Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study

Advertising the leading US nicotine pouch brand: a content analysis of ZYN advertisements from 2019 to 2023

BACKGROUND

ZYN is the leading nicotine pouch brand and a predominant driver of nicotine pouch advertising. In November 2022, Philip Morris International (PMI) acquired Swedish Match, the manufacturer of ZYN.

METHODS

We conducted a content analysis of 207 US-based consumer-facing ZYN advertisements (ads) from January 2019 to June 2023 to delineate the characteristics of ZYN ads and compare them before and after Swedish Match was acquired by PMI.

RESULTS

Most ZYN ads were on digital media, and nearly all included information on nicotine strength and flavour. Peppermint was the most advertised flavour across time. After the acquisition, ZYN ads included significantly fewer 'tobacco-free' claims, whereas 'spit-free' claims significantly increased. The most common marketing claims were that multiple choices of products were available, followed by easy to buy, change, sales success, ability to use anywhere and improved social interaction before and after the acquisition. The percentages of ads with easy to buy, change and sales success claims, reward programmes and those linked to websites significantly increased after the acquisition.

CONCLUSIONS

After PMI acquired Swedish Match, ZYN ads used 'tobacco-free' claims less frequently. The most advertised marketing claims remained unchanged but were made more frequently in post-acquisition ads. Such claims, together with the promotion of reward programmes and links to websites for easy purchase, may attract young people or those who do not use tobacco to ZYN, indicating a need for increased monitoring and potential restrictions.

Cardiovascular and metabolic changes following 12 weeks of tobacco and nicotine pouch cessation: a Swedish cohort study

OBJECTIVES

Use of snus, including tobacco and nicotine pouches, is increasing in many countries. Nicotine increases blood pressure (BP) acutely, but the long-term effects of quitting the regular use of snus pouches are unknown. The aim was to evaluate the effects of snus cessation on home BP and markers of the metabolic syndrome.

METHODS

Volunteers aged 18-70 years using snus daily were invited to abruptly end their snus intake and followed using home BP and metabolic measurements before and for 12 weeks after cessation.

RESULTS

Fifty volunteers were recruited. Of these, 46 (92%) attempted snus cessation and 37 (74%) did not use snus for at least 3 weeks and were included in the study. Of those included, 33 maintained snus cessation for all 12 weeks. The mean age was 38 (± 10) years and 24 (65%) were men. At week 12, the mean changes in systolic home BP was 3.7 (95% CI 1.5-5.9) mmHg, in body weight was 1.8 (95% CI 1.1-2.4) kg, and in HbA1c was 0.7 (95% CI 0.0-1.6) mmol/mol.

CONCLUSIONS

Cessation of tobacco and nicotine pouches in individuals who regularly used snus negatively impacted systolic home BP, body weight and HbA1c after 12 weeks. Whether these effects would be reversed by snus re-initiation cannot be determined by this study, but our novel findings suggest that successful cessation of regular snus usage does not immediate improve these cardiovascular risk factors. We call for further research to confirm our findings and evaluate the effects over longer time frames.

CLINICAL TRIAL REGISTRY NUMBER

NCT06019910, https://clinicaltrials.gov/study/NCT06019910 .

A comprehensive review on oral nicotine pouches: Available scientific evidence and future research needs

Oral nicotine pouches (ONPs) are an emergent class of tobacco products that, unlike conventional oral smokeless tobacco products, contain a nicotine powder instead of tobacco leaves. This review synthesizes available data on ONPs in key research domains including survey studies, marketing/advertising studies, chemical characterization and in vitro studies, and clinical studies. Research findings relevant for ONP regulations are summarized, including who uses these products and why, how marketing tactics influence appeal and use intentions, what harmful and potentially harmful constituents they contain, and what acute effects they have on humans. Taken together, the current data suggest that ONPs likely produce less harm to individual users than conventional tobacco products (e.g., moist snuff, cigarettes) and can acutely suppress nicotine/tobacco withdrawal symptoms among current cigarette smokers. Thus, ONPs may be a viable harm reduction option for individuals who switch completely to using them from conventional products. However, randomized controlled trials are needed to determine if established tobacco users would use ONPs long term, and more independent academic research is needed given that most ONP studies to date are tobacco industry-funded. Additionally, ONPs have qualities (e.g., flavors, marketing claims of "tobacco free") that could increase appeal among youth and young adults, and these products can deliver nicotine at levels sufficient to cause dependence; widespread adoption of ONPs among otherwise nicotine-naive individuals may reduce their net public health benefit. This review concludes by suggesting future research directions necessary to increase scientific understanding of ONPs and inform regulations for these increasingly popular products. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Nicotine Toxicity From Repeat Use of Nicotine Pouches

BACKGROUND

Nicotine pouches have emerged as a novel way to administer concentrated nicotine and come as a white powder in flavored, microfiber pouches placed between the cheek and gums to dissolve without requiring spitting. While marketed as a safe alternative to smoking, nicotine pouches have the potential for toxic exposure to users.

