Youth “addiction” to nicotine pouches and other smoke-free nicotine products is increasingly invoked as a political shorthand, often without reference to how addiction is actually defined in modern clinical science. This matters, because the DSM-5 framework, the global reference standard for diagnosing substance-related disorders, does not define addiction by frequency of use alone, nor does it treat all forms of nicotine use as equivalent in terms of harm or clinical significance.
Under DSM-5, problems with nicotine fall under Tobacco (Nicotine) Use Disorder, which is assessed on the basis of impairment, distress, and continued use despite harm. The framework explicitly moves away from casual or rhetorical use of the term “addiction” and instead focuses on whether a person’s nicotine use constitutes a problematic pattern that interferes with health, functioning, or daily life. This distinction has direct relevance for how youth use of nicotine pouches is discussed in media, politics, and regulation.
DSM-5 makes clear that nicotine use alone is not synonymous with a disorder. Diagnosis depends on meeting a threshold number of behavioural and harm-related criteria, such as repeated failure to cut down, interference with school or family obligations, persistent use despite clear physical or psychological harm, or clinically significant withdrawal. A young person who uses nicotine intermittently, experiences no meaningful role impairment, and shows no sustained harm would typically not meet criteria for more than a very mild use disorder, if any at all.
This clinical nuance is often lost in public debate. Surveys that apply DSM-5 criteria with a very low threshold can classify a large share of adolescents as having a “use disorder,” largely because symptoms like craving or tolerance are relatively common even among light users. However, the proportion of young people meeting criteria for moderate or severe Nicotine Use Disorder, closer to what clinicians would consider true addiction, is far smaller, and more closely resembles earlier dependence diagnoses that required demonstrable impairment. This gap between clinical meaning and public rhetoric risks overstating harm and misdirecting policy responses.
Why Product Type Still Matters Under DSM-5
DSM-5’s criteria for Tobacco (Nicotine) Use Disorder are deliberately product-agnostic: the same diagnostic framework applies whether nicotine is delivered through cigarettes, pouches, or other products. However, this does not mean the consequences of dependence are the same. The DSM framework evaluates behaviour and impairment, not toxicological exposure, and this is where delivery method becomes crucial for public-health interpretation.
Cigarettes remain uniquely harmful because they deliver nicotine alongside thousands of combustion-derived toxicants, driving the overwhelming burden of tobacco-related cancer, cardiovascular disease, respiratory illness, and premature death. In contrast, nicotine pouches expose users to far lower levels of toxicants, with no combustion and no second-hand smoke exposure. While pouches are not risk-free and can sustain dependence, their harm profile is fundamentally different from that of smoking.
For young people, this distinction is particularly important. Adolescents are vulnerable to nicotine’s effects on the developing brain, and sustained use of any nicotine product is undesirable. However, the nature and magnitude of harm differ sharply. Youth smoking is associated with rapid escalation of dependence and early physiological damage, while current evidence suggests that youth use of nicotine pouches is more often characterised by intermittent use, milder dependence symptoms, and limited evidence of serious functional impairment at the population level. These patterns align with DSM-5’s emphasis on impairment rather than mere exposure.
This does not minimise youth protection. Rather, it clarifies it. Over-diagnosing “addiction” risks collapsing very different behaviours and risks into a single category, obscuring where intervention is most urgent and effective. From a DSM-aligned perspective, it is entirely possible and scientifically consistent, to strongly discourage all youth nicotine use while still recognising that dependence linked to cigarettes carries far greater clinical and public-health consequences than dependence linked to low-toxicant, non-combustible products.
Implications for Youth Policy and Harm Reduction
For GINN, the DSM-5 framework supports a balanced, evidence-based position. Youth should not use nicotine products, and robust safeguards, including age limits, marketing restrictions, and strength controls are essential. At the same time, language matters. Using “addiction” as a blanket label for all youth nicotine use stretches the term beyond its clinical meaning and risks undermining harm-reduction strategies aimed at adults who smoke.
DSM-5 and the broader evidence base point toward a more coherent approach: distinguish between dependence and harm, recognise the continuum of risk across nicotine products, and ensure that youth-focused narratives do not unintentionally erase these distinctions. When policy collapses all nicotine use into a single moral or medical category, it risks both overreacting to lower-risk behaviours and under-addressing the uniquely severe harms of smoking.
In this sense, youth protection and harm reduction are not competing goals. They are complementary, provided regulation and communication remain grounded in clinical definitions, toxicological evidence, and proportionality. Aligning youth policy with DSM-5’s emphasis on impairment and harm, not rhetoric, offers a clearer path toward protecting young people without distorting the science of nicotine and risk.
