Popular nicotine pouches like Zyn are a 'potent medicine for addiction'

Key takeaways:

• Nicotine pouches have soared in popularity recently with many users thinking they are harmless.
• But these pouches have high concentrations of nicotine and present major public health risks, experts said.

Nicotine pouches are the latest tobacco trend physicians need to know about, and they should adjust screening methods accordingly, according to experts.

Data from the CDC suggest that huge strides have been made in reducing cigarette use in the United States. In 2024, 1.7% of high school students reported smoking cigarettes at least once in the past 30 days. For comparison, in 1997, 36.4% of 12th graders had smoked a cigarette in the past 30 days.

Although these developments are promising, “it’s not enough,” Joanna Cohen, PhD, Bloomberg professor of disease prevention, chair of the department of health, behavior and society, and director of the Institute for Global Tobacco Control at Johns Hopkins Bloomberg School of Public Health, said during the school’s recent press briefing on the topic.

“There are far too many ways in which the tobacco industry has an upper hand, particularly in the ways that it's able to sell and advertise its products with very limited restrictions,” Cohen said.

Regulatory action has fought against the massive tobacco industry with varying degrees of success.

In 2009, Congress first mandated that cigarette packs should have graphic warning labels, as 138 other countries have — “yet here we are, 15 years later, and we still don't have graphic warnings due to repeated legal challenges by the tobacco industry delaying the progress,” Cohen said. Much more recently, the FDA proposed a cap on nicotine levels in cigarettes — 0.7 mg/g — noting that it could avert about 1.8 million tobacco-related deaths by 2060.

Naturally, the industry has countered with new ways to use nicotine. First, vaping became incredibly popular, in large part because of the attractive new flavors. CDC data showed that, in 2022, at least 2.5 million middle and high schoolers in the U.S. used e-cigarettes.

But the FDA cracked down on marketing tactics designed to hook young users, e-cigarette use among youth started dropping, and the industry seemed to shift its focus.

New threat

In January 2025, the FDA approved the sale of 20 Zyn nicotine pouches: a smoke-less, “fresh way to enjoy nicotine,” according to the Zyn website. Although it is the first time the agency authorized the sale of nicotine pouches, that does not signify their safety.

“Unfortunately, just like vaping several years ago, while this product has been approved to help people stop using more dangerous nicotine products, it's being marketed to people as a first-line nicotine product — especially younger people,” Daron W. Gersch, MD, FAAFP, American Academy of Family Physicians (AAFP) vice speaker, told Healio. “So the good taste, the colorful packaging, all the stuff that vaping did 10 years ago, the nicotine pouches are doing now as an effort to catch younger people and get them hooked into nicotine, because they know that once you start the nicotine, it is an incredibly potent medicine for addiction, and they will have a very hard time stopping.”

Johannes Thrul, PhD, an associate professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health, said during the briefing that these pouches do not contain tobacco leaves, but rather crystallized nicotine powder. This convenience associated with these “small, discrete products” is a detail many advertisements capitalize on, Thrul said.

“These pouches are gaining popularity, particularly among young adults, and they represent a significant challenge for public health and policymakers in the U.S.,” Thrul said. “From the nicotine pouch advertisements we are tracking, we see that potentially youth-appealing claims like those that highlight flavors and convenience of use are common and have increased over time. This gives us some reason for concern that these ads are predominantly targeting young people.”

Thrul and Gersch said one major concern with these pouches is that users underestimate their potential for harm.

In 2022, BMJ’s Tobacco Control journal published a study revealing that, of the 44 nicotine pouches analyzed from 20 different manufacturers, 26 included known carcinogenic chemicals found in tobacco products.

A more recent study published in Lancet Oncology reported that, in 2022, smokeless tobacco or areca nut consumption was responsible for approximately 120,000 (95% uncertainty interval, 115,300-124,300) cases of oral cancer across the globe. That equated to an estimated 30.8% (95% uncertainty interval, 29.6-31.9) of all global oral cancer cases (389,800 total).

