A new trend with a dark side: smoke- and tobacco-free nicotine

Oral nicotine pouches without tobacco are already very popular in the USA, especially among young people. What do doctors need to know?

One of the fastest growing nicotine products on the market

The possible effects on oral health are still unknown

Dr Joseph Nemeth, a world-renowned periodontist who has pioneered several advanced treatments in use today, sees a potential risk of gum changes from his 30-plus years of experience. He warns that if the pouches are repeatedly placed in the same area of the gums, it can cause irritation to the tissue. With chewing tobacco, he has seen cases where cancer has developed at these sites. Currently, there is no data on whether white nicotine pouches also pose this risk, but it could promote gum recession and gum recession can also mean bone recession, according to Dr Nemeth.4 This would definitely need to be thoroughly investigated, because a person with poor oral health is not healthy overall.

It is not known what role nicotine plays as a potential carcinogen.5 Nicotine replacement products have been associated with the development of oral diseases, such as hyperkeratotic lesions.5 Nicotine also has effects on immune cells and influences inflammatory responses to microbial challenges. It is also suspected of increasing reactive oxygen species, cytokines and growth factors, as well as disrupting the microbiome and miRNA expression.2 In addition to nicotine, the pouches' market success is also due to their enticing flavours. Unfortunately, studies show that the flavourings contained in the pouches damage the innate immune response of the gums and increase the penetration of nitrosamines.2

What other ingredients are there?

Nicotine pouches are available in different strengths and many flavours. Dr Nemeth emphasises the extremely rapid transfer across the oral mucosa directly into the bloodstream, without the usual breakdown or reduction. Since nicotine is one of the most addictive substances and the pouches induce a strong nicotine kick (more effective than smoking), the potential for addiction and habit formation should not be underestimated.4 Nicotine causes the brain to release large amounts of dopamine, which produces euphoria and makes users dependent.6

The pre-filled pouches contain not only nicotine but also flavourings and fillers that dissolve in the mouth. ‘Traces of tobacco-specific nitrosamines (TSNAs) and toxic chromium were detected in the pouch products. This raises concerns for general and periodontal health,’ summarises a review in a renowned dental journal.2 Even pouches declared as “unflavoured” contain relevant amounts of controversial artificial sweeteners, such as acesulfame K, which is suspected of being associated with an increased risk of cancer and diabetes as well as other long-term effects.7,8 In the quantities they contain, these artificial sweeteners increase nicotine consumption. Some manufacturers add more sweetener to pouches with higher nicotine strengths.9

Experts concerned about rapidly growing number of young consumers

Although the pouches are officially not intended for minors, this appears to be the fastest growing market in some countries.10 Especially teenagers, who often have not smoked before, and report that they use these products excessively on a daily basis, as well as corresponding videos on social media with millions of views, should be a clear indication that education and caution are needed here.1 According to the National Youth Tobacco Survey 2023, approximately 420,000 middle and high school students in the United States alone reported using Zyn (one of the best-selling white nicotine pouches) in the last 30 days.3 ‘The first time you take one, it's probably going to be awful,’ describes one student. ‘It tastes bad, and a lot of people I know have gotten ‘nicotine sick’ and have been throwing up. But once you get used to the taste, it feels like you're floating through the clouds."3

Of course, it is beneficial for the respiratory tract if nothing is inhaled (smoked or vaped), but the marketing messages ‘smoke and tobacco free’ could encourage the idea, especially among adolescents, that oral pouches with potent synthetic nicotine pose little or no health risk. However, there is little evidence to justify this perception of safety.2 The absence of smoke and tobacco odour also makes the small pouches more discreet and easier to use without being noticed, and they can be taken into areas where smoking is prohibited.1

Users like the ‘high’ that gives them a feeling of increased alertness and attention, but this is short-lived. Over time, tolerance to nicotine may develop, so that more and more is needed to achieve this feeling again.1,11

‘Policymakers should ensure [...] that a new wave of nicotine addiction does not emerge among young people,’ urge the authors of the above-mentioned review.2 The fact that the products are particularly appealing to teenagers and young adult non-smokers is also due to the fact that the advertising is often young and colourful and the cans, with flavours such as Tropic Breeze and Berry Frost, which are sold in many countries in grocery stores, look like chewing gum or sweets.10

Another smoking substitute that is highly addictive?

