In an era of declining cigarette smoking, a new source of nicotine is rising in the U.S.: nicotine pouches. While policymakers and clinicians are still catching up with the youth vaping epidemic, now an even more discreet and harmless-appearing product promises to deliver nicotine without smoke, smell, or stigma. As a psychiatry resident in my late 20s, I increasingly meet young people, patients and beyond, who insist that they “don’t smoke” or use tobacco products, yet slip a nicotine pouch under their lip every few hours. Urgent awareness and a shift in public perception are needed before this new trend becomes an entrenched epidemic.

Epidemiology and Scope

Nicotine pouch use among young Americans has nearly quadrupled since 2022 with Zyn branded pouches dominating the majority of the youth market, followed by On!, Velo, and Rogue. The appeal is obvious: a small, odorless, and easily concealed pouch delivering powdered nicotine salt, stabilizers, and flavorings. This route bypasses the harmful byproducts of combustion or vaping aerosol — allowing manufacturers to market these products as “cleaner” or “safer.” However, the absence of smoke does not mean the absence of harm.

Current data suggest that approximately 1 in 20 male and 1 in 50 female adolescents or young adults use nicotine pouches, with the highest use among rural, white males and those not pursing four-year college degrees. Among youth surveyed, the most common reason for pouch usage was “to get a high or buzz from nicotine.” The image of pouches as a benign alternative obscures two key truths: we have signs of rapid dependence emerging in populations whose brains are still developing, and we have no robust, long-term safety data.

Risks and Health Consequences

With human brain development continuing into the mid-20s, this demographic is uniquely vulnerable to nicotine’s effects. Smoking cigarettes during one’s teenage years, for example, has been associated with lasting behavioral and cognitive impairments in the realm of attention, working memory, and prefrontal cortex activation. Oral nicotine pouches may avoid carbon monoxide or volatile organic compounds, but nicotine itself still carries significant physiologic consequences.

Nicotine-mediated sympathetic stimulation leads to increased heart rate, blood pressure, arterial stiffness, and risk for arrhythmias through catecholamine release. Metabolically, nicotine’s sympathetic stimulation triggers lipolysis, insulin resistance, and even reduces beneficial high-density lipoprotein (HDL) cholesterol. It is no wonder that the American Heart Association cautions against the use of smokeless tobacco products, which have been associated with oral cancers and increased rates of fatal heart attacks and strokes.

Yet research on “tobacco-free” nicotine pouches like Zyns remains strikingly limited. Their recent emergence, paired with ethical constraints on studying youth populations, means we are largely extrapolating risk from other nicotine products. The absence of data should not be mistaken for evidence of safety, and the risks must be addressed by clinicians and public health institutions.

Another concerning pattern is dual use. More than 78% of young pouch users use at least one other tobacco product, commonly electronic nicotine delivery systems (ENDS) such as e-cigarettes or vapes. Dual use has been most studied in populations using ENDS, commonly studying the smoking cessation process, but a recent JAMA study indicated that dual use of pouches and ENDS is rising in youth populations. Previously, dual or poly-use of multiple tobacco products was identified as increasing addiction risk, but this trend remains unclear for pouches and other tobacco products. Whether pouches increase the risk of transitioning to cigarette smoking, as is documented with e-cigarette use, remains an urgent research question as well.

Implications for Health Care Practitioners

Given these risks, cessation counseling remains essential, but clinicians must adapt their approach to account for this newer form of nicotine exposure. Nicotine withdrawal in teens often presents with irritability, anxiety, insomnia, and concentration difficulties. Without explicit screening, these symptoms may be mistaken for primary psychiatric disorders or lead to unnecessary medication adjustments. Pediatricians, psychiatrists, and primary care clinicians must ask specifically about nicotine pouch use — especially because many adolescents do not consider them “tobacco products.”

Additionally, safe storage education is warranted. Over the past decade, U.S. poison centers have documented a 763.1% increase in nicotine ingestion by children younger than six. For these ingestions, nicotine pouches are disproportionately associated with serious medical outcomes or hospital admission, underscoring that these products are not only a risk to teens but also to younger children in the home.

Implications for Health Policy

Health policy invariably lags behind shifts in youth behavior, but the U.S. has developed increasingly robust regulatory tools for tobacco product control in the past decade. FDA authority expanded to ENDS in 2016, the federal minimum age for tobacco purchases was raised to 21 in 2019, and manufacturers are now required to submit Premarket Tobacco Product Applications demonstrating that their products are “appropriate for the protection of public health.”

Despite these efforts, enforcement remains uneven. FDA and DOJ task forces have cracked down on illegal ENDS sales, and flavored products targeting youth have been restricted, yet underage access to nicotine products remains widespread. In 2020, nearly 20% of high school students were still vaping — illustrating how porous retail and social access channels remain.

Nicotine pouches now sit at this regulatory crossroads. They present themselves as “tobacco-free,” yet deliver high-dose nicotine in youth-friendly flavors, are aggressively marketed through social media, and currently lack the same degree of scrutiny applied to vaping products. We are again at risk of letting a youth-oriented nicotine epidemic establish itself before the guardrails are fully in place.

As nicotine pouches continue their quiet spread among young Americans, clinicians cannot afford to treat them as a harmless fad or passing curiosity. The warning signs are unmistakable: a rapidly addictive product, engineered for concealment, marketed in popular flavors, and increasingly used alongside vapes. We have seen this trajectory before. If physicians do not explicitly screen for pouch use, educate patients and families, and advocate for robust regulatory oversight and enforcement, we will repeat the failures of the early vaping era. A preventative and proactive approach is a steadfast requirement.

Christian Hardoy, MD is a psychiatry resident at University of Arizona, Tucson. He is involved in psychiatric research, medical education, and mentorship.

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