Tobacco and Vaping Products Act and are not subject to the pre-market safety testing required for pharmaceuticals. Brand overlap with NRT products (e.g., Velo, Rogue) may further confuse patients. Screening studies suggest a more complex risk profile than marketing implies. One analysis of 48 products identified 186 distinct chemical components (mean 17 per pouch).1 Tobacco-specific nitrosamines were detected in multiple samples, and some products contain formaldehyde at levels comparable to conventional smokeless tobacco. These constituents are not disclosed on product labels. What to Look for Chairside Long-term independent data are limited, but early clinical findings include gingival recession and localized mucosal changes at the placement site (blanching, leukoplakiatype lesions). These findings may be overlooked without targeted examination. A key clinical concern is the masking of periodontal disease. Nicotine is a vasoconstrictor and suppresses bleeding on probing, a primary marker of gingival inflammation. Active periodontitis may be present but undetected using conventional screening. Additional considerations include altered salivary flow, xerostomia related to flavouring agents, and potential long-term carcinogenic risk associated with identified compounds. Emerging literature on smokeless nicotine products also describes localized oral mucosal irritation, keratotic changes, and reversible epithelial alterations at sites of direct placement. The absence of long-term data reflects the early stage of evidence in this product category and should not be interpreted as reassurance. Cessation: A Conversation + Action Patients may ask whether nicotine pouches can be used for smoking cessation. They are not approved for this purpose in Canada, there is no randomized controlled trial (RCT) evidence supporting their use, and dual use (concurrent smoking and pouch use) negates any potential harmreduction benefit. For patients who cannot or will not quit nicotine entirely, complete substitution of smoking with nicotine pouches may represent reduced harm compared to continued smoking. Cigarettes deliver more than 7,000 chemicals, including at least 69 known carcinogens. Nicotine pouches deliver fewer. Acknowledging this is not an endorsement, but reflects a pragmatic, patientcentred approach. Where patients have transitioned away from smoking using pouches, this should be supported while establishing a plan for full cessation. Who is Using Them? Canadian prevalence data are emerging, but U.S. data2 demonstrate high susceptibility and awareness: Susceptibility is increasing most rapidly among individuals aged 18–34. Flavoured products (e.g., mint, citrus, berry) are widely marketed online. The primary concern is not harm reduction, but the potential to establish nicotine dependence in previously tobacco-naive patients. Screening studies suggest a more complex risk profile than marketing implies. One analysis of 48 products identified 186 distinct chemical components (mean 17 per pouch). Worth Noting Nicotine pouches are marketed as a “modern, smoke-free way to enjoy nicotine.”The emphasis is on use, not cessation, and there is no evidence supporting their role as cessation aids. 27 Issue 3 | 2026 | Issues and People
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