Sir, nicotine pouches, also referred to as non-medicinal nicotine pouches or tobacco-free snus, are small receptacles that contain white nicotine powder which a user places in the anterior maxillary vestibule.1 They originated in Scandinavia and their distribution is rapidly widening to other countries, with five tobacco manufacturers currently selling their products in the UK.1 Currently unregulated in the European Union, their packaging carries no health warnings and are widely advertised online, on billboards and buses as 'harmless tobacco-free alternatives'.2

The evidence behind the correlation of nicotine and cancer development is inconclusive, although several studies have illustrated that nicotine can facilitate a tumour-supporting environment and has proven genotoxic effects.3 Oral mucosal changes (for example, hyperkeratotic changes) behind habitual oral nicotine use have been documented.4

These nicotine pouches are being marketed as a vogue and safe way to get a 'nicotine hit' without the associated negative health consequences of traditional tobacco or snus use. They are available in a wide variety of flavours and packaged in fashionable tins with coloured logos which have great visual appeal.1,2

As a hospital clinician, I had no prior knowledge of these products despite distributing smoking cessation advice on a daily basis. With such a paucity of information available regarding these products and their associated potential harmful consequences, how is a layperson supposed to make an informed decision regarding their use?

I am deeply concerned that these pouches provide a gateway to traditional tobacco smoking via nicotine addiction. Even if they may offer a harm-reduction means for established tobacco users to get their 'nicotine hit', we must not take tobacco companies at their word; rigorous independent research is imperative. We have seen an uptake of new-generation smokers with vaping and smokeless tobacco and now know of the established detrimental health effects.5 We must act urgently and in unison, lest we repeat our mistakes.