What Are Oral Nicotine Pouches

Oral nicotine pouches were introduced in the United States in 2016, with the intention to move the population away from conventional cigarettes but instead created a global epidemic among young adults. Oral nicotine pouches have dramatically increased recent appeal to young adults due to constant promotion with advertisements, convenience, and accessibility, with a wide variety of brand selections available in many flavors.⁴ Oral nicotine pouches are prepared in discrete, dissolvable, prefilled pouches with penetrating properties, consisting roughly of 80-90% water, cellulose, along with crystalized nicotine powder or plant-based fibers.⁵ Nicotine in ONPs is either tobacco-derived nicotine (TDN), extracted from tobacco leaves and converted into nicotine salts, or chemically synthesized (SyN). Chemically synthesized oral nicotine pouches are a combination of nicotine and other constituents, which are produced by a chemical process instead of directly derived from an actual tobacco plant.¹ Oral nicotine pouches have been inaccurately marketed as a less harmful alternative to nicotine products, allegedly because lack of combustion involvement and the absence of the direct tobacco leaves in the product, with limited data confirming this.¹ One container for purchase, holds approximately 20 nicotine pouches, clearly labeled “addictive chemical” product containing nicotine due to legal regulations in the United States.⁵

However, nicotine pouches are not currently regulated in the European Union (EU), but within the member states. European member states are cracking down on sales to minors, with increased taxes on the products. Each pouch is limited to 10-17 milligrams of nicotine. The labels must include increased health warnings, and only tobacco, mint, or menthol flavors are allowed. While some countries are waiting for guidance for the European Commission, other countries such as France, Austria, Belgium, Germany and the Netherlands have already implemented a ban for the sale of the products.⁶

Placed in the oral cavity on the labial mucosa, adjacent to gingiva, nicotine is released and absorbed in the blood stream. The time frame and amount of grams per pouch directs how quickly the nicotine is delivered. While some stronger products reach 17 mg per pouch, the average nicotine content typically ranges from 1.29 to 6.11mg per pouch.⁵ Nicotine in pouches are absorbed from the lining of the mouth with a steady intake, whereas nicotine in cigarettes is absorbed more rapidly through the lungs.⁷ A standard cigarette contains about 10-13mg of nicotine but approximately 1-2mg of nicotine is absorbed, due to inefficiencies with combustion delivery with inhalation. The level of milligrams in the ONPs must be reviewed when comparing nicotine absorption between a cigarette and an oral nicotine pouch. A higher milligram pouch could present more nicotine intake and the patient’s metabolism will also affect the rate of nicotine absorption.^7,8