Cigarette smoking has been on the decline, but other forms of tobacco are seemingly taking their place, including nicotine pouches such as Zyn, On!, and Velo. In a poll, a majority of Sermo members said they’re mainly concerned about nicotine pouch use in young adults, a group in which products are increasingly becoming popular with.
Nicotine pouches’ discrete nature often makes detection difficult for parents and doctors. While vaping left a trail of clouds and scent, nicotine pouches are a stealth addiction which can make use more difficult for parents and clinicians to detect.
To help you overcome these barriers, physicians can benefit from familiarizing yourself with nicotine pouch terminology, reading a breakdown of the harm-reduction debate, and finding a framework for screening in an era of invisible nicotine use.
What are nicotine pouches?
Unlike other oral tobacco products that contain shredded tobacco leaf, nicotine pouches contain nicotine (often synthetic or nicotine salts), flavorings and sweeteners inside a small envelope made of cellulose. Users place the pouches between their lip and gums, delivering nicotine to their bloodstream through the oral mucosa. Nicotine pouches are small, easy to conceal, and come in a range of flavors, including mint, coffee and citrus.
Since they do not contain tobacco, nicotine pouches are often perceived as a less risky alternative to smoking. However, 4 mg pouches (a commonly used strength) deliver similar total nicotine exposure to cigarettes, suggests one 2025 study. While further research is needed to understand the long-term health effects of these products, nicotine exposure can increase blood pressure, and may also contribute to cardiovascular risk, cause oral irritation and have effects on reproductive health.
How young adults refer to nicotine pouches
If you know the terms adolescents and young adults use to refer to nicotine pouches, you’ll be better able to detect when patients are referring to nicotine pouch usage. Some of the most common terms include:
- Zyn: Zyn is the most commonly used nicotine pouch brand, and as such, the term Zyn is often used generically to refer to nicotine pouches, similarly to how people often say “Kleenex” when referring to any brand of facial tissue. Additionally, the act of using nicotine pouches is often referred to as “Zynning,” with people who use these products often referring to themselves as “Zynners.”
- Lil Zyn Diesel and other variations: Nicotine pouch users have created a number of puns to refer to nicotine pouches and their use, so that they don’t have to mention them by name. Common nicknames for nicotine pouches include:
- El Zynco de mayo
- The Zynternational space station
- Zynbabwe
- Zynachinos
- Zyneronis
- Upper decky/lower decky: These terms refer to the placement of the pouch, either behind the upper or lower lip. The term “full decky” may also be used to refer to using multiple nicotine pouches at once to fill every space in the upper and lower gums. This practice could increase the risk of nicotine overexposure. Some teens also commonly use the word “decky” to refer to the pouch itself.
- Lip pillow/gum pillow: A nickname for nicotine pouches that refers to the small, white appearance of the pouches and their placement in the mouth.
- Hitting: Hitting refers to the “buzz” sensation reported by users when the nicotine is absorbed into the bloodstream.
- Trucker cocaine: Initially a slang term for the stimulant drug Benzedrine (amphetamine) or similar drugs that were historically used by long-haul truck drivers to stay awake during long trips, it is a less common colloquial term sometimes used to refer to nicotine pouches that highlights the stimulating, alerting effect of nicotine.
What does increased nicotine pouch use mean for public health?
Increased nicotine pouch usage poses a threat, potentially reversing progress made against nicotine and tobacco use in recent years. Here’s how nicotine pouches are shaping public health:
The re-normalization of nicotine
One of the main reasons nicotine pouches are becoming an increasing threat to youth populations is that they are re-normalizing nicotine. While decades of public health campaigns on the dangers of tobacco led to a reduction in smoking, the “tobacco-free” branding of nicotine may convince young people that nicotine pouches are safe. One review of studies estimated that somewhere from 9–21% of tobacco-naïve youth have tried nicotine pouches.
A hematologist on Sermo has noticed this. “We’re starting to see more teens using nicotine pouches—often thinking they’re harmless because they’re ‘tobacco-free,’” they write. “It’s becoming a new challenge in counseling and prevention, especially as awareness among parents and schools is still low.”
An emergency medicine doctor on Sermo shared a similar sentiment: “In my practice, I’ve seen growing use of nicotine pouches among youth, often driven by the misconception that they’re safe due to ‘tobacco-free’ marketing. I now screen specifically for these products, as they can lead to nicotine dependence.”
The developmental ‘time bomb’
Nicotine is a neuroteratogen for the developing brain, which continues to mature until age 25. Chronic nicotine use in adolescents can not only negatively impact brain development, but it may alter neural reward pathways and increase vulnerability to future substance use.
With some pouches as strong as 50 mg, the risk of acute nicotine poisoning, especially in adolescents, poses an issue. Many Sermo members are concerned about nicotine pouches’ potential effects on younger generations. In a poll, 24% said they’re even more concerned about adolescent nicotine pouch use than e-cigarettes/vaping, and another 42% said they’re equally concerned about both.
