Nicotine pouches for your mouth are becoming increasingly popular. Here’s why health experts are concerned

(CNN) — A relatively new nicotine product with a tobacco-free and smokeless design has drawn in a wave of new users in just the past year: oral nicotine pouches that sit at the gums and are nearly undetectable when in use.

The leading brand Zyn, introduced in the United States in 2014, shipped 350 million cans, about 15 pouches per can, in 2023 — a 62% increase compared with the previous year, Philip Morris International announced in February.

While the product is aimed at adults who already use nicotine, some health professionals and researchers are worried the attention could attract an influx of brand-new users, especially among younger people.

Zyn does not use social media influencers to market, and the company’s social media posts on Facebook and Instagram for US audiences are age-gated to 21 and older, a spokesperson for Philip Morris International said in an email. Yet colleges across the United States have seen a rise in Zyn usage on campus, while social media has a new type of unofficial influencer for nicotine — a “Zynfluencer.”

Senate Majority Leader Chuck Schumer recently called for Federal Trade Commission and Food and Drug Administration regulators to investigate Zyn’s marketing strategies and health impacts. “I’m delivering a warning to parents, because these nicotine pouches seem to lock their sights on young kids — teenagers, and even lower — and then use the social media to hook them,” he said in a January press conference.

Here’s what experts have to say on the health risks of the product.

Are nicotine pouches better than vaping?

Tobacco is a known carcinogen that can cause several types of cancer. Cigarette smoking is the primary cause of lung cancer, according to the American Cancer Society. Zyn, among other brands of nicotine pouches such as Rogue, On! and Velo, markets its pouches as an alternative product to smoking and using tobacco.

While using a nicotine pouch does not entail inhaling chemicals as with cigarettes or vape pens, Kecia Christensen, a nurse practitioner in pulmonary disease and thoracic surgery at Nebraska Medicine, does not recommend the use of pouch products as a means to quit smoking at this time.

“It’s good that these companies are trying to come up with nontobacco-related forms of nicotine for people to try to wean their addiction. … The problem, I think, with products like this is that until they are completely regulated by the FDA, what I tell my patients is, ‘I don’t really know for sure what’s in those things,’” said Christensen, who is also a certified tobacco treatment specialist.

Philip Morris International’s application for FDA authorization has been pending since 2020, according to the company. However, FDA officials have allowed the nontobacco nicotine product to stay on the market while the application is under review.

While more research on the product is needed, Christensen said, the nicotine pouches could potentially help curb cravings for those looking to ultimately stop tobacco and nicotine use altogether if the amount of nicotine is incrementally decreased to be less than what a person was taking in with cigarettes or chewing tobacco.

The numbers can vary, but Christensen often tells patients to think of one cigarette as having 5 to 10 milligrams of nicotine each, with the actual amount inhaled probably less than that. Nicotine pouches have varying degrees of nicotine strength; 3 or 6 milligrams per pouch is most common, but some brands have pouches that contain upward of 28 milligrams.

Nicotine addiction and mental health

Oftentimes, patients who are trying to quit tobacco instead get addicted to nicotine through vaping, sometimes even more so than with cigarettes, according to Christensen. That’s because vapes are easier to use and are often used indoors rather than outside on smoke breaks, she said. Nicotine pouches are even more discreet, with a small pouch measuring at 0.6 inches by 1.1 to 1.3 inches (14 millimeters by 28 to 32 millimeters), similar to a piece of chewing gum, that can be popped in the mouth virtually anywhere without anyone else knowing.

A dependency on nicotine causes cravings and withdrawal symptoms such as irritability, headaches, dizziness and fatigue. Researchers have found long-term usage may be connected with heart disease, vascular disease, reproductive disturbances and more, according to the National Cancer Institute. Nicotine does not cause cancer or lung disease, according to the FDA.

Addiction to nicotine can be particularly tough to break when the usage is associated with coping methods for stress, anxiety or depression, Christensen said.

“Mental health is really wrapped pretty tightly up with nicotine addiction,” she added. “The biggest reason why people relapse and start smoking again or chewing again is because something bad happens in their life, you know, they have some new stress or somebody dies or they lost their job or they’re getting a divorce, and then they start smoking again, because they can’t handle those emotions, or they don’t think they can without smoking.”

And the habit can be particularly difficult to kick for those who have been using nicotine since they were teenagers, Christensen added.

Zynfluencers and Zyn users

Zyn does not have official social media influencers, but the hashtag “Zynfluencer” has hundreds of posts on TikTok and Instagram, and “Zyn” has upward of tens of thousands.

“Nicotine products should only be used by legal-age adults, which means those 21-plus. The latest CDC (US Centers for Disease Control and Prevention) and FDA data show that underage nicotine pouch use has remained low while providing many adult smokers with a better alternative than continued smoking,” Philip Morris International said in a statement to CNN.

The data from Swedish Match, a tobacco company that makes Zyn and acquired by Philip Morris International in February 2023, also shows that most Zyn users are “previous consumers of traditional oral, vaping and cigarette products with others coming from other nicotine product categories,” the company noted.

The advertisements for Zyn use terms such as “smoke-free,” “spit-free” and “odor-free” and can contain imagery of the products being used in places a cigarette or an e-cigarette wouldn’t be allowed, said Meghan Moran, an associate professor of health, behavior and society at Johns Hopkins Bloomberg School of Public Health in Baltimore. The discreetness is cause for concern when it comes to the attractiveness to people under 21, she added.

“When you think about young people who are not already using tobacco and who we don’t want to use tobacco, a product being discreet is potentially very attractive, because younger folks, teenagers, often find themselves in situations such as, you know, school, maybe home with the parents, where if it were discovered that they were using a tobacco product, there would likely be repercussions,” Moran said.

What’s more, the Zyn nicotine pouches come in a variety of flavors, including cool mint, wintergreen, coffee and cinnamon, that could be appealing to younger people, according to Christensen.

In October, 1.5% of middle school and high school students reported using nicotine pouches in the previous 30 days, according to the 2023 National Youth Tobacco Survey conducted by the FDA and CDC.

“The FDA remains concerned about any tobacco product that may appeal to youth,” said Brian King, director of the FDA’s Center for Tobacco Products, in a statement. “As always, we are committed to holding those accountable who sell unauthorized tobacco products, including those labeled, advertised, and/or designed to encourage youth use.”

For those not used to nicotine, high amounts can cause vomiting and nausea (or “nicotine sickeness”), Christensen said. Nicotine products can also “harm the developing adolescent brain,” according to FDA and CDC research.

Zyn and mouth soreness

Nicotine pouch users hold the pouch to their gum for up to an hour, which may cause a sore mouth or gum irritation. But the full effects of the oral product are not known as of yet, with more research needed to understand how nicotine usage might be associated with gum disease or cavities, said Yanfang Ren, a professor and chairman of the department of diagnostic sciences at the University of Rochester Eastman Institute for Oral Health in upstate New York.

“If you put something, anything in the mouth for a long time, potentially you might have some irritation to the gum — but to what extent, that’s something we really don’t know yet,” Ren said. He was a part of a December 2017 study that looked at the effect cigarette smoke had on the color of the teeth that was partially funded by Philip Morris International.

For those looking to quit tobacco and nicotine altogether for a healthier lifestyle, Moran recommends visiting a primary health care provider, as well as using resources provided online by the Mayo Clinic Nicotine Dependence Center. The CDC also has online resources to help those aiming to quit smoking.

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