Examining the Scientific Case for Tobacco Harm Reduction
As nicotine pouches become an increasingly prominent feature of nicotine policy discussions worldwide, debate often moves faster than the science itself. Regulators, public health stakeholders, researchers, and policymakers are grappling with important questions about risk, cessation, consumer behaviour, and appropriate regulatory frameworks.
While long-term epidemiological evidence is still developing, a growing body of peer-reviewed research has begun to provide important insights into the role nicotine pouches may play within tobacco harm reduction strategies.
The emerging evidence does not suggest that nicotine pouches are risk-free. However, it increasingly indicates that they differ substantially from combustible cigarettes in terms of toxicant exposure and may offer a lower-risk alternative for adult smokers who are unable or unwilling to quit nicotine entirely.
Understanding Nicotine Pouches
Nicotine pouches are small oral pouches placed between the gum and lip. They deliver pharmaceutical-grade nicotine through the oral mucosa but contain no tobacco leaf and involve no combustion.
Unlike cigarettes, nicotine pouches do not produce smoke, tar, carbon monoxide, or the thousands of combustion-related toxicants associated with smoking-related disease.
This distinction is central to the scientific discussion surrounding nicotine pouches and explains why researchers increasingly evaluate them through a harm reduction lens rather than solely through traditional tobacco control frameworks.
Toxicant Exposure and Relative Risk
One of the clearest findings emerging from the scientific literature is the significant reduction in toxicant exposure associated with nicotine pouches compared with combustible cigarettes.
A 2025 biomarker study found that adults who switched from smoking to nicotine pouches experienced reductions in biomarkers of exposure ranging from 42% to 96% within just seven days of switching. Importantly, these reductions were observed across multiple harmful constituents associated with cigarette smoke.
Research has also demonstrated that exclusive nicotine pouch users exhibit substantially lower levels of tobacco alkaloids, heavy metals, and other toxicants compared with cigarette smokers.
Similarly, toxicological analyses published in 2024 and 2025 have reported that tobacco-specific nitrosamines (TSNAs), among the most important carcinogens associated with tobacco use, are either absent or present at near-undetectable levels in nicotine pouches.
Taken together, these findings suggest that nicotine pouches expose users to substantially fewer harmful substances than combustible tobacco products.
The Polosa, Fagerström and Rodu Analysis
One of the most comprehensive reviews of nicotine pouch science to date was published in 2025 by Riccardo Polosa, Karl Fagerström, and Brad Rodu in Internal and Emergency Medicine.
Their paper, The Emerging Role of Oral Nicotine Pouches in Tobacco Harm Reduction, examined toxicology, user behaviour, regulatory considerations, and potential public health implications.
The authors concluded that nicotine pouches eliminate exposure to the thousands of toxicants produced through tobacco combustion and substantially reduce exposure to carcinogens compared with smoking. They further argued that incorporating nicotine pouches into tobacco harm reduction frameworks represents an important opportunity to reduce smoking-related disease among adults who continue to smoke.
While acknowledging the need for additional long-term research, the paper identified nicotine pouches as a potentially significant addition to the spectrum of lower-risk nicotine products.
What Clinical Studies Show
The clinical evidence surrounding nicotine pouches is still developing, but several studies have produced encouraging findings.
A 2025 pilot randomised controlled trial found that smokers using 4 mg nicotine pouches reduced daily cigarette consumption from approximately 15 cigarettes per day to just over eight cigarettes per day during an eight-week study period. Researchers also reported significant reductions in nicotine dependence scores.
Importantly, no serious adverse events were recorded. Reported side effects were generally mild and included symptoms such as throat irritation, headache, and cough.
These findings suggest that nicotine pouches may support smoking reduction among some adult smokers, although larger and longer-term studies are needed to establish broader population effects.
The Ottawa Heart Institute Systematic Review
In 2025, researchers from the Ottawa Heart Institute published one of the first major systematic reviews examining nicotine pouches and smoking outcomes.
Led by Hassan Mir and Javad Heshmati, the review assessed available clinical studies and concluded that nicotine pouches appear capable of reducing cigarette consumption while being generally well tolerated by users.
The review also found that nicotine pouches produced outcomes broadly comparable to nicotine gum and Swedish snus.
Importantly, researchers did not find evidence that nicotine pouches were superior to established nicotine replacement therapies. Instead, the findings suggested that nicotine pouches may represent an additional option for smokers seeking alternatives to combustible cigarettes.
This distinction is important because tobacco harm reduction is not necessarily about replacing existing cessation tools. It is about expanding the range of options available to smokers with different preferences and behavioural needs.
What the Cochrane Review Found
The most influential evidence review published to date is the 2025 Cochrane Review, Oral Nicotine Pouches for Cessation or Reduction of Use of Other Tobacco or Nicotine Products, led by Jamie Hartmann-Boyce and colleagues.
The review evaluated four randomised controlled trials involving adult smokers.
Researchers found low-certainty evidence that nicotine pouches reduce exposure to harmful toxicants compared with continued smoking. Carbon monoxide exposure and tobacco-specific nitrosamine exposure were lower among nicotine pouch users than among those who continued smoking cigarettes.
