Nicotine sachets, vaping or cigarettes: which nicotine product is actually the least harmful?

“Do you smoke cigarettes?” I asked my patient succinctly during a recent clinic appointment.

He responded matter-of-factly, “Not anymore, I use Zyn pouches now.” »

As with any patient, I assessed their willingness – or reluctance, in some cases – to discontinue their nicotine consumption.

I asked him about his interest in trying nicotine replacement therapy, a medical treatment that provides low, controlled amounts of nicotine. At first, his answer surprised me.

“Don’t I already use nicotine replacement products? » he asked astutely.

I collected my thoughts and explained that while nicotine pouches are indeed a form of nicotine replacement, there are some important caveats. Nicotine replacement therapy products are regulated by the Food and Drug Administration to help people quit smoking. In contrast, I explained that Zyn and other nicotine pouches are commercial tobacco products regulated by the FDA, but are not FDA-approved smoking cessation medications.

My patient was surprised because he didn’t realize there was a difference, which is a common misunderstanding. This meeting proved pivotal in the direction I would take in my subsequent clinical encounters.

As an addiction doctor, I often speak with patients who use nicotine in various forms.

Understanding how these products differ and what we know about their relative risks can help people make more informed choices.

Put an end to good/bad thoughts

One of the most important distinctions I make when talking to patients is the distinction between harm caused by nicotine itself and harm caused by the way it is administered.

Combustible tobacco products such as cigarettes expose users to thousands of chemicals produced by burning tobacco, while newer products such as vapes deliver nicotine without combustion.

But the absence of combustion does not make newer products inherently safe. Nicotine remains addictive, and studies have raised concerns about its cardiovascular effects, including changes in heart rate, blood pressure, and underlying vascular function.

The long-term health effects of new nicotine products – particularly nicotine pouches – are not yet well established.

As a result, discussions about which nicotine product is right for a given person do not fall into categories of “good” or “bad.” Rather, they involve nuanced conversations with patients to help them achieve their goals and reduce overall harm.

Additionally, the health consequences of a nicotine product depend not only on what it contains, but also on who uses it, how they use it, and what it replaces. The relative harms vary greatly when talking about a current smoker switching to e-cigarettes versus a non-smoker starting vaping. The same distinction applies to nicotine pouches: Their low exposure to many toxic chemicals does not make them risk-free, especially for teens and other nonsmokers who have never used nicotine before.

Relative harms

In 1965, 42.4% of the American population smoked. By 2022, this figure had fallen to 11.6%.

This dramatic decline is not due to a single intervention, but to decades of accumulating scientific evidence, public education campaigns, warning labels, restrictions on advertising, smoke-free policies, higher tobacco taxes, and changes in social norms. At the same time, the tobacco landscape has evolved, with more and more non-combustible nicotine products such as e-cigarettes and nicotine pouches.

In the United States, 6.5% of adults reported using e-cigarettes in 2023, while past-year nicotine pouch use increased from 3.4% in 2023 to 5.9% in 2024. This rapidly growing trend makes it clear that the public needs a better understanding of the relative harms of nicotine products.

Let’s be clear: the main source of cigarette-related harm is the combustion of tobacco, not just the presence of nicotine.

Tobacco smoke contains thousands of chemicals, many of which are toxic and carcinogenic, leading to an estimated 2.5 million cancer deaths per year worldwide.

Patients also often land in the hospital with smoking-related complications, including chronic obstructive pulmonary disease and cardiovascular disease.

While nicotine itself is the cause of addiction, it is the toxic mixture generated by burning tobacco leaves that makes cigarettes so extraordinarily harmful.

Nicotine products compared

So where do vaping cigarettes, heated tobacco – also known as “heat-not-burn products” – and oral nicotine fall on the safety spectrum?

• Electronic cigarettes – or vapes – generally contain lower and lower levels of many toxic chemicals compared to cigarette smoke. However, inhaled aerosols may still contain harmful substances such as propylene glycol, which is often found in some medications, cosmetics and food products. Although propylene glycol is classified as “generally safe” by the FDA for use in foods, this designation does not establish that it is safe for inhalation. The lungs process substances differently than the digestive system, and the health effects of chronic inhalation of propylene glycol via e-cigarette aerosol remain incompletely understood.

• Heated tobacco products such as processed tobacco sticks, loose-leaf chambers, tobacco capsules and pods, or carbon-tipped pods generally heat tobacco to lower temperatures instead of burning it. This can lead to less exposure to harmful substances compared to conventional cigarettes. However, the Centers for Disease Control and Prevention considers any tobacco product to be harmful, since these products still contain nicotine and other tobacco-derived toxins.

• An increasingly important product is the nicotine pouch, such as the Zyn brand product. Sales of nicotine pouches in the United States have increased significantly in recent years, especially since 2023. Unlike traditional smokeless tobacco, nicotine pouches do not contain any tobacco leaves; instead, they contain nicotine, flavorings and other ingredients. Users typically place a pouch between the upper lip and the gum, where the nicotine is absorbed into the tissues of the mouth.

Nicotine pouches generally result in less exposure to many toxic substances, since there is no combustion or inhaled aerosols. However, they can deliver significant amounts of nicotine. Depending on the product, a single pouch can contain several milligrams of nicotine – an amount comparable to or greater than the amount of nicotine you would otherwise get from a cigarette. These products therefore remain addictive.

For all nicotine products, the relevant comparison is not “safe” versus “unsafe,” but rather “more harmful” versus “less harmful.”

FDA-approved nicotine replacement therapy

Nicotine replacement therapy, on the other hand, is an FDA-approved medical treatment that delivers low, controlled amounts of nicotine without the many carcinogens and toxic chemicals found in tobacco smoke. These products come in the form of patches, gums, lozenges, nasal sprays and inhalers, intended to reduce cravings and withdrawal while helping people gradually transition away from smoking.

Unlike nicotine replacement therapies, which are FDA-approved and supported by strong evidence of their effectiveness in quitting smoking, e-cigarettes are not FDA-approved cessation treatments, despite evidence that they can help some people quit smoking. Evidence for the usefulness of nicotine pouches as a cessation aid remains limited, and they have not been approved by the FDA for this purpose.

Nicotine and tobacco consumption patterns also vary considerably between countries and populations, reflecting differences in culture, tobacco control policies, product availability and consumption patterns.

Similarly, access to smoking cessation treatment and harm reduction resources varies significantly between countries. In the United Kingdom, for example, cessation services are integrated into the country’s National Health Service, while Australia offers state-based “Quit” line services and allows regulated access to certain nicotine vaping products through pharmacies. Many countries have limited or no comprehensive services focused on smoking cessation, and access to medications such as nicotine replacement therapies remains uneven.

Putting the risk linked to nicotine into perspective

For people who don’t use nicotine, there’s no reason to start. For smokers, quitting remains the best option. But if quitting smoking isn’t immediately feasible, moving away from combustible tobacco can reduce exposure to harmful chemicals in cigarette smoke.

The goal is not to label every nicotine product as “good” or “bad,” but to help people understand the tradeoffs — and make choices that lead them to less harm and, ultimately, away from nicotine addiction.