“Do you smoke cigarettes?” I asked my patient succinctly in a recent clinic appointment.
He matter-of-factly responded, “Not anymore, I use Zyn pouches now.”
As with any patient, I gauged his readiness – or reluctance, in some instances – to disrupt his use of nicotine.
I asked about his interest in trying nicotine replacement therapy, a medical treatment that provides low, controlled amounts of nicotine. Initially, his response caught me by surprise.
“Aren’t I already using nicotine replacement products?” he asked astutely.
I gathered my thoughts and explained that while nicotine pouches are indeed a form of nicotine replacement, there are important caveats. Actual nicotine replacement therapy products are regulated by the Food and Drug Administration to help people quit smoking. In contrast, I explained that Zyn and other nicotine pouches are commercial tobacco products that are regulated by the FDA but are not FDA-approved smoking cessation medications.
My patient was surprised, because he had not realized there was a difference, which is a common misunderstanding. This encounter proved pivotal in the direction I would take in my subsequent clinical encounters.
As an addiction medicine physician, I often talk with patients who use nicotine in various forms.
Understanding how these products differ and what we know about their relative risks can help people make more informed choices.
Doing away with good/bad thinking
One of the most important distinctions I make when I talk to patients is distinguishing between the harms caused by nicotine itself and the harms caused by the way it is delivered.
Combustible tobacco products such as cigarettes expose users to thousands of chemicals produced by burning tobacco, while newer products such as vapes deliver nicotine without combustion.
But the lack of combustion does not make the newer products inherently safe. Nicotine remains addictive, and studies have raised concerns about its cardiovascular effects, including changes in heart rate, blood pressure and underlying vascular function.
The long-term health effects of newer nicotine products – particularly nicotine pouches – are not yet well established.
As a result, discussions about which nicotine product is appropriate for a given person do not fall into categories of “good” or “bad.” Rather, they involve nuanced conversations with patients to help them reach their goals and reduce overall harm.
What’s more, the health implications of a nicotine product depend not only on what is in it, but also on who is using it, how they use it and what it replaces. Relative harms vary significantly when talking about a current tobacco smoker who switches to an e-cigarette compared with a nonsmoker who starts vaping. The same distinction matters for nicotine pouches: Their lower exposure to many toxic chemicals does not make them risk-free, particularly for adolescents and other nonsmokers who have not previously used nicotine.
Relative harms
In 1965, 42.4% of the U.S. population smoked. By 2022, that figure had dropped to 11.6%.
This dramatic decline did not happen because of a single intervention, but through decades of accumulating scientific evidence, public education campaigns, warning labels, restrictions on advertising, smoke-free policies, higher tobacco taxes and shifts in social norms. At the same time, the tobacco landscape has evolved, with noncombustible nicotine products such as e-cigarettes and nicotine pouches becoming increasingly prominent.
In the U.S., 6.5% of adults reported using e-cigarettes in 2023, while past-year nicotine pouch use rose from 3.4% in 2023 to 5.9% in 2024. This fast-growing trend makes it clear that the public is in need of a better understanding of the relative harms of nicotine products.
To be clear, the major source of cigarette-related harm is burning tobacco, not simply the presence of nicotine.
Tobacco smoke contains thousands of chemicals, many of which are toxic and carcinogenic, culminating in approximately 2.5 million cancer deaths per year worldwide.
Patients also often land in the hospital with complications related to tobacco use, including chronic obstructive pulmonary disease and cardiovascular disease.
While nicotine itself is the reason for dependence, the toxic mixture generated by burning tobacco leaves is what makes cigarette smoking so extraordinarily harmful.
Nicotine products compared
So, where do vaping, heated tobacco – also known as “heat-not-burn products” – cigarettes and oral nicotine fall on the spectrum of safety?
