As a dental hygiene student, I expected quick, straightforward answers when I asked patients about their tobacco use. Many patients told me, “I don’t smoke.” Then later in the appointment they would casually mention using nicotine pouches. This was surprising at first, but over time I noticed a trend. Even in social settings, I saw friends discreetly popping in nicotine pouches with little thought or discussion.
Nicotine pouches are rapidly gaining popularity, especially among teens and young adults. Social media platforms are flooded with videos and posts that spread awareness of these products. Most of our time in dental hygiene training is spent learning about the effects of traditional tobacco products on the oral cavity. As nicotine pouches become mainstream, it’s time to expand our focus beyond cigarettes and vapes. What exactly are nicotine pouches doing to the oral cavity, and what do we need to know to stay ahead?
What is a nicotine pouch?
Nicotine pouches are a recent addition to the nicotine product market, gaining widespread availability starting in 2019 in Europe, the United States, and Japan.1 They’re small, discreet, smokeless alternatives to traditional tobacco products. Each nicotine pouch typically contains between 1.29 mg and 6.11 mg of nicotine, although some are now being marketed with levels as high as 11 mg per pouch.
These pouches are typically made from plant fibers, nicotine salts, and flavoring agents, offering individuals an “easy-to-use” form of nicotine delivery.2 Additionally, many nicotine pouches include food-grade additives and flavorings such as mint, coffee, and various fruit flavors aimed at appealing to a wide range of consumers, particularly young users.
Most of these pouches use artificial sweeteners instead of sugar, which may lower the risk of dental caries.3 However, the absence of sugar doesn’t eliminate oral health concerns, as keeping the pouches in the same spot in the mouth for extended periods can cause localized tissue irritation, mucosal changes, and inflammation.
Unlike traditional smokeless tobacco products, these alternatives eliminate the need to spit, making them more socially acceptable and attractive for those looking for a cleaner option.4 Marketed as a more convenient and “lower risk” choice with a reduced potential for misuse, these products are rapidly gaining popularity among tobacco users, and dental professionals should be mindful of this.
One popular brand is Zyn, a Swedish nicotine pouch available in nicotine strengths ranging from 3 mg to 8 mg per pouch.2 Users place the pouch between their gum and lip, and it gradually releases nicotine into their bloodstream.5 Another brand is On!, which offers nicotine strength from 1.5 mg to 8 mg.6 Lastly, there’s Lucy, which provides 4 mg, 8 mg, and 12 mg nicotine strength options. All three brands offer a wide range of flavors.
Adverse effects of nicotine pouches
Though nicotine pouches are marketed as a safer alternative to smoking or chewing tobacco, they still carry significant risks for oral health.7 One study, which compared Zyn nicotine pouches to traditional Swedish and smokeless tobacco products, found that even the lower amounts of nicotine in Zyn pouches could deliver nicotine to the bloodstream as effectively as other smokeless products. Participants in the study reported mild side effects, such as dry mouth, after using the pouches. These effects are concerning, as dry mouth can increase the risk of tooth decay, periodontal disease, and other oral health issues.
A case series investigating the effects of nicotine pouches on oral health highlighted the potential for adverse outcomes.8 The study examined five users, focusing on oral health and conducting histopathological analyses. In each case, users developed white lesions in their mouths, usually near the upper lip and frenum where the pouches were placed.
Histopathological analysis revealed inflammation, tissue thickening, changes in the oral mucosa, and parakeratosis, a condition in abnormal growth of cells in tissue. These findings suggested that nicotine pouch use can directly impact oral tissues, potentially leading to long-term damage.
A systematic review of the potential oral health risks of nicotine pouches, especially among young users, analyzed three studies involving 190 participants.9 The researchers discovered that frequent use of nicotine pouches was linked to several oral health issues, including mucosal changes (white lesions), dry mouth, soreness, and gum blisters.
These problems were commonly observed among regular and long-term users. The review noted concerns that nicotine pouch use might contribute to inflammation and increase the risk of oral cancer, although the evidence was limited and the studies involved had a high risk of bias.
Our call to action
As nicotine pouches rise in popularity, particularly among adolescents and young adults, there is a pressing need for robust, long-term research. While current studies highlight oral mucosal changes, inflammation, and dry mouth, the full extent of systemic and long-term oral health effects remain unclear, especially regarding potential links to oral cancer and chronic tissue damage.
As key players in oral health, dental hygienists are essential in identifying early signs of damage caused by new nicotine products. We must stay up to date, ask the right questions during patient assessments, and include nicotine pouches in our patient education and tobacco cessation conversations. By doing this, we can empower patients to make more informed choices and potentially prevent long-term damage.
References
1. Robichaud MO, Seidenberg AB, Byron MJ. Tobacco companies introduce 'tobacco-free' nicotine pouches. Tob Control. 2020;29:145-146. doi:10.1136/tobaccocontrol-2019-055321
2. Ingredients, how to use, freshness, and more. ZYN. https://us.zyn.com/questions/
3. Patwardhan S, Fagerstrom K. The new nicotine pouch category: a tobacco harm reduction tool? Nicotine Tob Res. 2022;24: 623-625. doi:10.1093/ntr/ntab198
4. Liu J, Rensch J, Wang J, Jin ., Vansickel A, Edmiston J, Sarkar M. Nicotine pharmacokinetics and subjective responses after using nicotine pouches with different nicotine levels compared to combustible cigarettes and moist smokeless tobacco in adult tobacco users. Psychopharmacology Berl. 2022;239(9):2863-2873. doi:10.1007/s00213-022-06172-y
5. On! nicotine pouches. On nicotine. https://www.onnicotine.com/
6. Lucy US nicotine pouches. https://lucy.co/products/pouchesf?variant=41980094742714&selling_plan=711688378#
7. Lunell E, Fagerström K, Hughes J, Pendrill R. 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
8. Miluna-Meldere S, Vanka SA, Skadins I, Kroica J, Sperga M, Rostoka D. Correction: oral mucosal changes caused by nicotine pouches: case series. Diagnos Path. 2025;20(1):12. doi:10.1186/s13000-025-01606-5
9. Rungraungrayabkul, D., Gaewkhiew, P., Vichayanrat, T., Shrestha, B., & Buajeeb, W. (2024). What is the impact of nicotine pouches on oral health: a systematic review. BMC Oral Health, 24(1), 1–10. https://doi.org/10.1186/s12903-024-04598-8
