It seems like every publication wants to trump up the alleged harm of nicotine pouches. Now, the increasingly popular harm-reduction product is in the crosshairs of the dental hygienist magazine RDH.
What is RDH Magazine?
RDH Magazine is a monthly publication in the United States dedicated to registered dental hygienists. It’s an educational and professional resource that covers various subjects such as nicotine use trends, periodontal disease, antibiotic use, ergonomics, and water safety in dental settings.
The magazine writes a lot about nicotine pouches and vaping. These novel nicotine products seem to feature far more on their website, despite smoking being much more common in the US, and many times more corrosive to oral health.
Their latest article, "The latest oral health threat: Nicotine pouches," aims to educate readers on how to ask the right questions during patient assessments and include nicotine pouches in patient education and tobacco cessation conversations.
The article
The article, penned by a registered dental hygienist, starts with a story. The writer claims that as a dental hygiene student, when she asked patients about their tobacco use, they told her they didn’t smoke, only to reveal later that they use nicotine pouches.
She says these exchanges surprised her. But should they have? Nicotine pouches do not contain tobacco and are not combustible, so the patients were being accurate.
Of course, as pouches grow in popularity, the questions hygienists ask their patients must change with the times. This includes understanding basic concepts related to language and thinking about pouches. Additionally, dental workers must have the correct information to advise and treat their patients.
So, let’s see how the article does.
Risk reduction
Something that really jumped out from the article is the persistent use of scare quotes when talking about the risk of nicotine products.
See some examples below.
Scare quotes are placed around a word or phrase to draw attention to an unusual or arguably inaccurate use.
Quite often, the function of scare quotes is to subtly cast doubt on a statement. In this case, the author uses these quotes to signal to her tribe that “yes, I can turn my critical faculties on and off like a light switch if it’s professionally or politically expedient.”
We see this a lot with “safer” being put in scare quotes when referencing vapes or pouches. Again, there can be no doubt at all that these harm reduction tools are safer than cigarettes because there is simply no plausible mechanism where they could be worse than one of the most toxic and harmful products on the planet.
So the function of the scare quotes here is another signal to prove that even the speaker's understanding of rudimentary English can be compromised to meet ideological expectations. What else could explain the confusion over the word safe and its comparative form safer, which means having a lower risk of harm, danger, or injury compared to something else.
Perhaps these people really believe that the comparative risks of combustible tobacco and nicotine pouches are still unsettled. But that’s more grounded in a personal ignorance of the data rather than research or reality.
Pouch risks
The article goes on to talk about pouches' “significant risks for oral health”. Now, I personally welcome any and all research that looks into these topics. A big part of believing in personal choice is ensuring that the consumer has the information to make the best decisions for themselves or those around them.
So, what are the significant risks suggested by the author?
- One study showed mild side effects, such as a dry mouth, which, per the article, “can increase the risk of tooth decay, periodontal disease, and other oral health issues.” [1]
- Another five-person study showed that users “developed white lesions in their mouths, usually near the upper lip and frenum where the pouches were placed.”[2]
- The final 190 participant study found that “frequent use of nicotine pouches was linked to several oral health issues, including mucosal changes (white lesions), dry mouth, soreness, and gum blisters.” [3]
For anyone arguing that nicotine pouches were as safe as drinking Fiji Mountain water, this research would be devastating. But for the few of us rare souls left who understand the distinction between safe and safer, it’s not entirely surprising that some people experience some mild problems from pressing a nicotine pouch against the gums for extended periods.
The oral cancer question
The article also points out that the 190-person review “noted concerns that nicotine pouch use might contribute to inflammation and increase the risk of oral cancer, although the evidence was limited and the studies involved had a high risk of bias.”
It’s interesting that the author included this speculative suggestion, albeit noting the problems with the review, which by my count include:
- Small sample size.
- Limited geographic diversity.
- Variability in nicotine pouch usage patterns.
- Potential confounding factors in the study.
- No control groups.
- Short follow-up periods.
- Inconsistent measurement of oral health outcomes.
But what if there was a way to address this question without dropping the c-bomb on readers and walking away with your hands up and saying you were just asking questions?