Public advocacy
Sermo members have highlighted the role that doctors can play in advocating for stricter regulations and age verification. “It is imperative that clinicians advocate for immediate regulatory changes like restricting flavors, improving packaging safety, and limiting youth access while also prioritizing adolescent screening, parental counseling, and education campaigns to mitigate both experimental and inadvertent harm within communities,” writes an ophthalmologist.
And it’s not just young people who stand to benefit from raised awareness, according to a resident GP on Sermo. “As a medical resident, I’ve started noticing more cases of nicotine pouch use; not only in clinical practice but also among my friends and my social circle,” they write. “…It’s definitely becoming more common, and I think we need more awareness around the risks and long-term impact of these products even among us Doctors!”
How to prevent nicotine pouch use among teenagers
Physicians can update their clinical workflows to screen for nicotine pouch use. In particular, doctors can plan how to intervene if they suspect an adolescent patient is using nicotine pouches, as traditional anti-smoking lectures aren’t sufficient. To successfully intervene and promote cessation in teenagers using nicotine pouches, physicians can implement the following tactics:
“De-influence” the nicotine pouch
Youth use of nicotine pouches is often driven by public personas or social media influencers who link pouches to productivity, focus and fun activities. To combat this, doctors can explain to young patients how they are being manipulated by these influencers—who often stand to gain financially from brand partnerships. Additionally, it can help to explain how synthetic nicotine and specific flavors can reinforce nicotine dependence through the brain’s reward pathways. The goal is to frame cessation as helping patients to “reclaim their brains” and overcome social media manipulation.
Adapt the 5 A’s for the “stealth” era
You’re likely already familiar with the five A’s of tobacco intervention. With the growing use of stealth nicotine products such as nicotine pouches, you can adapt the first three principles to help patients using nicotine pouches:
- Ask: it’s no longer sufficient to simply ask patients if they use tobacco; you should also ask them if they have tried nicotine pouches, Zyn, or lip pillows. Using slang can be useful, as younger patients may not even realize that what they are using are nicotine pouches.
- Advise: The long-term health complications of nicotine usage can feel far off and abstract to teenage patients, but you can try to connect nicotine use to things the patient cares about now. For instance, if they are an athlete, you can highlight the negative effects nicotine can have on the cardiovascular system and overall performance, or you can also emphasize to patients that nicotine use can affect their oral health, leading to more time spent at the dentist.
- Assess: If you suspect a teenage patient is addicted to nicotine pouches, use tools like the Hooked on Nicotine Checklist (HONC) to help you make a formal diagnosis. The development of high-concentration pouches means that dependence can happen faster than with early-generation vapes, making it important that you have the tools to diagnose dependence so you can intervene as early as possible.
Clinical interventions
If you suspect dependence, you need resources to help your patients quit. Fortunately, the American Lung Association has tobacco cessation and education resources. You should also make sure to familiarize yourself with the drugs (such as Zyban) that can be used for nicotine withdrawal.
Parental guidance
Due to the discreet nature of nicotine pouches, many parents do not know that their teenager is using the products, or even that they exist. Doctors can educate parents on what to look for, and encourage parents to have open conversations with their kids. Instead of starting with a “drug search” of their kids’ room, which often leads to resentment and deeper concealment, parents can start with open conversations about what their kids are seeing on social media.
What growing nicotine pouch use means for doctors
Some Sermo members are adapting to the popularity of nicotine pouches. 20% of polled members said they’ve updated their screening or patient education protocols, and 35% said they occasionally use new protocols, depending on the patient. “We may be underdetecting [the prevalence of nicotine pouches], particularly among younger workers or those shifting from traditional smoking,” notes one general practitioner. “This calls for an update in screening questions and educational efforts, even outside adolescent care.”
As mentioned, it’s not necessarily sufficient to ask patients whether they smoke. You can screen patients, and young patients in particular, for other types of nicotine use. Screening questions you can ask include:
- “Besides smoking or vaping, are you using any other products that contain nicotine?”
- “Have you heard of or tried nicotine pouches like Zyn or Velo?”
- “How are you getting information about these products?”
Asking these questions can help you identify patients using nicotine pouches and why they decided to start using these products, which would provide you with an opportunity to discuss nicotine risks and advocate against misleading marketing.
Key takeaways
While nicotine pouches do not contain tobacco, they still pose a risk to public health. The nicotine in these products poses risks like cardiovascular and oral health problems, and impaired brain development in adolescents. You can protect your teenage patients by updating your screening protocols, helping them to understand how nicotine can affect their growth, and offering cessation support.
The Sermo community is discussing how to counteract public health threats like these, by sharing knowledge gained from real-life experiences. Join the community to share real-time clinical strategies and advice, and add your voice to the collaborative effort to combat the spread of nicotine addiction.
