Joseph Hart 16 February 2026

 

Pouches can help reduce the prevalence of combustible cigarettes worldwide. However, in some regions, the impact of the harm-reduction product may be particularly significant due to existing preferences for other oral tobacco products. A new mini-review explores the potential of pouches in South and Southeast Asia.

A new paper published in Frontiers, titled “Nicotine pouches, oral cancer and tobacco harm reduction: current evidence and research priorities,” is now available. As the title suggests, it evaluates what is currently known about nicotine pouches, their effects on oral health, and how they might influence oral cancer risk as part of tobacco harm‑reduction strategies.

What is the paper about?

The paper looks at how smoking and high‑nitrosamine smokeless tobacco (i.e., gutkha, paan with tobacco, naswar, etc.) affect oral cancer rates around the world, with a particular emphasis on South and Southeast Asia. Then, the authors ask where products such as nicotine pouches fit within this landscape.

It’s a particularly good region to examine because smokeless tobacco is already a significant part of the culture, unlike many European states, where it constitutes a smaller or emerging share of the market. 

While most of us are all well aware that smoking is a leading cause of death and illness around the world, the impact of high‑nitrosamine smokeless tobacco rarely makes headlines, despite its devastating effect on the health of users.

Products such as Swedish snus have far lower levels of tobacco‑specific nitrosamines (TSNAs). What’s more, these products have a large cohort of data, and systematic reviews suggest no clear increase in oral cancer risk. What is true of snus’s reduced toxicity is even more true of nicotine pouches.

Academic papers on oral cancer and nicotine pouches spread across a desk with a regional map and unbranded pouch tins.

What does the paper say about nicotine pouches as an alternative?

The paper gives a brief of the composition of pouches, before stating that toxicological analyses show much lower levels of harmful constituents than cigarettes and conventional smokeless tobacco. 
It also cites four studies that suggest nicotine pouches:

  • Improve snus-related oral mucosal lesions.
  • Reduce gingival inflammation indices in smokers who switch.
  • Cases of parakeratosis and chronic inflammation have been observed at pouch placement sites from nicotine pouches.

Furthermore, the authors caution that pouches are new and that existing studies are too small and heterogeneous to firmly state that nicotine pouches increase, decrease, or do not affect oral cancer risk.

Links to the studies are here:

  • The effect of a non‑tobacco‑based nicotine pouch on mucosal lesions caused by Swedish smokeless tobacco (snus).[1]
  • Self‑reported oral health outcomes after switching to a novel nicotine pouch technology: a pilot study. [2]
  • Oral health effects among adults switching from cigarettes to on!® nicotine pouches compared to those who continue smoking. [3]
  • Oral mucosal changes caused by nicotine pouches: case series. [4]

What does the paper recommend about pouches going forward?

The paper argues that, for adults who cannot or will not quit smoking or high‑risk smokeless products, switching completely to low‑toxin products like nicotine pouches could plausibly reduce carcinogen exposure. However, they also urge caution.

The authors recommend the following: 

  • Long‑term studies that follow people over many years to see how their mouth lining changes, whether early warning spots appear, and whether any cancers actually develop.
  • Test the contents and chemicals of nicotine pouch products in the same way for all brands, using labs that are not paid by the manufacturers.
  • Keep track of how people actually use these products in everyday life, i.e., who uses them, whether they continue to smoke, and how many teenagers or young adults begin using them.
  • Put rules in place so products are made safely, have clear labels and non‑misleading advertising, and so that health messages explain, in plain language, how the risks of different nicotine products compare.

Final thoughts

The paper is a sober and pragmatic look at nicotine pouches and their potential impact. Smoking and high‑nitrosamine smokeless tobacco are lethal, which is why products with substantially lower toxin profiles can have a positive impact on global health. Of course, much depends on a sensible regulatory approach from governments across different regions.