Oral Tobacco-Free Nicotine Pouches: a promising alternative or growing threat? – literature review
More details
Hide details
Dolnośląski Szpital Specjalistyczny im. T. Marciniaka – Centrum Medycyny Ratunkowej, Wrocław, Polska
Miejskie Centrum Medyczne im. dr Karola Jonschera, Łódź, Polska
Wielospecjalistyczny Szpital Wojewódzki w Gorzowie Wlkp. Sp. z o.o., Polska
Uniwersytecki Szpital Kliniczny im. Jana Mikulicza-Radeckiego we Wrocławiu, Polska
4 Wojskowy Szpital Kliniczny z Polikliniką SP ZOZ, Wrocław, Polska
Dolnośląskie Centrum Onkologii Pulmonologii i Hematologii, Wrocław, Polska
Corresponding author
Nicola Joanna Stencel   

Dolnośląski Szpital Specjalistyczny im. T. Marciniaka- Centrum Medycyny Ratunkowej, Wrocław, gen. Augusta Emila Fieldorfa 2, 54-049, Wrocław, Polska
Med Srod. 2024;27(2):51-59
Introduction and objective:
Nicotine addiction is an environmental risk factor for many diseases. The adverse health effects of smoking have led to the development of a strategy encouraging smokers to use less harmful sources of nicotine. Oral tobacco-free nicotine pouches (TFNPs) represent the latest innovation on the market, gaining increasing popularity. Easy availability of pouches may bring benefits to public health and negative consequences, particularly among young people. The aim of this study is to present the issue of TFNPs, with particular emphasis on the increasing prevalence of these products, potential benefits for smokers, and possible health effects of their use, especially among young individuals.

Abbreviated description of the state of knowledge:
TFNPs have the form of pouches filled with non-tobacco powder containing nicotine and additives. They are applied between the gum and upper lip, where released nicotine is absorbed through the oral mucosa into the bloodstream. There has been a significant increase in their sales from 2016–2020, indicating an increasing interest in these products. It is projected that the TFNPs market value will reach approximately 33 billion dollars by 2026. Among their side effects, local reactions including periodontal and oral cavity diseases are distinguished, and the occurrence of risks of other organ disorders resulting from the systemic effect of nicotine has been noted.

Monitoring the frequency of TFNPs usage and its associated health issues is crucial for assessing their impact on public health. While they may assist smokers in quitting, they also bring a risk of increasing the number of nicotineproduct consumers. Limited knowledge about their health effects raises concerns, highlighting the need for regulations governing their distribution on the market.

Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of Tobacco Smoking: A Review. JAMA. 2022;327(6):566–577. doi:10.1001/jama.2022.0395.
World Health Organization (WHO). Tobacco. (access: 2024.05.08).
Thandra KC, Barsouk A, Saginala K, et al. Epidemiology of lung cancer. Contemp Oncol (Pozn). 2021;25(1):45–52. doi:10.5114/wo.2021.103829.
Chapman F, McDermott S, Rudd K, et al. A randomised, open-label, cross-over clinical study to evaluate the pharmacokinetic, pharmacodynamic and safety and tolerability profiles of tobacco-free oral nicotine pouches relative to cigarettes. Psychopharmacology (Berl). 2022;239(9):2931–2943. doi:10.1007/s00213-022-06178-6.
Grandolfo E, Ogden H, Fearon IM, et al. Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review. Cureus. 2024;16(2):e54228. doi:10.7759/cureus.54228.
Morean ME, Bold KW, Davis DR, et al. “Tobacco-free” Nicotine Pouches: Risk Perceptions, Awareness, Susceptibility, and Use Among Young Adults in the United States. Nicotine Tob Res. 2023;25(1):143–150. doi:10.1093/ntr/ntac204.
Clarke E, Thompson K, Weaver S, et al. Snus: a compelling harm reduction alternative to cigarettes. Harm Reduct J. 2019;16:62. doi:10.1186/s12954-019-0335-1.
Idris AM, Ibrahim SO, Vasstrand EN, et al. The Swedish snus and the Sudanese toombak: are they different? Oral Oncol. 1998;34(6):558–66. doi:10.1016/s1368-8375(98)00047-5.
Azzopardi D, Liu C, Murphy J. Chemical characterization of tobacco-free “modern” oral nicotine pouches and their position on the toxicant and risk continuums. Drug Chem Toxicol. 2022;45(5):2246–2254. doi:10.1080/01480545.2021.1925691.
