Nicotine pouches are often sold as the gentler cousin of traditional snus — tobacco-free, cleaner, easier on the mouth. A new Swedish clinical study suggests that is only half right. Pouches cause less of the thickening that snus is known for, but they produce a different and in some ways more aggressive kind of oral irritation — and every ulcer researchers saw was in a pouch user.

The study, published in the peer-reviewed journal Oral Diseases by researchers at Karolinska Institutet and Folktandvården Stockholm (the Public Dental Service), examined 272 young adults aged 18–30 with a mean age of about 22. They were split into three groups: users of tobacco-free nicotine pouches, users of traditional portion snus, and a control group who used neither. Smokers and anyone using nicotine replacement therapy were excluded. Each participant had a clinical examination of their oral mucosa and dental health.

What the study found

Mucosal changes were common in both groups, but the type of damage was strikingly different:

• 79% of nicotine pouch users had some form of local change in the mouth, compared with 89% of traditional snus users. The changes were generally less extensive among pouch users.
• Snus users developed hyperkeratosis — a thickening of the mucous membrane, the classic "snus lesion" or callus-like patch where the pouch sits. This is a long-term tissue adaptation.
• Pouch users showed more erythema — redness and inflammation — and reported more oral discomfort.
• Every ulcerative lesion observed in the study was in a nicotine pouch user. None were found among traditional snus users or the control group.

One of the most notable findings was about dose. With traditional snus, oral changes became more pronounced as people used more — a clear dose-response pattern. With nicotine pouches, that pattern disappeared: inflammatory reactions did not correlate with how much someone used or for how long. Some users had strong reactions at low consumption; others had little at high consumption. The severity was, as the researchers put it, more individual and harder to predict.

Mint-flavoured pouches showed a possible link to stronger mucosal reactions, but the relationship did not reach statistical significance and the researchers cautioned against over-interpreting it.

On two questions people often ask — does either product cause tooth decay or receding gums? — the study found no statistically significant difference between the snus groups and controls in caries, periodontitis, or gingival recession, across up to six years of use.

Why it matters

The findings challenge a simple "pouches are milder" narrative without flipping to "pouches are worse." The picture is more specific: pouches and snus damage the mouth in different ways. Snus produces the familiar thickened patch — a slow tissue adaptation. Pouches produce inflammation, redness, and in some cases open ulcers that appear more rapidly and less predictably.

That distinction matters for the millions of young adults who have picked up nicotine pouches in the past few years, many of whom switched from snus or cigarettes believing pouches are gentler. The study suggests that "tobacco-free" does not automatically mean "easy on the mouth." High pH levels — needed to push nicotine through the oral mucosa — and flavouring agents, especially mint and menthol, are the likely culprits behind the irritation, not nicotine itself.

Lead researcher Lars Fredriksson, Senior Dental Officer at Folktandvården Stockholm, said the mucosal reactions from white snus are "more difficult to predict than those seen with traditional snus" and that their "severity also appears to be more individual."

The study also puts the findings in a wider context: cigarette smoking is clearly associated with tooth loss, gum disease, tooth decay and oral cancer, while epidemiological studies of Swedish portion snus have not demonstrated links to those diseases. The local mucosal changes observed in pouch and snus users are, as the researchers note, a different and less serious type of effect — but that does not mean they should be ignored, especially when young users are developing lesions and ulcers.

What's next

The researchers call for larger, long-term studies to understand how different nicotine pouches affect oral health over time — particularly how flavourings and pH adjusters interact with oral tissue. A separate study is already underway at the University of Gothenburg, led by Professor Gita Gale, investigating redness and irritation following reports from users of acute changes under the lip.

The study was funded by the Public Dental Service (Folktandvården), not by industry — a detail that matters given how much of the existing pouch research is industry-funded. It was published in Oral Diseases (Wiley), a peer-reviewed dental journal.

For people who use nicotine pouches, the practical takeaway is not to panic but to pay attention: redness, soreness, or ulcers under the lip are not something to ignore, and if they persist, a dentist should look. The study suggests that moving the pouch to different spots in the mouth and paying attention to flavour and pH may reduce irritation — though the long-term answers still have to come from the research that has not been done yet.

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SOURCES:

• Daneshian et al. "Oral Lesions and Dental Status in Individuals Using Oral Tobacco-Free Nicotine Pouches." Oral Diseases (Wiley), 2026. DOI: 10.1111/odi.70409. Wiley Online Library
• Vejpkollen. "Fewer long-term health problems – but more irritations with white snus." 4 July 2026. vejpkollen.se
• Tobacco Journal International. "Study questions white snus safety." 7 July 2026. tobaccojournal.com