse epithelial, mesenchymal, and immune cell populations resident in the lung. Paradoxically, among key triggers for metastatic outgrowth, lung tissue remodeling arising from damage induced by the treatment of primary tumors play a significant role. In addition, growing evidence emphasizes roles for inflammation and aging in opposing the factors that maintain dormancy. Finally, we discuss strategies being developed or employed to reduce the risk of metastatic recurrence.

Effect of fruit and mint flavored Rogue® oral nicotine product use on smoking reduction and quitting in a 6-Month prospective cohort of adults who smoke cigarettes

BACKGROUND

Quitting cigarette smoking can substantially reduce or eliminate the risk of developing numerous chronic diseases. Use of flavored tobacco or nicotine products is commonly cited by adults who smoke cigarettes to be important in helping them reduce or quit smoking. The purpose of this analysis was to understand the association between the levels of use of flavored oral nicotine products and smoking reduction and quitting and how reduction or quitting may differ between predominant users of fruit/other versus mint flavored oral nicotine products after six months of use.

METHODS

Participants were provided with their choice of a variety of forms and flavors of Rogue® nicotine products (Study Products) over a 6-month actual use period and completed online surveys assessing tobacco, nicotine and Study Product use at Baseline and Months 1, 2, 4, and 6 thereafter.

RESULTS

Among the 1393 participants at Month 6, 41.4% and 52.5% used predominantly fruit/other or mint Study Product flavors, respectively. Compared to predominant mint users, predominant fruit/other users had greater cigarette reduction (mean reduction: 50.0% vs. 48.4%) and a higher proportion had quit smoking (proportion quit: 15.4% vs. 11.6%) at Month 6. Additionally, 38.8% of predominant fruit/other users and 39.3% of predominant mint users reduced their cigarette consumption by ≥ 50% from Baseline. Increased use of fruit/other flavors was independently associated with smoking reduction (8.6% greater reduction per 10 pieces/day; p < 0.001) and odds of quitting smoking (OR = 1.29 [95% CI: 1.04-1.59] per 10 pieces/day; p = 0.017). Increased use of mint flavors was independently associated with smoking reduction (7.5% greater reduction per 10 mint pieces/day; p < 0.001) but not with odds of quitting smoking.

CONCLUSIONS

Increased use of either fruit/other or mint flavored Study Products at Month 6 was associated with significantly increased smoking reduction, whereas only increased use of fruit/other flavors was associated with greater odds of quitting smoking among participants in the study.

TRIAL REGISTRATION

This study was observational. Participants were not prospectively assigned to one or more health-related interventions and could choose to use or not use the commercially available study products provided during the study. Thus, the study was not registered in a trial database by the Sponsor.

Patterns of nicotine pouch use among young Australians

BACKGROUND

Despite increasing interest in the use of nicotine pouches in Australia - where retail sale of the products is illegal - research exploring patterns of pouch use and reasons for use is lacking. Accordingly, this study explored young Australians' experiences with nicotine pouches.

METHODS

An online survey was administered to 1598 Australians aged 16-39 years (53 % women). We assessed (i) awareness and use (lifetime and past 30-day) of nicotine pouches, (ii) patterns of use (e.g., flavours and nicotine strength used), (iii) product source, and (iv) reasons for use. Regression analyses were conducted to assess socio-demographic predictors of awareness and use.

RESULTS

Just over three-quarters (77 %) of the sample reported being aware of nicotine pouches. Lifetime use was reported by 26 % of respondents and past 30-day use by 19 %. Among those who reported past 30-day use, fruit (35 %) and menthol/mint (34 %) flavours were most commonly used. In terms of pouch source, one-third (33 %) reported obtaining the product from a tobacconist. The most common reasons for use were "they come in flavours I like" (34 %) and "to help me quit smoking" (32 %). Awareness, lifetime use, and past 30-day use of nicotine pouches were more likely among men, those who reported current use of tobacco products, and those who reported current use of e-cigarettes.

CONCLUSIONS

Awareness and use of nicotine pouches among young Australians may be substantial enough to warrant the inclusion of items measuring pouch use in national surveys. Efforts should be made to better enforce existing laws regarding the sale of nicotine pouches.

Beyond Tobacco: Bridging Gaps in Social History Records for Tobacco-Free Nicotine Pouch Consumers

Objective

Nicotine-containing products have historically been tobacco derivatives like cigarettes, cigars, and dip. Recently, tobacco-free nicotine (TFN) products have been marketed as a healthy alternative. TFN pouches are small, discreet, flavored pouches containing nicotine designed to be placed between the gum and lip. This product does not fit a conventional tobacco category, leading to inaccurate reporting. This study aims to investigate discrepancies in physician documentation of TFN pouches.

Methods

A retrospective chart review was conducted on TFN users.

Setting

Single Health Care System.

Methods

Statistical analyses assessed TFN documentation concordance between social history templates and physician notes.

Results

There were 150 patients who used TFN and 841 patients who vaped. Concordance was higher for vape documentation than TFN pouch documentation (55.9%, 470/841 vs 25.3%, 38/150; P < .001). Of those who used TFN, 60% (90/150) were classified as "Smokeless Tobacco Users" in the social history; however, 35 were inaccurately classified as chew, and 17 did not specify TFN use. Only 38 specified TFN use; only 25% (38/150) of records demonstrated concordance.