“These products are still too new to know what the long-term exposure will be,” Gersch said.

Also, many consumers have reported adverse events like sore throats, upset stomachs and mouth lesions after use, Thrul said.

“In a survey study we conducted with people who use nicotine pouches, 97% reported experiencing at least one negative effect,” he added.

The Tobacco Control study also revealed that most products — 29 of 44 — lacked a clear label of the nicotine content and had ambiguous strength descriptions.

Notably, the typical cigarette contains between 8 to 20 mg of nicotine. Some of the nicotine pouches evaluated in the study had nicotine content nearing 50 mg per pouch.

“The high level of the nicotine in the pouches makes this product extremely addictive and much more likely to cause increased blood pressure, heart rate and breathing problems from the nicotine,” Gersch said. “That’s why I worry about these pouches, because they are so potent.”

Gersch said this high level of nicotine content makes these pouches discernable from nicotine gum, which usually come in two strengths: 2 mg and 4 mg.

“The pouches are generally anywhere from six to nine milligrams per pouch,” he said. “The gum is made to release over a period of time, whereas the pouches release relatively quickly, to kind of give you that burst of nicotine — that rush. Well, that rush is coming because it's increasing your heart rate, increasing your blood pressure, increasing all that.”

He recounted a case in which this created a significant issue for a patient.

“I saw a patient in the ER who was drinking a couple of caffeinated drinks per day to get through his workday and just decided that he was going to try a nicotine pouch on top of it,” Gersch said. “His heart rate went real high, he had heart palpitations and everything like that. [Caffeine and nicotine] together really caused that particular patient a fair amount of distress.”

Although the patient was alright, he stressed that this was a healthy 20-year-old, and others may have more severe reactions.

“Fortunately for him, his body could handle what he had just done to it,” Gersch said. “But if he had been older, or if he had been a 20-year-old who, say, maybe had some heart issues, that certainly could have been a troublemaker for him.

“I think patients need to realize that these aren't totally harmless,” he continued.

Another troubling point for Gersch is that the actual prevalence of nicotine pouch usage is unknown and that any analysis would likely underestimate the true numbers.

Very few patients tend to report using nicotine pouches unless their health care provider branches off from the typical screening question to ask about their use by name, Gersch said.

“They see it as something that they're just buying — it's not a big deal, it's not harmful, and they will not tell you about it unless you specifically ask,” he said. “When people come in to see us in the clinic, a lot of times we ask, ‘Are you smoking?’ or ‘Are you using tobacco products?’ And they will say no. As family physicians and primary care doctors, we have to get used to the concept of asking, ‘Are you using anything that has nicotine in it, including vaping or pouches, or any other product that might be out there?’”

Solutions

The AAFP offers resources for PCPs looking to help patients with smoking cessation, including:

• a tobacco and nicotine prevention guide;
• the quit smoking guide, which PCPs can share with patients to help them through the process;
• a cessation guide specifically for patients using smokeless tobacco; and
• a treatment guide including medications and behavioral interventions.

Health care professionals, including PCPs, “are really an essential component to helping people quit,” Cohen said in the press briefing.

“Even very brief advice from a physician is effective,” she added. “It’s really essential to bring [nicotine and tobacco] up [with patients]. I know a lot of health care providers get nervous to do that and feel ‘maybe my patient doesn’t want to hear from me,’ but we know that it really makes a difference.”

Gersch agreed.

“PCPs are the best trained and equipped people to help patients quit their tobacco use and manage their cravings throughout their treatment, and help patients to realize that quitting nicotine can greatly improve their overall health,” he said.

References:

• Jamal A, et al. MMWR Morb Mortal Wkly Rep. 2024;doi:10.15585/mmwr.mm7341a2.
• Mallock N, et al. Tob Control. 2022;doi:10.1136/tc-2022-057280.
• Rumgay H, et al. Lancet Oncol. 2024;doi:10.1016/S1470-2045(24)00458-3.
• Tobacco use among high school students — United States, 1997. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00051762.htm. Published April 3, 1998. Accessed March 10, 2025.