A massive review of 54 peer reviewed papers found that tobacco free nicotine pouches expose users to far fewer harmful chemicals than cigarettes and most smokeless products, while early clinical signs point to lower disease risk for people who switch. Researchers warn that the evidence is still emerging and that regulators need more data before drawing firm public health conclusions.The scoping review published in the academic journal Cureus combed through studies up to May 31, 2023. Laboratory work found “dramatically reduced” toxicant levels in nicotine pouches.In one analysis, only trace amounts of a handful of 26 priority chemicals were detectable, giving the products a toxicant profile comparable to nicotine replacement gums and lozenges. A separate study reported that 20 of 21 pouches tested had undetectable levels of the cancer linked compounds benzoapyrene, nitrite, and tobacco specific nitrosamines.Human biomarker work echoed those findings. Among exclusive Velo pouch users, seven of eight exposure markers were between 23% and 97% lower than in current smokers, while the lung carcinogen metabolite NNAL fell by 91%. .Markers tied to heart disease, inflammation, and oxidative stress, including carboxy-haemoglobin and white blood cell count, also dropped by up to 46%, and exhaled nitric oxide, typically suppressed in smokers, rebounded by 97%.Nicotine delivery profiles suggest pouches may satisfy smokers without matching cigarettes addictive peak. Across multiple trials, the rise in blood nicotine was smaller and peaked later than with smoking, a pattern that usually signals lower abuse. Crucially, the maximum blood concentration was reached when users removed the pouch, meaning use time, not rapid lung absorption like cigarettes, drives dosing levels.Behavioural data hinted at real world benefits. In a six week US observational study, 82 out of 100 smokers cut their daily cigarette intake after adding Velo pouches, with almost one sixth cutting in half their cigarette consumption. Retail surveys show most regular Zyn buyers are former or current smokeless tobacco users, and more than 60% of smokers who take up Zyn say they do so to quit or cut down on cigarette usage.At the population level, a modelling exercise projected that introducing Zyn in 2000 could avert about 320,000 deaths overall and 700,000 product related deaths in the US by 2050, even under conservative assumptions about relative risk..Importantly, the nicotine pouch market appears to be drawing mainly from existing tobacco users rather than teens. A British survey of 25,698 adults put current use at just 0.26% in 2021, with prevalence among never-smokers only 0.06%. US youth surveys also found “ever use” below two percent and frequent use below one percent among high school students.Still, researchers caution that most studies are short-term and use older nicotine pouch formulas. Evidence gaps include long run cardiovascular outcomes, flavour specific toxicology, and real world switching rates beyond six months. The weight of evidence supports meaningful risk reduction should smokers fully substitute nicotine pouches for cigarettes.But, the researchers said that additional longitudinal work is needed to confirm sustained health benefits and to monitor unintended uptake, such as among teens..This meta-study review adds to a growing case for a risk proportionate regulatory approach.One that keeps youth protections but gives adult smokers clear information on relative dangers. Large scale publicly funded cohort studies are only now getting underway in Europe and the US.For now, the consensus emerging from 54 studies of peer reviewed papers is cautiously optimistic. Nicotine pouches are not risk free, yet they appear far less dangerous than lighting up a cigarette. In Canada, only Zonnic nicotine pouches are available for sale in flavourless and mint at pharmacies.Whether the potential of nicotine pouches translates into meaningful public health gains will depend on how many of Canada’s roughly four million smokers are willing and helped to switch to them.