CASE PRESENTATION

We present a case of a 21-year-old male with acute nicotine toxicity through repeated administration of nicotine pouches. Over the course of 12 hours, he consumed 15 extra-strength nicotine pouches (10.9 mg per pouch) as a study tool to prepare for the next-day exams. He presented to the emergency department with bizarre behavior requiring admission for persistent confusion and nausea which resolved after 24 hours.

CONCLUSIONS

This case represents the first case of acute nicotine toxicity secondary to nicotine pouch use. These pouches are emerging as a novel way to use nicotine and present a serious risk of inadvertent overdose and harm.

IMPLICATIONS

Nicotine pouches are emerging as a novel way to use nicotine, and second to e-cigarettes, are the most frequently used nicotine product among youth. These pouches, which lack clear warning labels, are promoted among social media forums and present a serious risk of inadvertent overdose and harm, especially among young adults. Healthcare professionals should be aware of this risk, especially from acute, repeated exposures, and should ensure the public is cautioned appropriately.

Evaluating the Role of Nicotine Stereoisomer on Nicotine Pouch Abuse Liability: A Randomized Crossover Trial

INTRODUCTION

Many oral nicotine pouch (ONP) brands use synthetic nicotine, which typically contains a racemic (50:50) mixture of nicotine's two stereoisomers: S-nicotine and R-nicotine. Because tobacco-derived nicotine contains more than 99% S-nicotine, the effects of R-nicotine in humans are not well known. We compared systemic nicotine exposure and product appeal of ONPs containing more than 99% S-nicotine versus racemic nicotine.

AIMS AND METHODS

N = 18 adult smokers (Mage = 45 years, 66.7% male, 77.8% White) enrolled in a three-visit single-blind, randomized crossover study. During each visit, participants used one wintergreen-flavored, 3 mg nicotine ONP for 30 min following at least12 h nicotine abstinence. Study ONP #1 contained more than 99% S-nicotine and the other two study ONPs contained racemic nicotine (collapsed for analyses). Plasma nicotine assessments and measures of withdrawal relief occurred at t = 0, 5, 15, 30, 60, and 90 min; measures of product appeal were assessed following ONP use.

RESULTS

Using the ONP with more than 99% S-nicotine resulted in greater plasma nicotine concentration from 15 to 90 min (p < .0001) and greater maximum plasma nicotine concentration than the ONPs with racemic nicotine (M = 9.9 ng/mL [SD = 2.5] vs. M = 5.7 ng/mL [SD = 2.8], respectively; p < .0001). Product liking and withdrawal relief were similar across ONPs, although participants reported more "bad effects" when using the ONP with more than 99% S-nicotine.

CONCLUSIONS

Participants reported few subjective differences in ONPs according to nicotine stereoisomer, but plasma nicotine concentration was greater for ONPs using more than 99% S-nicotine. ONPs with more than 99% S-nicotine (vs. racemic nicotine) might be better substitutes for cigarettes, but research into other ONP characteristics (eg flavors, freebase nicotine) is needed to inform regulation.

IMPLICATIONS

Little is known about the effects of racemic (vs. S-) nicotine in humans. In a sample of adults who smoke cigarettes, we identified that oral nicotine pouches containing racemic nicotine exposed participants to less nicotine than oral nicotine pouches containing only S-nicotine, but both types of oral nicotine pouches held similar, moderate appeal. Additional research evaluating the roles that flavorings, total nicotine concentration, and freebase nicotine play in the abuse liability of oral nicotine pouches would inform comprehensive product regulations to support public health.

The Potential Impact of Oral Nicotine Pouches on Public Health: A Scoping Review

INTRODUCTION

Oral nicotine pouches (ONPs) are a new class of nicotine products. This scoping review summarizes evidence on ONPs and explores their potential public health impact.

AIMS AND METHODS

We conducted a structured literature search for empirical studies across three electronic databases through January 10, 2024. Outcomes included ONP product characteristics, use patterns, beliefs and perceptions, toxicity, and marketing and sales.

RESULTS

Sixty-two studies were included, 17 were industry-funded. Most studies were from the United States. While large variations across studies were observed in ONP youth prevalence estimates, nationally representative U.S. studies find current use at 1.5% and lifetime use below 2.5% through 2023. Between 35% and 42% of U.S. adolescents and young adults have heard of ONPs, and 9-21% of tobacco-naïve youth were susceptible to trying them. U.S. adult-use estimates varied widely (0.8%-3% current; 3%-16% lifetime use) and were limited to populations with a history of tobacco use. The chemical composition of ONPs suggests fewer harmful/potentially harmful compounds at lower levels than cigarettes and smokeless tobacco (SLT), except formaldehyde. Industry-funded studies find substantially less cytotoxicity compared to cigarettes and suggest that higher nicotine-strength ONPs can deliver nicotine at levels comparable to or higher than SLT or cigarettes, although with slower nicotine release than cigarettes. Evidence on the cytotoxicity of ONPs relative to SLT is mixed.