White nicotine pouches are often touted as an ‘easy’ way to quit smoking.1 This is also viewed critically by various experts. Hayley Nelson, PhD, neuroscientist and founder of the Academy of Cognitive and Behavioural Neuroscience, says: ‘The primary function remains the same: to satisfy nicotine cravings, which can lead to dependence, especially in young, developing brains.’ For teenagers, it is often not a stop, but the start of nicotine consumption, and it is well known that nicotine (including e-cigarettes) is particularly dangerous during adolescence due to its effect on key receptors, and increases the likelihood that these people will later turn to nicotine and cigarettes.1,6 For young people, as little as 5 mg of nicotine per day is enough to develop an addiction (this is roughly the amount of nicotine in a quarter of an e-cigarette pod).6

But developing an addiction-prone brain is not the only issue. The brain continues to develop well into our mid-20s. Nicotine abuse during adolescence can interfere with the formation of neural circuits and has been linked to increased rates of attention disorders, learning difficulties, depression, anxiety and increased stress levels, among other things.1,6,10

Conclusion

The possible long-term health consequences are not yet sufficiently known. Parents and adolescents should be especially mindful.1 Full-flavoured oral nicotine pouches increase the risk of dual or poly-tobacco use in young adults, which could compound harmful effects. Given the increasing number of users, studies are needed to examine the effects on systemic and periodontal health.2

Sources
  1. Teens Are Getting Hooked on Zyn With Help From Social Media ‘Zynfluencers’. Parents https://www.parents.com/what-is-zyn-and-why-are-teens-using-it-8599249.
  2. Ye, D. & Rahman, I. Emerging Oral Nicotine Products and Periodontal Diseases. Int J Dent 2023, 9437475 (2023).
  3. Detmer, A. What the heck is a Zyn? The Harvard-Westlake Chronicle https://hwchronicle.com/109127/features/what-the-heck-is-a-zyn/.
  4. Joseph R Nemeth DDS. ZYN - Oral Health Risks and Benefits! Reviewed by Dr. Nemeth. https://www.youtube.com/watch?v=e4CgMpGZbJ0 (2024).
  5. Tebbutt, J., Khan, Z. & Ariyaratnam, R. A case report of oral nicotine-associated keratosis and a review of oral mucosal changes in tobacco and similar products. Br Dent J 228, 757–760 (2020).
  6. Nicotine and the young brain. https://truthinitiative.org/research-resources/harmful-effects-tobacco/nicotine-and-young-brain.
  7. Debras, C. et al. Artificial sweeteners and cancer risk: Results from the NutriNet-Santé population-based cohort study. PLOS Medicine 19, e1003950 (2022).
  8. Debras, C. et al. Artificial Sweeteners and Risk of Type 2 Diabetes in the Prospective NutriNet-Santé Cohort. Diabetes Care 46, 1681–1690 (2023).
  9. Jabba, S. V., Silinski, P., Yang, A. Y., Ouyang, W. & Jordt, S. E. Artificial Sweeteners in US-Marketed Oral Nicotine Pouch Products: Correlation with Nicotine Contents and Effects on Product Preference. bioRxiv 2024.01.26.577472 (2024) doi:10.1101/2024.01.26.577472.
  10. Gallant, I. Despite the harm, young people are using nicotine pouches. Experts say it’s giving them déjà vu. CBC Radio https://www.cbc.ca/radio/whitecoat/nicotine-pouches-youth-1.7158053 (2024).
  11. Why People Start Using Tobacco, and Why It’s Hard to Stop. https://www.cancer.org/cancer/risk-prevention/tobacco/why-people-start-using-tobacco.html.