Electronic cigarettes – or vapes – generally contain fewer and lower levels of many toxic chemicals compared with cigarette smoke. However, inhaled aerosols can still contain harmful substances such as propylene glycol, which is often found in certain medicines, cosmetics and food products. While propylene glycol is classified as “generally safe” by the FDA for use in food, that designation does not establish that it is safe to inhale. The lungs process substances differently from the digestive system, and the health effects of chronic inhalation of propylene glycol through e-cigarette aerosol remain incompletely understood.
Heated tobacco products such as processed tobacco sticks, loose-leaf chambers, tobacco capsules and pods, or carbon-tipped pods typically heat tobacco to lower temperatures as opposed to burning it. This can lead to lower exposure to harmful substances compared with conventional cigarettes. However, the Centers for Disease Control and Prevention considers any tobacco product harmful, given that these products still deliver tobacco-derived nicotine and other toxins.
An increasingly prominent product is the nicotine pouch, such as the brand-name product Zyn. Sales of nicotine pouches in the U.S. have increased substantially in recent years, particularly since 2023. Unlike traditional smokeless tobacco, nicotine pouches contain no tobacco leaf; instead, they contain nicotine, flavorings and other ingredients. Users typically place a pouch between the upper lip and gum, where nicotine is absorbed through the tissues of the mouth.
Nicotine pouches generally result in lower exposure to many toxic substances, given that there is no combustion or inhaled aerosols. However, they can deliver substantial amounts of nicotine. Depending on the product, a single pouch may contain several milligrams of nicotine – comparable to or exceeding the amount of nicotine you would otherwise get from a cigarette. These products therefore remain addictive.
With all nicotine products, the relevant comparison is not “safe” versus “dangerous,” but rather “more harmful” versus “less harmful.
FDA-approved nicotine replacement therapy
Nicotine replacement therapy, on the other hand, is an FDA-approved medical treatment that delivers controlled, low amounts of nicotine without the many carcinogens and toxic chemicals found in tobacco smoke. These products come in the form of patches, gum, lozenges, nasal sprays and inhalers, intended to reduce cravings and withdrawal while helping people gradually move away from tobacco use.
Unlike nicotine replacement therapies, which are FDA-approved and supported by strong evidence of effectiveness for smoking cessation, e-cigarettes are not FDA-approved cessation treatments, despite evidence that they can help some people quit smoking. Evidence for nicotine pouches as a cessation aid remains limited, and they have not been FDA-approved for this purpose.
Patterns of nicotine and tobacco use also vary considerably across countries and populations, reflecting differences in culture, tobacco-control policies, product availability and patterns of use.
Similarly, access to smoking-cessation treatment and harm-reduction resources varies substantially from country to country. In the U.K., for example, cessation services are integrated into the country’s National Health Service, while Australia provides state-based "Quit” line services and permits regulated access to some nicotine vaping products through pharmacies. Many countries have limited or no comprehensive services focused on smoking cessation, and access to medications such as nicotine replacement therapy remains uneven.
Putting nicotine risk in perspective
For people who do not use nicotine, there is little reason to start. For people who smoke, quitting remains the best option. But if quitting is not immediately achievable, moving away from combustible tobacco may reduce exposure to harmful chemicals in cigarette smoke.
The goal is not to label every nicotine product “good” or “bad,” but to help people understand the trade-offs – and to make choices that move them toward less harm and, ultimately, away from nicotine dependence.
This article is republished from The Conversation, a nonprofit, independent news organization bringing you facts and trustworthy analysis to help you make sense of our complex world. It was written by: Emma Fenske, University of Colorado Anschutz; Oregon Health & Science University
Read more:
- How the pro‑nicotine ‘wellness’ movement rebranded an addictive drug
- The US government’s call for deep nicotine reduction in cigarettes could save millions of lives – an expert who studies tobacco addiction explains
- Oral nicotine pouches deliver lower levels of toxic substances than smoking – but that doesn’t mean they’re safe
Emma Fenske does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
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