CONCLUSIONS

ONPs appear to be less toxic than cigarettes and deliver comparable nicotine, presenting an alternative for combustible product users, although key data are mainly available from industry-funded studies. Data from independent research is critically needed. Industry marketing of ONPs may encourage initiation in youth and situational and dual use in adults.

IMPLICATIONS

The review provides an initial assessment of the potential role of ONPs in harm reduction and aims to determine unintended consequences of their use (youth uptake and dual-use) and identify populations that disproportionately use the product. This information is essential for tobacco regulatory bodies in determining the net public health impact of nicotine pouches.

Randomized crossover clinical studies to assess abuse liability and nicotine pharmacokinetics of Velo Oral Nicotine pouches

Introduction

Oral nicotine pouches (ONPs) are a newer category of smokeless tobacco products containing pharmaceutical-grade nicotine but no tobacco leaf. These products have the potential to help smokers transition away from cigarettes. To assess their potential role as alternatives to cigarettes, we evaluated the abuse liability (AL) of Velo ONPs with varying nicotine content (4-12 mg per pouch), pouch size (600 mg or 400 mg) and flavor (six varieties) in comparison to high (cigarettes) and low (nicotine replacement therapy [NRT] gum) AL comparators.

Methods

Independent randomized crossover clinical studies were conducted to assess AL, including subjective effects (product liking [PL], urge to smoke, product effects, overall PL, and overall intent to use again) and nicotine pharmacokinetic (PK) parameters of Velo ONPs. Participants used test products under controlled conditions, and subjective effect measures were collected using validated questionnaires. Nicotine PK parameters, including peak nicotine concentration (Cmax), time to maximum concentration (Tmax), were assessed.

Results

Mean PL scores for all Velo ONPs (p < 0.0042) and Velo Mini Pouches (p < 0.0031) were significantly lower than cigarettes, regardless of nicotine level, pouch size, or flavor, but similar to NRT gum. Other subjective measures for Velo ONPs were less favorable than cigarettes and comparable to or lower than NRT gum. Nicotine uptake with Velo ONPs was slower (reflected by a longer Tmax) and had lower Cmax than cigarettes but was comparable or slightly lower than NRT gum. Overall nicotine uptake increased with increasing nicotine content and was comparable to that of cigarettes for Velo ONPs with higher nicotine levels. Flavor had no effect on nicotine uptake of Velo ONPs.

Discussion

Velo ONPs demonstrated an AL profile lower than cigarettes and similar to NRT gum, suggesting a reduced potential for abuse compared to cigarettes. The slower nicotine uptake and lower peak nicotine levels further support their potential as a lower-risk alternative. These findings highlight the potential role of ONPs in tobacco harm reduction strategies by providing an alternative nicotine source with a lower AL than combustible cigarettes.

Systematic Review Registration

The clinical studies were registered at ClinicalTrials.gov; NCT05129657, NCT05294497, and NCT05081154.

What is the impact of nicotine pouches on oral health: a systematic review

BACKGROUND

Increase in nicotine pouch (NP) users, particularly among the young, is a matter of concern requiring a comprehensive understanding of its short- and long-term oral health implications. The objective of this research was to systematically review potential oral side-effects associated with NP usage.

METHODS

This systematic review was conducted following the PRISMA guidelines. Databases (Medline via PubMed, Scopus, Cochrane Trial, and Google Scholar) were searched for relevant studies up to February 2024. Modified Newcastle-Ottawa Scale (NOS) and the Risk Of Bias In Non-randomized Studies - of Exposure (ROBINS-E) tool were used to assess the quality and bias of the included studies.

RESULTS

Three studies were included for this review, two from Europe and one from USA, and considered of a total of 190 participants. All studies were deemed to have a high risk of bias. Participants used NP for periods ranging from 1 month to 10 years. Among these studies, only one study provided information on the usage pattern between 1 and 5 units for an average of 11 ± 7 min per session. Oral mucosal changes at the site of placement were common among NP users. Oral lesions varied from slight wrinkling to various white lesions, seemingly related to the NP units consumed per day and their duration of usage. Other oral side effects included dry mouth, soreness, gingival blisters, and a strange jaw sensation.

CONCLUSIONS

Research on the use of NP and its effect on oral health are currently limited. The use of NP should take into consideration the short-and-long-term effects, especially on oral health. Further studies are crucial to understand oral health implications associated with NP usage.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration number CRD 42,024,500,711.