Major review finds nicotine pouches considerably less toxic than cigarettes

Researchers examining the rapidly growing evidence on the products found lower exposure to several harmful substances among people using pouches instead of cigarettes.

Laboratory studies also suggested substantially lower toxicity than cigarettes, strengthening the evidence for pouches’ potential role in reducing smoking-related harm.

Using the abbreviation for oral nicotine pouches, the authors write: “ONPs are considerably less toxic than cigarettes, but their long-term health impacts remain understudied.”

The review, published in Nicotine & Tobacco Research on 6 September, was led by Nargiz Travis of Georgetown University’s Lombardi Comprehensive Cancer Center. Its authors include tobacco researchers Kenneth Warner, Jamie Hartmann-Boyce and Maciej Goniewicz.

The team searched six databases for research available up to 30 September 2025, identifying 73 additional studies. Together with their earlier review, the evidence base covers 135 studies examining product contents, toxicity, use, perceptions and marketing.

Lower exposure to harmful substances

Nicotine pouches are placed in the mouth and deliver nicotine without burning tobacco or inhaling smoke.

The researchers’ earlier review found that pouches contained fewer harmful or potentially harmful substances, and at lower levels, than traditional tobacco products. The update adds evidence from studies measuring exposure in people.

One analysis of US survey data found that people using only nicotine pouches had lower levels of cadmium, uranium and minor tobacco alkaloids than cigarette smokers.

Their lead levels were also lower than those of smokers and people using vapes, and comparable to people who did not use tobacco.

The study involved a small sample, so its results need cautious interpretation.

An Altria-funded trial also reported improvements in gum inflammation and enamel staining after 24 weeks among smokers who switched to pouches, compared with those who continued smoking.

The authors describe the evidence for short-term health benefits from switching as limited and mainly industry-funded. Some laboratory studies found inflammatory responses and cell damage associated with pouch ingredients, underlining the need to investigate individual formulations.

Early trials show reduced cigarette consumption

Two small pilot trials involving smokers who had no intention of quitting found that pouches reduced cigarette consumption. Their short duration limits what they can tell us about lasting quit success.

In one eight-week pilot trial involving 33 smokers across three groups, participants were assigned to continue smoking, use vapes or use 4mg pouches instead of cigarettes. Among those assigned pouches, cigarette consumption fell by nearly half from a starting average of 15 a day. Only one participant switched completely to pouches.

A separate four-week trial involving 30 smokers found that both 3mg and 6mg pouches reduced cigarette consumption. Two participants, both using the 6mg products, stopped smoking completely.

The researchers write: “Dual use may also reflect a transitional stage to a complete cessation of the initial tobacco product, but, to date, there is insufficient evidence on ONP as a smoking cessation aid.”

In the four-week trial, using pouches alongside cigarettes did not reduce measured levels of tobacco-specific nitrosamines, a group of harmful tobacco compounds, despite the reduction in smoking.

The review calls for independent, well-designed trials and longer-term studies tracking whether people replace cigarettes with pouches or continue using both.

Strength makes a difference

The nicotine delivered by pouches varies considerably between products, with some higher-strength versions producing greater nicotine uptake than cigarettes in adult smokers.

Delivery depends on factors including nicotine content, how quickly it’s released and the proportion in a form readily absorbed through the mouth.

The authors caution against making a single claim about nicotine delivery that applies to every pouch.

Higher nicotine delivery didn’t consistently translate into greater appeal. Studies generally found that smokers rated pouches less positively than cigarettes, suggesting that the sensory and behavioural aspects of smoking also matter.

One study examining higher-strength products found that 20mg and 30mg pouches increased blood pressure and arterial stiffness to levels comparable with the effects of a cigarette. Heart rate also increased with nicotine dose.

Those findings concern immediate effects and don’t establish that pouches carry the same long-term disease risks as smoking. They do, however, reinforce the need to assess different strengths separately.

Growing sales and youth use

The review found that US pouch sales more than tripled between 2021 and 2024. Current use among US adults remained below one per cent in the national surveys covering 2022-2023, with use more common among people already using tobacco or vapes.

The US National Youth Tobacco Survey reported that 1.8 per cent of middle and high school students currently used pouches in 2024, up from 0.8 per cent in 2021.

The authors highlight marketing that stresses flavours, convenience and discreet use, with social media playing a prominent role. They call for closer monitoring of how promotion affects people who have never used tobacco.

The review itself received US public research funding, including from the National Institutes of Health and Food and Drug Administration. Twelve of the 73 additional studies were industry-funded.

The authors didn’t formally assess the risk of bias in each study, a limitation when judging how much confidence to place in individual findings.