Over half of nicotine pouch users in a Saudi dental school study had visible lesions in their mouths — but the people who had been using pouches longer did not necessarily have worse damage. The finding, published in the peer-reviewed journal Tobacco Induced Diseases on 5 August 2026, pushes back against the simple assumption that more time with a pouch under your lip means more harm to the tissue underneath.

The study also turned up a counterintuitive signal about placement habits that the researchers say deserves a closer look.

What the study found

Researchers at King Abdulaziz University Faculty of Dentistry in Jeddah recruited 50 male students and interns who used DZRT — a popular tobacco-free nicotine pouch brand in Saudi Arabia — and included 42 in the final analysis after excluding those who used other smokeless tobacco or medications that affect the mouth. Data was collected between January and March 2025.

Each participant had a clinical oral examination. Lesions were graded on a three-degree scale borrowed from smokeless tobacco keratosis research: Degree I is mild superficial keratosis with slight opaqueness; Degree II is a white patch with moderate wrinkling; Degree III is a thickened white lesion with deep furrows.

The headline numbers:

• 54.8% had some form of oral mucosal lesion. 38.1% were mild (Degree I), 11.9% moderate (Degree II), and 4.8% severe (Degree III). The remaining 45.2% had no visible lesions at all.
• Median duration of use was 11 months, ranging from 2 to 96 months. The median frequency was 5.5 pouches per day, ranging from 1 to 30.
• No significant association between cumulative pouch exposure and lesion severity. The adjusted odds ratio was 1.001 (95% CI: 1.000–1.002, p=0.161) — statistically indistinguishable from no effect.
• Age and smoking status also showed no significant link to lesion severity.
• A borderline finding on placement behaviour. Participants who consistently placed the pouch in the same spot in the mouth trended toward less severe lesions (AOR=0.194, p=0.064) — the opposite of what you might expect. The researchers flagged this as warranting further investigation but cautioned it did not reach statistical significance after adjustment.

Why it matters

The null result on duration is the interesting part — and it comes with important caveats.

The intuitive assumption is that the longer you use nicotine pouches, the worse the tissue damage gets. This study did not find that. But the researchers are explicit about why: they calculated they needed 170 participants for adequate statistical power and recruited only 42. With 80% of users having used pouches for less than a year, any cumulative effect may simply not have had time to show up. A cross-sectional design also means exposure and outcome were measured at the same moment — it cannot establish cause and effect.

The placement-behaviour signal is the more novel finding. If moving the pouch to different spots in the mouth — rather than keeping it in one place — is associated with more severe lesions, that would be unexpected. One possible explanation the researchers raise: the duration each pouch stays in the mouth per session was not measured, and people who move the pouch around may also keep individual pouches in longer. The result is a hypothesis generator, not a conclusion.

The study also adds to a growing and sometimes contradictory body of evidence. A Swedish clinical study at Karolinska Institutet, published earlier in 2026, found that pouch users had more redness and ulcers than snus users but that the inflammatory reactions did not correlate with consumption volume — a similar lack of dose-response. A systematic review by Rungraungrayabkul et al., by contrast, reported that mucosal changes in pouch users did relate to units consumed per day and duration of use. The Saudi study's authors note that varying nicotine concentrations, flavour formulations, and product compositions across studies may explain the differing results.

All participants used the same brand (DZRT), which removes one source of variability but also limits how far the findings generalise to other products and markets.

What's next

The researchers recommend that dental professionals routinely ask patients about nicotine pouch use, inspect placement sites for keratotic changes, and counsel users about potential local effects — particularly limiting per-session contact time until more definitive evidence is available. They call for larger, multi-centre cohort studies with longer follow-up, better measurement of per-session pouch contact time, and data on nicotine concentration and flavour formulation.

For people who use nicotine pouches, the practical takeaway is measured: lesions under the lip are common but, in this sample at least, did not clearly worsen with more use. That is not the same as proof that pouches are harmless to oral tissue — the study was too small and too short to answer that. It is a signal that the relationship between how much you use and what happens in your mouth is less straightforward than it might seem, and that where you place the pouch may matter as much as how long you have been using them.

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SOURCES:

• AlFarabi Ali S, Sahab D, Bukhari A, Baobied M, AlMazrooa S, Akeel S. "The association between duration of nicotine pouch use and oral mucosal lesions in male dental students and interns: A cross-sectional study." Tobacco Induced Diseases, 2026. DOI: 10.18332/tid/224437. tobaccoinduceddiseases.org