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Leana Wen: Do nicotine pouches have a public health benefit?

Thought Leader: Leana Wen
July 24, 2025
Source: The Washington Post
Written by: Leana S. Wen
Advocates love to tout these products as harm reduction tools. Here’s what the evidence says.
Last week, I wrote about how easy-to-conceal nicotine pouches manufactured by tobacco companies are addicting youths to the drug, just as e-cigarettes did before them. Most readers I heard are concerned that the product is the latest cynical ploy by Big Tobacco to draw in a new generation of users.

Many did not agree. Some reached out to stress that replacement products such as e-cigarettes and pouches helped them cut back on cigarettes. This is a position echoed by Philip Morris International, the manufacturer of the most-used nicotine pouch, ZYN.

Matthew Holman, a vice president at PMI who previously worked on tobacco regulation at the Food and Drug Administration, told me his company aims to get all smokers to completely switch from cigarettes to other nicotine products with less health risk. He cited industry data and a recent study that found pouch users reduced cigarette consumption.
The study was small, with only 30 participants, and only lasted four weeks. Moreover, the results highlighted a key issue: Though pouch users reduced cigarette smoking, their exposure to tobacco-related harm didn’t change — likely, as the authors stated, because few participants quit smoking altogether.

This pattern, often referred to as “dual-use,” refers to people who start using nicotine pouches, smokeless tobacco, e-cigarettes and similar products but continue smoking cigarettes. They might think they are engaging in healthier behavior, but dual-use may not be helping them as much as they think, if at all.

Mitch Zeller, former director of the FDA’s Center for Tobacco Products, explained that as much as 70 percent of people who vape continue to smoke. He showed me industry data from two years ago that showed 84 percent of adult pouch users kept up cigarette use.“The question of dual-use is complicated because whatever survey we look at, you are only looking at one moment in time,” he said. It could be that smokers interested in quitting are just beginning to try pouches and that newer surveys would show a lower number. Or it could be that previously health concerned people started with the intention of stopping smoking but have since adopted a new normal where they consume a variety of nicotine-containing products in addition to cigarettes.

But research suggests that this might not be better for their health. A 2023 study conducted by the tobacco industry concluded that dual-users who vaped and continued to smoke 10 cigarettes a day or more did not have a significant difference in harmful biomarkers as exclusive smokers. Other studies have found similar exposure to tobacco-related toxicants between dual-users and those who just use cigarettes. And a meta-analysis of 107 studies, published in New England Journal of Medicine Evidence, concluded that dual users did not have a lower risk of cardiovascular disease, and may even have a higher risk of some diseases compared to smokers.

This doesn’t mean that harm reduction products are pointless. But it does raise a difficult question: If these products didn’t exist, might more smokers have been motivated to quit rather than concluding that they don’t have to?

Which leads to me another important point: Pouches, e-cigarettes and the like are not authorized by the FDA as smoking cessation products. The FDA has approved a variety of over-the-counter nicotine replacement therapies, including skin patches, nicotine gum and lozenges. It also approved a nicotine spray and inhaler, as well as two medications (bupropion and varenicline), that require a prescription.
The FDA is clear that “these approved medications, along with behavioral counseling, should be the first line of therapeutic treatment for adults seeking to quit smoking.” Counseling and medications are “independently effective,” but are even more effective when used together. People trying to quit smoking should start with these proven cessation methods rather than products that move them from one tobacco company profit center to another.

Then there is the question of unintentional harm: Even if some adults may benefit from cigarette alternatives, does that outweigh the risk of hooking a new generation on nicotine?

PMI insists it does not market to teens. After my last article, a spokesperson for the company followed up multiple times with links to corporate materials emphasizing this point. Fair enough, but a cynical person might point out that tobacco companies adopted this stance after the peak of the e-cigarette boom, when 1 in 4 high-schoolers and 1 in 10 middle-schoolers reported using the product.

Besides, if Big Tobacco really wanted smokers to switch completely to these alternatives, it has a straightforward way to make that happen: Stop selling cigarettes.

Dr. Leana Wen is a compelling keynote speaker because she combines her expertise as a physician and public health leader with a unique ability to translate complex medical issues into clear, actionable guidance for the public. Her thoughtful commentary on critical health topics—from vaccines to health equity—makes her an invaluable voice in today’s fast-evolving healthcare landscape. With her deep experience in both clinical practice and policy, she empowers audiences to make informed decisions and engage meaningfully with public health challenges. To host her at your event, contact us.

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