A recent study reported increased oral nicotine pouch exposure in the United States especially among adolescents. Lifetime use among youths rose from 3.0% in 2023 to 5.4% in 2024, and past-30-day use doubled from 1.3% to 2.6%. During the same period, youth e-cigarette use declined. In a nationally representative adult sample of nearly 40,000 individuals, 2.9% had ever used pouches, with prevalence of about 10% among current smokers and about 1% among never-smokers.
On January 16, the US Food and Drug Administration (FDA) authorized the marketing of 20 oral nicotine pouch products, and stated that it would monitor youth consumption and compliance with marketing restricted to adults 21 years and older. Chemical analyses cited by the authors detected low levels of constituents, including formaldehyde, chromium, nickel, and tobacco-specific nitrosamines in some products. Reports described local oral findings associated with use, such as gingival blisters and smokeless-tobacco–type keratosis, and noted elevations in inflammatory markers with exposure.
Product features relevant to exposure risk were summarized. Pouches were placed between the gum and lip and delivered nicotine via the oral mucosa without spitting. Commonly available strengths contained about 3 mg per pouch, with ranges reported from approximately 1.5 mg to 12 mg, and some products reported at almost 50 mg per pouch. Sales of oral nicotine pouches increased 641% from 2019 to 2022. Brands included ZYN, VELO, On!, and Rogue, and flavors included fruit, mint, and coffee.
Marketing content was summarized for 2021 to 2023 and demonstrated a shift in messaging. Advertisements that featured terms such as “tobacco-free,” “smoke-free,” and “spit-free” declined, while convenience, discreteness, and discounts appeared more often; some containers carried codes linked to rewards programs. In discussing the shift in messaging, Sophia Chen, MD, of the Department of Head and Neck Surgery, David Geffen School of Medicine, University of California, Los Angeles, wrote, “This change in messaging undermines arguments for oral nicotine pouches as harm reduction for people who use tobacco and suggests that the companies producing nicotine pouches may be instead appealing to tobacco-naive audiences.” The article also noted brand activity on social platforms and colloquial references such as “Zyndemic” and “Zynfluencers.”
Study methods consisted of a narrative synthesis of recent surveillance datasets, market reports, dental and oral-medicine literature, and chemical-constituent assays. Youth estimates were derived from national surveillance covering 2023 to 2024, while adult prevalence was derived from a large, nationally representative survey. Chemical and oral-finding summaries drew on laboratory studies and clinical case-based reports. Regulatory details were taken from the FDA’s marketing authorization documents for the indexed products.
Limitations reflected the underlying context. The evidence base included cross-sectional surveys that did not establish causality or long-term outcomes. Oral findings were reported in small studies and case-based literature, limiting generalizability. Constituent profiles varied by product and study methodology, and exposure characterization across strengths and flavors was incomplete. The article was a viewpoint and did not present new primary data or a systematic meta-analysis.
Current knowledge on oral nicotine pouches remained preliminary and largely observational, according to the authors. Long-term oral health risks, including carcinogenic potential and persistent mucosal changes, had not been determined. They indicated the need for prospective research to define dose–exposure relationships, product variability, and use patterns in tobacco-naive populations and youths, along with continued regulatory surveillance.
The authors reported no conflicts of interest.
