Sir, I read with great interest the article by Cameron et al. discussing the effects of e-cigarettes on oral cancer risk.1 Among other Alternative Nicotine Delivery Systems, I would like to draw your attention towards the oral nicotine pouches (ONPs) which have recently been garnering attention on social media platforms due to their rising popularity among adolescents.

Tobacco harm reduction tools are strategies or products designed to minimise the health risks associated with tobacco use, particularly smoking. These tools aim to provide smokers with safer alternatives to traditional combustible tobacco products like cigarettes. This entails guiding adult smokers to switch to alternative nicotine-containing products that are expected to pose significantly lower risks compared to tobacco smoking.2 Among the latest developments are ONPs, containing pharmaceutical-grade nicotine extracted from tobacco leaves. Functioning similar to Swedish snus, they are placed between the user's lips and gums, delivering nicotine through the oral mucosa, where it is absorbed via mucous membranes and enters the bloodstream.3

Recently, Zyn nicotine pouches have gained traction on social media platforms like TikTok and Instagram. Their growing popularity among teenagers, aka ‘Zynfluencers', who might otherwise have abstained from nicotine, has sparked debate among healthcare professionals and policymakers. A range of appealing flavours like citrus, coffee and mint coupled with powerful marketing tactics make it appear cool and attractive to young people. The emergence of this trend has raised concerns that Zyn may become the latest nicotine product to entice underage teens, similar to the vaping surge triggered by an e-cigarette brand Juul over several years.4 Ongoing research continues to investigate the safety of these ONPs. Research indicates a correlation between nicotine use and the development of periodontal diseases. As these pouches are held in close proximity to the gingival tissues for prolonged periods, nicotine has been demonstrated to interact with host cells, potentially harming the periodontal innate immune system.5 An additional concern regarding ONPs is the potential ‘gateway effect' which could lead non-users to initiate cigarette smoking owing to its combination of addictive properties and appealing flavours.3 However, the proponents of nicotine pouches argue that despite the potential side effects, the advantages offered by ONPs outweigh the drawbacks. To mitigate the misuse of ONPs among underage individuals and to ensure their effectiveness as a smoking cessation aid for intended users, the implementation of a strong regulatory policy framework could prove beneficial.