Oral nicotine pouches studied as a tool to quit smoking

In ongoing efforts to pinpoint the best evidence-based ways to quit smoking, a University of Massachusetts Amherst public health researcher has turned her attention to a tobacco-free product gaining in popularity across the country—oral nicotine pouches.

In the first Cochrane review on the topic, the evidence suggests that switching to oral nicotine pouches from smoking reduces exposure to harmful substances, “which is what we would expect to find,” says senior author Jamie Hartmann-Boyce, assistant professor of health policy and management at the School of Public Health and Health Sciences and an editor for Cochrane, the global health research nonprofit based in the United Kingdom.

Because the Cochrane team only found four small studies that were appropriate for their review, the evidence is not yet clear on whether oral nicotine pouches can help people quit smoking or vaping. But the foundation now exists for Hartmann-Boyce and team to continue their investigation. Their ongoing Cochrane reviews have revealed the best evidence-based ways to quit both vaping and smoking.

“Other nicotine products, like patches, gums, and nicotine vapes, are definitely beneficial for helping people quit smoking,” says Hartmann-Boyce, a leader in tobacco health policy and management in the U.S. “We knew that we weren’t going to have that many studies of pouches in this review when we published the first time, but we also know there are loads in the pipeline, and we hope to regularly update this as those new studies come out. We’ve given ourselves a platform to collect that data and integrate it quicker than we would have been able to before.”

About the size of a tea bag, oral nicotine pouches contain nicotine powder and flavorings, but no tobacco leaf. The pouches are marketed as a smokeless alternative to tobacco products and occasionally as a way to reduce or quit smoking.

Unlike nicotine gum, patches, lozenges, nasal sprays and inhalers, the nicotine pouches are not FDA-approved smoking cessation aids. But earlier this year, the FDA approved the marketing of 20 Zyn nicotine pouches in the U.S., concluding that the evidence showed it offered “greater benefits to population health than risks.”

It was the first oral nicotine pouch to be so approved in the U.S., a significant FDA decision, Hartmann-Boyce notes. “An inherent argument behind the decision for these new products to enter the market is that they have the potential to move people away from smoking,” she says.

“From an academic perspective, one of the most interesting things about oral nicotine pouches is that for a long time, we have been promoting nicotine replacement therapies, like patches and gums, to help people quit smoking. The World Health Organization lists them as an essential medicine. They are a critical tool within public health, and it’s currently difficult to come up with a compelling, detailed description of why we think the risks of oral nicotine pouches—if well-regulated—would be meaningfully different than nicotine replacement therapy to an individual user.”

The pouches are placed between the lip and gum, which allows nicotine to be absorbed through the mouth. They appear similar to snus, a Swedish oral pouch filled with ground-up tobacco leaves and flavorings. The user doesn’t need to spit when using either oral nicotine pouches or snus.

“So in the same way vaping is different from smoking, because it doesn’t involve tobacco leaf, oral nicotine pouches are different from snus,” Hartmann-Boyce says. “Snus isn’t going to increase your risk of lung cancer, but it is going to increase your risk of mouth cancer, throat cancer and tongue cancer because of the tobacco leaf and chemicals in it.”

She adds that rates of smoking and smoking-related disease and death have gone down significantly in the countries that allow snus. “So, there’s certainly a harm-reduction element in thinking about non-combusted tobacco and nicotine products.”

Hartmann-Boyce notes that for people who don’t use any nicotine products, it’s best not to start. Nicotine is highly addictive, and the risks of new products are not yet well understood, particularly in people who don’t have a history of smoking.

“But it is rational, if you are someone who is addicted to smoking, to switch to using an alternative nicotine product if you can’t quit completely,” she says.