Canada’s decades-long fight against tobacco and smoking now confronts a new adversary: nicotine pouches. Though authorized in Canada for smoking cessation, these dissolvable, microfiber buccal pouches containing flavored, concentrated nicotine powder or salts have quickly become the fastest growing nicotine category used by young people.

On social media platforms like TikTok, health influencers tout benefits that include greater focus and concentration, appetite suppression and weight loss, anxiety and stress relief, and a cleaner alternative to vaping. Stopping smoking is rarely, if ever, the reason for use. And most of the pouches have been acquired illegally online or by mail.

“Nicotine pouches are likely to have a greater role in expanding the nicotine market overall,” David Hammond, PhD, University Research Chair and professor of public health sciences at the University of Waterloo in Ontario, told Medscape News Canada.

“Tobacco companies, almost entirely due to e-cigarettes and now pouches, have been able to increase nicotine sales for the first time in many decades. They’ve managed to bring in a new generation of people who will probably never smoke but are interested in using a vape or, more recently, a pouch.”

In addition to reversing the strides made against nicotine and tobacco, illegally obtained products entail risk for exposure to potentially adulterated additives and elevated levels of nicotine powder. They might also lead to oral problems (eg, gum irritation and tooth decay), elevated blood pressure, cognitive side effects, and gastrointestinal issues.

Black-Market Products

Initially, Health Canada authorized only one nicotine pouch product under the Natural Health Products Regulation, Hammond explained. That product is Zonnic nicotine pouch, which contains 4 mg of concentrated, mint-flavored nicotine powder. The category of natural health products is commonly reserved for lower risk products, such as sunscreens, vitamins, or minerals; carries no age restrictions; and can be often sold in convenience stores and gas stations.

Due to the proliferation of multiflavored black-market products and the growing appeal to youth markets, Zonnic was subsequently moved to behind-the-counter pharmacy sales for adults (aged 18 years or older), limited to low nicotine doses (< 4 mg), and restricted to only mint or menthol flavors.

But the ship appears to have already sailed. In Canada, an ongoing longitudinal study led by the Ontario Tobacco Research Unit underscored a significant, greater than twofold increase between 2022 and 2026 (from 7.6% to 34.8%) in the percentage of 16- to 25-year-old adolescents and young adults who reported ever using nicotine pouches.

“We saw a significant increase in people who had tried pouches, as well as more regular use,” said Michael Chaiton, PhD, a senior scientist at the Centre for Addiction and Mental Health’s Institute for Mental Health Policy Research, director of research at the Ontario Tobacco Research Unit, and associate professor at the University of Toronto’s Dalla Lana School of Public Health and the Institute of Medical Sciences.

“Currently, there’s only one product, Zonnic, that’s sold legally in Canada. But because of this interest and advertising and social media exposure, other products are more commonly known,” said Chaiton.

Chaiton was referring to Zyn, a nicotine pouch manufactured in Sweden and the US that is sold in various flavors and strengths. A newer ultra version contains up to 11 mg of nicotine powder per pouch. “They’re being seen (and used) as stimulant products. The real interest is that they’re convenient and very discreet,” said Chaiton.

His data have also showed a positive association between vaping and pouch use. “Nearly everyone who had tried or was currently using the pouches had also tried vaping. This appeared to be associated with the type of people who are interested in novelty-seeking and looking to try other substances, and this also wasn’t their first experience with nicotine,” Chaiton said.

Risk for Nicotine Toxicity

Despite the limitations on the amount of nicotine powders or salts that can be placed in each pouch, some users appear to be inserting more than one at a time.

“These products are almost certainly harmful when they’re used over the long term,” said Hammond, also noting that nicotine salts in many current products have rapid absorption, which has been associated with acute nicotine poisoning.

Jessica Kent, MD, emergency medicine physician, clinical pharmacologist, and toxicologist at St. Michael’s Hospital, Toronto, and assistant professor at the University of Toronto, underscored the potential for nicotine toxicity following repeated nicotine pouch exposures. In addition to her work at the University of Toronto, she is also a medical toxicologist at the Ontario Poison Centre, Toronto.

Kent said that she may see a case or two per month of nicotine toxicity when she is on call. She is also lead author of a case study published last year in Nicotine and Tobacco Research, detailing a nicotine overdose in a 21-year-old male who consumed 15 extra-strength nicotine pouches (10.9 mg of nicotine/pouch) over 12 hours as a study aid. When he presented at the emergency room, he had elevated heart rate, confusion, and nausea; was admitted for supportive treatment; and received fluids and benzodiazepine for continued agitation.

“There’s a movement right now on social media promoting nicotine as a natural health product, a wellness aid like a supplement. I’ve had patients tell me they use various unregulated healthcare products for personal wellness,” said Kent. “This is something I am going to continue to be vigilant in screening for as it appears to be one of the latest trends.”

Healthcare professionals should be aware of the risks from repeated exposure, Kent and Chaiton noted. When asking about substance use, they should discuss nicotine pouches and provide education on nicotine use, abuse, and dependence. Parents should be advised to keep nicotine pouch containers, which are often brightly colored and look like candy, in safe storage places like locked or high cabinets. Kent encountered an 18-month-old who had gotten ahold of several pouches and ingested them.

“The treatment is relatively straightforward and consists of supportive care,” Kent said. “But there’s no antidote for nicotine toxicity. If you are exposed to enough, or use very large doses, you can stop breathing.”

Hammond, Chaiton, and Kent reported having no relevant financial relationships.

Liz Scherer is an independent medical/health journalist. She frequently reports on Canadian and European Health News.