No serious adverse events were reported across the studies examined.
The review also concluded that evidence regarding smoking cessation outcomes remains insufficient to support firm conclusions.
This finding has sometimes been misunderstood.
The review did not conclude that nicotine pouches are ineffective. Rather, the authors emphasised that existing studies are too small and too limited to provide definitive answers. Larger independent trials are currently underway and are expected to provide stronger evidence in the coming years.
As Professor Jamie Hartmann-Boyce noted following publication of the review, switching from smoking to lower-risk nicotine products remains a rational option for smokers who cannot quit nicotine entirely.
Real-World Consumer Evidence
Emerging population-level research is also beginning to provide useful insights.
A 2025 study conducted by researchers at Rutgers School of Public Health found that the highest prevalence of nicotine pouch use occurred among adults who had previously used tobacco and had recently quit smoking.
Lead researcher Professor Cristine Delnevo suggested that this pattern is consistent with the possibility that nicotine pouches may be functioning as lower-risk substitutes for combustible tobacco among some adult users.
While observational studies cannot establish causation, these findings align with broader harm reduction hypotheses that individuals may move along a continuum of risk rather than transition directly from smoking to complete nicotine abstinence.
Lessons from Sweden
No discussion of oral nicotine products would be complete without examining Sweden.
Sweden is the first European Union member state to achieve official smoke-free status, defined as smoking prevalence below five percent.
Many researchers have attributed this achievement in part to the widespread adoption of oral nicotine products, particularly snus, which has been used by Swedish consumers for decades.
The Polosa, Fagerström, and Rodu analysis identifies Sweden as an important proof-of-concept example for how lower-risk oral nicotine products may contribute to population-level smoking reduction.
Although nicotine pouches are not identical to snus, they share several characteristics, including oral administration, the absence of combustion, and substantially lower toxicant exposure compared with cigarettes.
For policymakers, Sweden provides an important real-world example of how risk-proportionate approaches may contribute to reducing smoking-related disease.
Looking Ahead
The evidence surrounding nicotine pouches remains incomplete, and important questions about long-term health outcomes continue to require further investigation.
At the same time, the scientific literature increasingly supports several conclusions.
Nicotine pouches expose users to substantially fewer harmful substances than combustible cigarettes. Tobacco-specific carcinogens appear at very low or undetectable levels. Clinical studies suggest nicotine pouches may help some smokers reduce cigarette consumption. Independent reviews have found no serious short-term health harms within available studies.
The strongest current evidence does not support claims that nicotine pouches are harmless. Nor does it support treating nicotine pouches as equivalent to combustible cigarettes.
As research continues to develop, policymakers face an important challenge: ensuring that regulatory frameworks reflect both scientific uncertainty and emerging evidence regarding relative risk.
For tobacco harm reduction advocates, public health stakeholders, and regulators alike, the key question is not whether nicotine pouches are risk-free. It is whether evidence supports their potential role as a lower-risk alternative for adults who would otherwise continue smoking cigarettes.
Endnotes
- Polosa R, Fagerström K, Rodu B. The Emerging Role of Oral Nicotine Pouches in Tobacco Harm Reduction. Internal and Emergency Medicine. 2025. DOI: 10.1007/s11739-025-04237-2.
- Biomarker study examining exposure reductions among adults switching from cigarettes to nicotine pouches, reporting reductions in biomarkers of exposure ranging from 42% to 96% within seven days of switching.
- Mir H, Heshmati J, et al. Nicotine Pouches and Smoking Outcomes: A Systematic Review. Addiction. 2025. Ottawa Heart Institute.
- Delnevo C, et al. Rutgers School of Public Health study examining patterns of nicotine pouch use among former smokers and recent quitters. 2025.
- Hartmann-Boyce J, Tattan-Birch H, Brown J, Shahab L, Goniewicz ML, et al. Oral Nicotine Pouches for Cessation or Reduction of Use of Other Tobacco or Nicotine Products. Cochrane Database of Systematic Reviews. 2025;2. DOI: 10.1002/14651858.CD016220.
- U.S. Food and Drug Administration. Marketing Granted Orders for ZYN Nicotine Pouch Products. January 2025.
- Plataforma para la Reducción del Daño por Tabaquismo (PRDTABAQUISMO). Tobacco Harm Reduction: Objective 2030 – A Smoke-Free Spain. White Paper. 2024.
- Standing Committee on Health and Research in Europe (SCOHRE). Response to Spain’s Public Consultation on Tobacco and Related Products. September 2024.
- Smoke Free Sweden. Report on Spain and Smoke-Free Alternatives. April 2025.
- Tholos Foundation / Dynata. Survey of Nicotine Pouch Users in Spain. 2025.
- EDADES Survey 2024 and associated peer-reviewed commentary on smoking prevalence trends in Spain.
- Science Media Centre expert commentary on the 2025 Cochrane Review of oral nicotine pouches.
- Oral Nicotine Commission. Report on Oral Nicotine Products and Tobacco Harm Reduction. November 2025.
