As Nicotine Pouch Use Increases, Patients Look to Physicians for Answers

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The increased use of tobacco-free nicotine products highlights the need for physicians to stay informed about nicotine pouches and be prepared for discussions with their patients.

In a research letter recently published in JAMA, investigators addressed the tobacco-free nicotine pouch brands that major tobacco manufacturers introduced to the US market, resulting in a significant increase in sales.1

These pouches provide an oral delivery of nicotine without the presence of tobacco leaf, similar to smokeless tobacco products. While these pouches are not authorized to make claims of cessation or reduced harm, they contain low levels of toxicants comparable to nicotine replacement therapies (NRTs).2

The letter reported a survey study conducted by Mary Hrywna, PhD, MPH, Rutgers Center for Tobacco Studies, Rutgers Biomedical and Health Sciences, and a team of investigators, which aimed to assess the extent to which physicians discuss tobacco-free nicotine pouches with their patients, given the similarities to NRTs and the increasing interest in these products among individuals attempting to quit smoking.1

Among the findings, it was clear that physicians are being asked by their patients about tobacco-free nicotine pouches.

Evaluating Physician-Patient Discussions

The team performed a cross-sectional survey study from May-October 2021 and data were analyzed using SAS software, version 9.4. Included in the investigation was a random sample of 500 board-certified physicians from each of 5 specialties: family medicine, internal medicine, pulmonology, cardiology, and psychiatry.

Out of the 745 participating physicians, 63 (9.7%) reported being asked by patients about tobacco-free nicotine pouches. Data showed discussions were more likely to occur with physicians younger than 46 years (17 [15.5%]), those specializing in family medicine (22 [13.2%]), and those using Public Health Service Clinical Practice Guidelines for tobacco treatment (16 [12.7%]).

Physicians were invited to participate via mail, with an online survey link and a $25 incentive given at the start. Investigators gathered information on the physicians' knowledge, perceptions, and communication about tobacco and nicotine product use and cessation treatment.

Approaching Nicotine Pouch Use

Results revealed 3 central themes in physician-patient conversations about nicotine pouches, according to a content analysis of open-ended responses from 50 physicians. The first theme involved discouraging the use of pouches (20 [40.0%]) with an emphasis on the need to quit or reduce combustible tobacco use.

The second theme involved learning about nicotine pouches from patients or neutral communication (19 [38.0%]), and the third was communication with the patient around pouch use for cessation or harm reduction (11 [22.0%]).

According to the study, physicians can benefit from previous guidance on e-cigarettes to inform their approach regarding nicotine pouches. Although the long-term effects of nicotine pouch use are still unknown, these products are likely less harmful than combustible tobacco but reduction or cessation of combustible tobacco use should be encouraged, investigators wrote.

The study emphasized that the rate of growth seen in the market for these products highlights the need for physicians to stay informed about nicotine pouches and be prepared to discuss them with their patients.


  1. Hrywna M, Bover-Manderski MT, Wackowski OA, Steinberg MB, Delnevo CD. US Physicians’ Self-reported Discussions About Tobacco-Free Nicotine Pouches During Clinical Encounters With Patients in 2021. JAMA Netw Open. 2023;6(5):e2313583. doi:10.1001/jamanetworkopen.2023.13583
  2. Jablonski JJ, Cheetham AG, Martin AM. Market Survey of Modern Oral Nicotine Products: Determination of Select HPHCs and Comparison to Traditional Smokeless Tobacco Products. Separations. 2022; 9(3):65.