It turns out that there is.
A comparison worth making
The function of the RDH Magazine article should be to give dental hygienists the information they need to both serve and educate their patients. It partially does this job, but I feel like it's excessively geared toward never-smokers who use pouches.
Now, there are many problems with this approach, including:
- The percentage of pouch users is dwarfed by active smokers.
- The percentage of never-smoking pouch users is even smaller.
- Implicit in this approach is the suggestion that smokers aren’t worthy of the same protections or concern due to the persistent stigma around those groups.
Additionally, if a hygienist wants to provide genuine patient-centric or person-centred care, that means meeting people where they are. For example, if someone who smokes comes to the clinic, they should be treated with dignity, compassion, and respect when it comes to their desire to continue to use nicotine in whatever form they like. That starts with the hygienists having a basic understanding of the relative risks of nicotine-containing products.
So, here is a comparison of cigarettes, snus, and nicotine pouches through the lens of their impact on oral health.
Cigarettes
- Toxic combustion byproducts like tar and carbon monoxide directly damage oral tissues. Additionally, per this paper, cigarettes can cause oxidative stress, DNA mutations, and impaired immune response.[4]
- Reduced blood flow from nicotine constriction can slow gum healing and increase the risk of gum disease. [5]
- Strong carcinogen exposure elevates oral cancer risk. [6]
Key points
Per the linked studies above:
- Smokers have an 85% higher risk of periodontitis.
- 100% higher risk of tooth loss.
- Oral cancer accounts for 80-95% of smoking-related oral malignancies.
Snus
- Tobacco-specific nitrosamines (TSNAs) such as NNN and NNK are carcinogenic. These compounds have been linked to oral lesions and precancerous changes. [7] However, large Swedish cohort studies found no significant association between Swedish snus use and oral cancer risk. [8][9]
- Prolonged pouch placement can cause localized gum recession and inflammation in some users.[10]
- Similar to smoking, some users may experience nicotine-induced vasoconstriction.
Key points
- Some reports suggest 20% of users experience gum recession. [11]
- Some studies linked above have reported precancerous white patches. However, the Norwegian Institute of Public Health suggests that “some oral lesions caused by snus are reversible and not proven to become cancerous.” [12]
Nicotine Pouches
- Localized vasoconstriction, as present in cigarettes and snus above.
- Gum abrasion with potential for chronic inflammation.[13]
- Additives or flavorings may cause dry mouth.
Key points
- Anecdotal reports of gum recession.
- No confirmed link to oral cancer.
- Non-detectable or trace TSNA levels (≤10 ng/g).
- 99.9% lower cytotoxicity in lung and liver cells compared with smoking.[14] [15]
- 2–3× lower cytotoxicity in HepG2 cells vs snus. [16]
Or, if you prefer a breakdown by table, try this.
Final thoughts
Concerns over oral health damage are the latest attack vector against nicotine pouches. I think it is vital for magazines like RDH to highlight any issues that users can experience due to pouch use. However, talking about these risks unmoored from the relative risks of cigarettes could dissuade people from giving up precisely because they are in the dark about how much safer (not “safer”) these products are.
Stigma against people who smoke still runs rampant in society. Person-centred care dictates that dental hygienists take a more pragmatic approach that acknowledges ideas like:
- Some people are predisposed to nicotine use. [17] Dental workers should be able to communicate the relative risks of different products and encourage users to seek safer alternatives.
- Evidence shows that excessive focus on the mild harms of harm-reduction products blurs the distinction between highly harmful products like smoking and reduces the likelihood of using alternatives like nicotine replacement therapies. [18]
- Highly theoretical speculation from studies with severe methodological problems should not be the basis for advertising unfounded links to cancer. Making these statements without including counterarguments, such as the fact that nicotine replacement therapies (NRTs) have been used safely for years without evidence of causing cancer, is frankly irresponsible.
- Awareness of products, such as Bengt Wiberg’s StingFree pouches, could help patients mitigate the mild side effects of nicotine pouches. In 2024, after a clinical trial, 20 out of 23 Swedish dentists recommended String Free for ‘patients with snus lesions or irritated gums.” [19]
