The benefits and risks of oral nicotine pouches: Implications for public health

The sale of non-tobacco oral products, particularly oral nicotine pouches, has recently increased in the U.S. and around the world, particularly among young adults. Such pouches provide the pharmacological effects of relatively pure nicotine without the risks of combusted or non-combusted tobacco products. The more important potential benefit for public health would be if people who smoke switched to ONP. The effectiveness of ONP for smoking cessation is not yet established, but clinical trials are ongoing. Other benefits reported by users of ONP include pleasure, mood modulation, cognitive enhancement (use at work or when studying), sports (golf, baseball – to promote concentration and focus), and partying (along with alcohol in bars where smoking is not permitted). It is clear that many people like to use nicotine and would like to continue its use in an ongoing way. The primary established risk of ONP is addictive use. In Scandinavia, compulsive daily use of snus is common among adolescent males, and this pattern is also observed in some U.S. users. There will likely be some risk of nicotine pouch use during pregnancy. Other potential harms of nicotine, including cardiovascular disease, impairment of adolescent brain development, oral disease, infectious disease risk and cancer, will be discussed, based on what is known about the harms of nicotine in Swedish snus. The overall impact of ONP on public health in the short term will likely depend on the balance of benefit in the promotion of smoking cessation vs the risks of addictive use, particularly among youth. Whether there will be public acceptance of ONP use once smoking is eliminated, based on the perceived cognitive and other benefits, remains to be seen.