Conclusion

Only 25% of records were concordant with physician notes, highlighting the need for a designated place for TFN use within social history templates. Nicotine use history is crucial in the setting of microvascular reconstruction and cosmetic surgeries. Thus, accurate reporting is crucial for future research on the long-term effects of TFN. This study's findings underscore a deficit in current social history templates and the need to recognize TFN pouches as distinct entities.

Using Pod Based e-Cigarettes and Nicotine Pouches to Reduce Harm for Adults With Low Socioeconomic Status Who Smoke: A Pilot Randomized Controlled Trial

INTRODUCTION

Alternative Nicotine Delivery Systems (ANDS) such as e-cigarettes (EC) and oral nicotine pouches (ONP) may facilitate the substitution of smoking for those unwilling to quit. This pilot study assesses the harm-reduction potential of EC and ONP among smokers with low socioeconomic status (SES).

AIMS AND METHODS

Adults who smoked daily in the past 6 months, had a household income < 250% federal poverty level and had no intention of quitting smoking in the next 30 days were randomized 2:2:1 to 8 weeks of 5% nicotine EC; 4 mg ONP or assessment-only control (CC). The primary outcome was a within-group change in cigarettes per day (CPD) from Baseline to week 8.

RESULTS

Forty-five individuals were randomized (EC: N = 18; ONP: N = 18; CC: N = 9). Analyses included 33 participants who completed the week 8 visit. The mean age was 50.1 years (SD: 10.7) and the average CPD at baseline was 13.9 (SD: 10.1). For those randomized to EC, the average CPD decreased from 14.7 (95% CI: 10.3 to 19.1) at the Baseline to 2.9 (95% CI: .1 to 5.8) at week 8 (p-value < .001). For those randomized to ONP, average CPD decreased from 15.0 (95% CI: 5.0 to 24.9) to 8.3 (95% CI: 1.3 to 15.2) by week 8 (p-value = .01). In the EC and ONP groups, respectively, 4 (28.6%) and 1 (8.3%) participant fully switched from smoking to the ANDS product by week 8.

CONCLUSIONS

Individuals with low SES who smoke had lower CPD after switching to EC or ONP. These findings show the potential of ANDS in helping smokers switch to less harmful devices.

IMPLICATIONS

This study provides novel evidence that e-cigarettes and nicotine pouches can be a harm-reduction tool for individuals with lower SES who smoke and are not willing to quit smoking, contributing to reducing tobacco-related disparities in this population.Clinical Trials Identifier: NCT05327439.

A Scoping Review of Behavioural Studies on Heated Tobacco Products

Heated tobacco products (HTPs) are electronic devices that heat tobacco sticks to temperatures much lower than those which cause pyrolysis and combustion in cigarettes. While this electrical heating causes the formation of an inhalable aerosol which contains nicotine, the aerosol from HTPs contains significantly fewer and lower levels of the harmful and potentially harmful chemicals found in cigarette smoke. As a result, HTP use potentially conveys reduced risks to health compared to cigarette smoking. While this relative reduction in individual health risk is becoming clearer, what is less certain is the impact of HTPs on overall population‑level health, taking into account both the potential positive impact on adult smokers who completely switch to using HTPs and any unintended impacts such as use by tobacco non‑users and particularly by youth. The aim of this scoping review was to collate and evaluate the published scientific evidence to date, with a cut‑off of 1 January 2024, investigating the impact of HTPs on population‑level health. This evaluation suggests that HTP use is almost exclusively observed among those with a history of cigarette smoking, and there is a growing body of evidence for the ability of HTPs to provide support for adult smokers to transition away from cigarette smoking, in the absence of any significant "gateway" into tobacco use initiation. Many studies have reported a significant degree of dual use of cigarettes and HTPs, and efforts to assess the reasons for such patterns of use, whether these provide overall exposure reductions, and whether dual use acts as a bridge towards a complete transition away from cigarette smoking, requires further investigation. In addition, correction of the widespread and increasing misperceptions of HTPs among adult smokers is recommended to promote HTP uptake as a potentially less harmful alternative to smoking in this population.

Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina

BACKGROUND

Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches.

METHODS

We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis.

RESULTS

Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches.

CONCLUSIONS

Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.

Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review

Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but may involve continued use of nicotine and/or tobacco. Next-generation products (NGPs) are a THR alternative as they do not burn tobacco or produce smoke and deliver nicotine and have fewer and substantially lower levels of harmful chemicals compared to cigarettes. Tobacco‑free nicotine pouches (TFNPs) are an emerging category of nicotine‑containing oral products that do not combust or contain tobacco leaf. Similar to Swedish snus, TFNPs are placed between a user's lip and gum, and nicotine is absorbed through the oral mucosa rather than being inhaled. The aim of this scoping review was to systematically collate and evaluate published scientific evidence (cut‑off of 31 May 2023) identified from bibliometric databases investigating the potential of TFNPs to contribute to THR. Overall, studies examining chemical constituents indicated that the use of TFNPs may result in lower exposure to toxicants than other tobacco or nicotine-containing products, both combustible and non‑combustible. This reduction in toxicant exposure has been demonstrated by multiple human biomarker studies and in vitro toxicological assessments to translate to harm reduction potential in smokers switching to TFNPs. However, further study is warranted. At present, there is some evidence from human behavioral research that TFNPs can support either transitioning away from smoking or reducing cigarette consumption. Furthermore, TFNP use appears very much limited to current users of traditional tobacco products, and youth uptake has been limited. In conclusion, the findings of this review indicate that TFNPs have the potential to support THR efforts and may help inform evidence‑based regulation.