The potential public-health benefits of nicotine pouches depend partly on how they are used. For adults who smoke, replacing cigarettes completely with a non-combustible product may reduce exposure to many substances associated with smoking-related disease. Using nicotine pouches while continuing to smoke, however, presents a different question.
A 2026 analysis published in Nicotine & Tobacco Research examines differences in nicotine and metal biomarkers among adults who smoke cigarettes, use nicotine pouches exclusively or use both products.
The findings suggest that dual use may not produce the same exposure reductions observed among exclusive nicotine pouch users.
What the Researchers Examined
Researchers analysed data from the US Population Assessment of Tobacco and Health (PATH) Study, comparing adults across different patterns of nicotine and tobacco product use. The analysis examined urinary nicotine metabolites and selected metals, including lead and cadmium.
The researchers found that exclusive nicotine pouch users generally had lower levels of several measured biomarkers than people who smoked cigarettes or used both products. By contrast, biomarker levels among dual users were broadly comparable to those observed among exclusive cigarette smokers for the outcomes examined.
The authors concluded that partial switching may not significantly reduce exposure to certain harmful constituents.
Why Complete Switching Matters
Cigarette smoking exposes users to numerous toxicants produced or released during tobacco combustion. Nicotine pouches do not involve combustion, which creates an important difference in exposure. However, when a person continues smoking cigarettes while using nicotine pouches, exposure from smoking remains.
The extent of any reduction will depend on how many cigarettes are displaced, the frequency of continued smoking and the substances being measured. This helps explain why complete switching is an important outcome in tobacco harm-reduction research. A decline in cigarette consumption may represent behavioural progress for some individuals, but it should not automatically be interpreted as a proportional reduction in toxicant exposure or disease risk.
What Biomarkers Can Tell Us
Biomarkers provide objective information about exposure to particular substances. They can help researchers move beyond self-reported product use and examine whether changes in behaviour are associated with measurable differences in exposure. However, biomarkers do not answer every health question.
Lower levels of a particular substance do not necessarily establish a corresponding reduction in long-term disease risk. Conversely, the absence of a statistically significant difference in a small study does not prove that two patterns of use are identical. The 2026 analysis focused on selected nicotine metabolites and metals. It did not comprehensively measure every toxicant associated with smoking.
Its findings should therefore be interpreted within the limits of the substances and populations examined.
Important Research Limitations
The analysis was observational, meaning it cannot establish that a particular pattern of nicotine pouch use caused the differences in biomarker levels. Product use was also self-reported, introducing the possibility of misclassification.
Differences in smoking intensity, duration of use and other individual characteristics may influence the results. Further longitudinal studies are needed to determine how exposure changes when adults move from exclusive smoking to dual use and, potentially, to exclusive nicotine pouch use.
Research should also examine whether dual use is temporary or sustained, since these patterns may have different implications for public health.
Implications for Harm-Reduction Policy
The findings underline the importance of distinguishing between product availability, product adoption and complete smoking substitution. A non-combustible nicotine product may have a substantially different toxicant profile from cigarettes, but population-level benefits will depend on how consumers use it.
For policymakers, this means evaluating actual changes in smoking behaviour rather than assuming that increased nicotine pouch use necessarily translates into reduced smoking-related harm.
Research and surveillance systems should distinguish exclusive smoking, exclusive nicotine pouch use, dual use and complete nicotine cessation. Such distinctions can help identify whether policies are supporting meaningful changes in exposure while also monitoring nicotine uptake among people who previously did not use nicotine.
Measuring Outcomes That Matter
The emerging evidence suggests that exclusive nicotine pouch use and continued cigarette smoking should not be treated as equivalent exposure patterns. At the same time, the benefits of partial substitution remain uncertain and require more detailed investigation.
For GINN, the central lesson is that regulatory assessments should consider both product characteristics and actual patterns of use. Understanding whether adults reduce, replace or continue smoking is essential to evaluating the public-health implications of novel nicotine products.
As the evidence develops, complete switching, sustained smoking abstinence and changes in toxicant exposure should remain important outcomes in research and policy evaluation.
Source
Lee and colleagues, Comparisons of nicotine metabolites and metal biomarkers by nicotine pouch use and cigarette smoking among US adults, 2022–2023, Nicotine & Tobacco Research, published 31 July 2026. https://academic.oup.com/ntr/advance-article/doi/10.1093/ntr/ntag173/8748287