Rinaldi S, Pieper E, Schulz T, et al. Oral nicotine pouches with an aftertaste? Part 2: in vitro toxicity in human gingival fibroblasts. Arch Toxicol. 2023;97:2343–2356. doi:10.1007/s00204-023-03554-9.
Valen H, Becher R, Vist GE, et al. A systematic review of cancer risk among users of smokeless tobacco (Swedish snus) exclusively, compared with no use of tobacco. Int J Cancer. 2023;153(12):1942–1953. doi:10.1002/ijc.34643.
Azzopardi D, Haswell LE, Frosina J, et al. Biomarkers of Exposure and Potential Harm in Exclusive Users of Nicotine Pouches and Current, Former, and Never Smokers: Protocol for a Cross-sectional Clinical Study. JMIR Res Protoc. 2022;11(10):e39785. doi:10.2196/39785.
Back S, Masser AE, Rutqvist LE, et al. Harmful and potentially harmful constituents (HPHCs) in two novel nicotine pouch products in comparison with regular smokeless tobacco products and pharmaceutical nicotine replacement therapy products (NRTs). BMC Chem. 2023;17(1):9. doi:10.1186/s13065-023-00918-1.
Mallock N, Schulz T, Malke S, et al. Levels of nicotine and tobacco-specific nitrosamines in oral nicotine pouches. Tob Control. 2024;33:193–199. doi:10.1136/tc-2022-057280.
Shaikh SB, Newton C, Tung WC, et al. Classification, Perception, and Toxicity of Emerging Flavored Oral Nicotine Pouches. Int J Environ Res Public Health. 2023;20(5):4526. doi:10.3390/ijerph20054526.
Ye D, Rahman I. Emerging Oral Nicotine Products and Periodontal Diseases. Int J Dent. 2023;2023:1–7. doi:10.1155/2023/9437475.
Tattan-Birch H, Jackson SE, Dockrell M, et al. Tobacco-free Nicotine Pouch Use in Great Britain: A Representative Population Survey 2020–2021. Nicotine Tob Res. 2022;24(9):1509–1512. doi:10.1093/ntr/ntac099.
Marynak KL, Wang X, Borowiecki M, et al. Nicotine Pouch Unit Sales in the US, 2016–2020. JAMA. 2021;326(6):566–568. doi:10.1001/jama.2021.10366.
Stanfill S, Tran H, Tyx R, et al. Characterization of Total and Unprotonated (Free) Nicotine Content of Nicotine Pouch Products. Nicotine Tob Res. 2021;23(9):1590–1596. doi:10.1093/ntr/ntab030.
Keller-Hamilton B, Alalwan MA, Curran H, et al. Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study. Addiction. 2024;119(3):464–475. doi:10.1111/add.16355.
Jackson JM, Weke A, Holliday R. Nicotine pouches: a review for the dental team. Br Dent J. 2023;235(8):643–646. doi:10.1038/s41415-023-6383-7.
Vogel EA, Barrington-Trimis JL, Kechter A, et al. Differences in Young Adults’ Perceptions of and Willingness to Use Nicotine Pouches by Tobacco Use Status. Int J Environ Res Public Health. 2022;19(5):2685. doi:10.3390/ijerph19052685.
Robichaud MO, Seidenberg AB, Byron MJ. Tobacco companies introduce ‘tobacco-free’ nicotine pouches. Tob Control. 2019;29(e1):e145-e146. doi:10.1136/tobaccocontrol-2019-055321.
Patel M, Kierstead EC, Kreslake J, et al. Patterns of oral nicotine pouch use among U.S. adolescents and young adults. Prev Med Rep. 2023;34:102239. doi:10.1016/j.pmedr.2023.102239.
Azzopardi D, Ebajemito J, McEwan M, et al. A randomised study to assess the nicotine pharmacokinetics of an oral nicotine pouch and two nicotine replacement therapy products. Sci Rep. 2022;12(1):6949. doi:10.1038/s41598-022-10544-x.
Snuzzer Poland. (access: 2024.05.08).
WHO. Global Caner Observatory. Cancer Today. (access: 2024.05.08).
UK Government. Nicotine vaping in England: 2022 evidence update summary. (access: 2024.05.08).
Kramer RD, Park-Lee E, Marynak KL, et al. Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021. Nicotine Tob Res. 2023;25(9):1610–1613. doi:10.1093/ntr/ntad080.
Berger P, Luckmann T. The social construction of reality. In: Longhofer W, Winchester D, editor. Social theory re-wired. Routledge; 2016. p. 110–122.
