Nicotine pouches: Harm reduction or a new generation of nicotine users?

My preteen son came home from summer day camp and told me his counselor had given the group two rules: “Be on time” and “Don’t ask about my mints.” Naturally, he was very curious to know what these mints were and why they were so important.

The “mints” were nicotine pouches: small, discreet sachets tucked between the upper lip and gum, where saliva releases nicotine for absorption by the oral mucosa. Unlike traditional smokeless tobacco products, such as chewing tobacco, nicotine pouches contain no tobacco leaf; their nicotine is either extracted from tobacco or produced synthetically. They may also contain flavorings, bulking agents, humectants, and pH-altering agents to facilitate absorption. Because they produce no smoke, vapor, or odor and require no spitting, they can be used almost anywhere, often without anyone noticing.[1]

In Canada, because pouches do not contain tobacco and are considered nicotine replacement therapy, they fall under the Food and Drugs Act rather than the Tobacco and Vaping Products Act, a regulatory distinction that Health Canada has recognized it may need to change.[2] Mint-flavored Zonnic (a product of Imperial Tobacco) can be legally sold in Canada by pharmacies to people 18 years of age and older for nicotine replacement therapy, and it must have a natural product number. Yet, unauthorized nicotine pouches are readily available online and can be found in convenience stores and gas stations. These grey-market products may contain higher concentrations of nicotine, as well as flavors and additional ingredients not on the label.[3]

As tobacco use among young people continues to decline, nicotine pouches are moving in the opposite direction.[4] In the United States, the 2025 National Youth Tobacco Survey found that overall youth tobacco use had fallen to 7.2%.[4] E-cigarettes remained the most commonly used product (5.2%), followed by nicotine pouches, which had more than doubled in prevalence over the past 4 years (0.8% in 2021 vs 1.7% in 2025).

JAMA published similarly concerning numbers from the Monitoring the Future study of US students in grades 10 and 12.[5] Between 2023 and 2024, past-30-day use of nicotine pouches doubled from 1.3% to 2.6%, while lifetime use rose from 3% to 5.4%. Despite declining e-cigarette use, dual use of e-cigarettes and pouches increased.[5] Canadian data tell a similar story. In a survey of nearly 14 000 Quebec secondary-school students participating in the COMPASS study, 2.6% reported using nicotine pouches in the past month, and nearly one-quarter were unsure about the health risks.[6]

The appeal to youth is not difficult to understand. Nicotine pouches are discreet, easy to conceal, and available in appealing flavors, and they can be used without obvious signs of smoking or vaping. But while they may represent a less harmful source of nicotine for adults who would otherwise smoke, they are not harmless—and nicotine is highly addictive.[7]

The World Health Organization published a report in May 2026 examining how nicotine pouches are marketed and how countries might regulate them.[8] A JAMA article captured the WHO’s concern in a commentary: “Fruity flavours, festivals, and F1—WHO report reveals how nicotine pouches hook consumers.”[7] Around the same time, in June 2026, the US Food and Drug Administration authorized reduced-risk marketing claims for some nicotine pouches. Can both perspectives be true? Can nicotine pouches be a less harmful alternative for adults who smoke while simultaneously being perilously attractive to young people who might never have used nicotine otherwise?

The evidence that nicotine pouches help people quit smoking is surprisingly limited. A 2025 Cochrane review included only four small studies and concluded that there was “very uncertain” evidence that nicotine pouches led to slightly higher smoking abstinence compared with no intervention.[9] Evidence about long-term health effects is also limited. The American Heart Association cautioned that smokeless oral nicotine products may negatively affect some biomarkers of cardiovascular disease risk and could increase the risk of oral cancers.[10]

This leaves physicians navigating a nuanced but important distinction. For an adult who smokes and cannot quit, switching from combustible tobacco to nicotine pouches may reduce exposure to harmful chemicals. But for a young person who does not use nicotine, we certainly would not recommend starting. The individual-level harm reduction message and the population-level prevention message are not contradictory, but they can become confused.

Perhaps this is a lesson we should have learned from vaping: “reduced risk” does not mean “safe.” As physicians, we may be well positioned to counsel patients on this distinction. But as a parent, making nicotine tastier, quieter, and easier to conceal scares me. I will definitely be asking about the “mints.”
—Caitlin Dunne, MD, FRCSC

References

1.    Piasecki TM, Piper ME, Kathuria H. Nicotine pouches. JAMA. 30 July 2026. Accessed 11 August 2026. https://doi.org/10.1001/jama.2026.11806.

2.    Health Canada. Notice of intent to address risks of youth appeal and access to nicotine replacement therapies. Modified 21 March 2024. Accessed 11 August 2026. www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/notice-intent-address-risks-youth-appeal-access-nicotine-replacement-therapies.html.

3.    Government of Canada. Only use authorized nicotine pouches as directed, and do not use unauthorized nicotine pouches. Public advisory. Updated 21 August 2025. Accessed 11 August 2026. https://recalls-rappels.canada.ca/en/alert-recall/only-use-authorized-nicotine-pouches-directed-and-do-not-use-unauthorized-nicotine.

4.    Glantz SA. Tobacco use among middle and high school students: 2025 National Youth Tobacco Survey. Pediatrics 2026. https://doi.org/10.1542/peds.2026-077008.

5.    Han D-H, Harlow AF, Miech RA, et al. Nicotine pouch and e-cigarette use and co-use among US youths in 2023 and 2024. JAMA Netw Open 2025;8:e256739. https://doi.org/10.1001/jamanetworkopen.2025.6739.

6.    Battista K, Piché-Ayotte M, Haddad S. Emerging use of oral nicotine pouches among Canadian adolescents: Findings from the COMPASS-Quebec study. Can J Public Health 2026;117:391-401. https://doi.org/10.17269/s41997-025-01100-x.

7.    Anderer S. Fruity flavors, festivals, and F1—WHO report reveals how nicotine pouches hook consumers. JAMA 2026;335:2097-2098. https://doi.org/10.1001/jama.2026.9536.

8.    World Health Organization. Exposing marketing tactics and strategies driving the global growth of nicotine pouches. 15 May 2026. Accessed 11 August 2026. www.who.int/publications/i/item/9789240114920.

9.    Hartmann-Boyce J, Tattan-Birch H, Brown J, et al. Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products. Cochrane Database Syst Rev 2025;(10):CD016220. https://doi.org/10.1002/14651858.CD016220.pub2.

10.    Dennison Himmelfarb CR, Benowitz NL, Blank MD, et al. Impact of smokeless oral nicotine products on cardiovascular disease: Implications for policy, prevention, and treatment: A policy statement from the American Heart Association. 2025;151:e1-e21. https://doi.org/10.1161/CIR.0000000000001293.