Dowd AN, Thrul J, Czaplicki L, et al. A Cross-Sectional Survey on Oral Nicotine Pouches: Characterizing Use-Motives, Topography, Dependence Levels, and Adverse Events. Nicotine Tob Res. 2024;26(2):245–249. doi:10.1093/ntr/ntad179.
Mallock-Ohnesorg N, Rinaldi S, Malke S, et al. Oral nicotine pouches with an aftertaste? Part 1: screening and initial toxicological assessment of flavorings and other ingredients. Arch Toxicol. 2023;97:2357–2369. doi:10.1007/s00204-023-03538-9.
Lee PN. Health risks related to dual use of cigarettes and snus – a systematic review. Regul Toxicol Pharmacol. 2014;69(1):125–34. doi:10.1016/j.yrtph.2013.10.007.
Wittenberg RE, Wolfman SL, De Biasi M, et al. Nicotinic acetylcholine receptors and nicotine addiction: A brief introduction. Neuropharmacology. 2020;177:108256. doi:10.1016/j.neuropharm.2020.108256.
Le Foll B, Piper ME, Fowler CD, et al. Tobacco and nicotine use. Nat Rev Dis Primers. 2022;8(1):19. doi:10.1038/s41572-022-00346-w.
Sansone L, Milani F, Fabrizi R, et al. Nicotine: From Discovery to Biological Effects. Int J Mol Sci. 2023;24(19): 14570. doi:10.3390/ijms241914570.
Grando SA. Connections of nicotine to cancer. Nat Rev Cancer. 2014;14(6): 419–29. doi:10.1038/nrc3725.
Hartmann-Boyce J, Chepkin SC, Ye W, et al. Nicotine replacement therapy versus control for smoking cessation. Cochrane Database Syst Rev. 2018;5(5):CD000146. doi:10.1002/14651858.CD000146.pub5.
Szymańska JA, Frydrych B, Bruchajzer E. Nikotyna. Dokumentacja dopuszczalnych wielkości narażenia zawodowego. Podstawy i Metody Oceny Środowiska Pracy. 2007;2(52):121–154.
McEwan M, Azzopardi D, Gale N, et al. A Randomised Study to Investigate the Nicotine Pharmacokinetics of Oral Nicotine Pouches and a Combustible Cigarette. Eur J Drug Metab Pharmacokinet. 2022;47(2):211–221. doi:10.1007/s13318-021-00742-9.
Struciński P, Góralczyk K, Czaja K, et al. Ocena ryzyka związana z narażeniem na pozostałości pestycydów w żywności pochodzenia roślinnego na etapie rejestracji środka ochrony roślin. Rocz Panstw Zakl Hig. 2006;57(4):303–315.
European Food Safety Authority. Potential risks for public health due to the presence of nicotine in wild mushrooms. EFSA Journal. 2009;7(5):RN-286.
Lunell E, Fagerström K, Hughes J, et al. Pharmacokinetic Comparison of a Novel Non-tobacco-Based Nicotine Pouch (ZYN) With Conventional, Tobacco-Based Swedish Snus and American Moist Snuff. Nicotine Tob Res. 2020;22(10):1757–1763. doi:10.1093/ntr/ntaa068.
Benowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. Trends Cardiovasc Med. 2016;26(6):515–23. doi:10.1016/j.tcm.2016.03.001.
Shaikh SB, Tung WC, Pang C, et al. Flavor Classification/Categorization and Differential Toxicity of Oral Nicotine Pouches (ONPs) in Oral Gingival Epithelial Cells and Bronchial Epithelial Cells. Toxics. 2022;10(11):660. doi:10.3390/toxics10110660.
Mills EJ, Wu P, Lockhart I, et al. Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals. Tob Induc Dis. 2010;8(1):8. doi:10.1186/1617-9625-8-8.
Chaffee BW, Couch ET, Vora MV, et al. Oral and periodontal implications of tobacco and nicotine products. Periodontol 2000. 2021;87(1): 241–253. doi:10.1111/prd.12395.
Deery C. What are the health impacts of nicotine and tobacco products on young people? Evid Based Dent. 2023;24(4):159–160. doi:10.1038/s41432-023-00945-w.
Leslie FM. Unique, long-term effects of nicotine on adolescent brain. Pharmacol Biochem Behav, 2020;197:173010. doi:10.1016/j.pbb.2020.173010.
Myszko J, Woike-Reguła E. Kancelaria prawna SK&S. Legal Alert. Kodeks branżowy woreczków nikotynowych opublikowany. (access: 2024.05.08).
Journals System - logo
Scroll to top