Naming the Risk, Telling the Harm

It's not just nicotine—it's the history behind it. For decades, the fight against tobacco focused on a visible enemy: the combustible cigarette. But in the 21st century, nicotine products are evolving faster than the policies designed to control them, and the risk landscape has grown more ambiguous—and more political. Curves, voices, nuances, and tensions now define the new battleground of public health.

In the United States, the map of youth nicotine use is once again shifting in shape and color. After the meteoric rise of vaping, which peaked in 2019, when 27.5% of high school students reported using e-cigarettes in the past month, the statistical curves finally began to trend downward.

The immediate temptation is to read that decline as a favorable verdict on restrictive policies. But numbers alone rarely tell stories of causality. Between the peak and the pullback, a tangle of regulatory reforms, shifts in supply, cultural mutations, and—not least—the emergence of substitutes all played a role.

In 2024, prevalence dropped to 7.8% among high school students and to 5.9% across the student population. A partial victory, no doubt—but partial nonetheless. The success of a measure isn't measured only by what it manages to drive out, but also by what fills the space left behind. And into that space, almost in the shadows, slipped nicotine pouches: small, smokeless, tobacco-free packets of powdered nicotine discreetly tucked between the gum and the lip.

In Sweden, a similar pattern with snus—a close relative of pouches—has helped produce the lowest smoking rate and one of the lowest lung cancer rates in Europe. However, transplanting that model to other contexts means confronting cultural resistance, regulatory friction, and vastly different commercial strategies.

In the latest edition of the National Youth Tobacco Survey (NYTS), nicotine pouches now rank as the second most commonly used product among teenagers: 1.8% overall and 2.4% among high school students. For some, they signal an emerging risk; for others, they represent evidence that nicotine—stripped of smoke and flame—can shift form without losing its allure, while substantially reducing the harm traditionally associated with its use.

At this crossroads, public health confronts a paradox as old as it is persistent: how to manage a product that, on one hand, offers the promise of reduced harm compared to more lethal alternatives, and on the other, threatens to reshape the landscape of addiction among the young.

Regulating too early could stifle a potential harm-reduction tool; regulating too late, however, allows the market to set its own rules—often driven more by profit than by the public good. In that uncertain space, where science moves slower than marketing, the challenge isn’t merely deciding what to ban or allow, but anticipating what forms—and faces—nicotine will take in the years ahead.

The Heart of the Dispute: Voices and Narratives

One of the loudest voices to recently reignite the debate came from Leana S. Wen, an emergency physician and columnist for The Washington Post. In her July 15, 2025, column, Wen warned that nicotine pouches pose an emerging threat to youth health. Her argument rests on three pillars:

Neurotoxicity in adolescents — backed by studies linking early nicotine use to deficits in memory, attention, and impulse control, as well as heightened vulnerability to anxiety and depression.

Rising youth use — citing research published in JAMA Network Open, which found a doubling in usage among 10th to 12th grade students: from 1.3% in 2023 to 2.6% in 2024. This is compounded by the prominent ranking of pouches in the 2024 NYTS.

Marketing echoing the vaping boom — appealing flavors, including childlike ones in illicit markets; indirect promotion through influencers; visibility at festivals and in fashion magazines; and an aesthetic that flirts with rebellion.

Wen’s approach, while firm in its warning about potential risks, operates in a space where the evidence remains fragmented.

Her diagnosis leans toward projecting high-impact scenarios from early signals—a recurring pattern in public health when the goal is total prevention. Yet this framing risks inflating preliminary correlations—not yet proven as causation—and overlooking the diversity in adolescent usage patterns. While her warning may serve as a useful trigger for early monitoring, it can also reinforce an alarmist narrative that prematurely shuts down discussion on the harm-reduction potential for adults.

In other words, Wen aligns with a zero-risk logic that has historically treated any new form of nicotine as a threat to be neutralized, rather than as a vector that, if properly managed, might displace more harmful practices.

At the opposite end of the debate stands Matthew Holman, Chief Scientific and Regulatory Strategy Officer at Philip Morris International (PMI) in the United States. In his formal response, Holman cites FDA reports that authorized the marketing of twenty ZYN products. According to these documents:

• The products have low appeal among individuals who have never used nicotine or who have quit.

• “A substantial proportion” of adults who try them fully replace cigarette consumption.

• While not zero, the risk of youth initiation was assessed as low.

• Full substitution is associated with significant health improvements, including marked reductions in biomarkers of exposure.

Holman also emphasizes that PMI does not market combustible cigarettes in the United States and points to a series of responsible marketing policies as evidence of the company’s commitment: no paid influencers, the use of models over 35, and digital content restricted to those over 21.

However, these commitments—while plausible on paper—are not without ambiguity: they rely entirely on the company’s self-assessment and lack independent audits to verify actual compliance. The absence of external oversight turns these policies into promises rather than guarantees.

His intervention fits within a broader corporate narrative which, though backed by FDA-validated data, operates on two fronts: on one hand, legitimizing the product as a lower-risk alternative to cigarettes; on the other, securing a strategic foothold in a market where the shift from combustible tobacco to smokeless nicotine represents both a public health opportunity and a commercial expansion path.

This overlap between health interests and corporate profit—unusual, but not impossible—demands ongoing scrutiny, precisely to ensure that the “harm reduction” narrative doesn’t become a rhetorical shield against stronger regulation.

Positioned between both camps is Brad Rodu, professor of medicine at the University of Louisville and a prominent figure in tobacco harm reduction research. Rodu challenges the figures cited by both Leana Wen and Mitch Zeller, former director of the FDA’s Center for Tobacco Products (CTP), regarding high rates of dual use.

Drawing on microdata from the 2024 National Health Interview Survey (NHIS), he argues that 40% of adults who vape are former smokers, 26% are current smokers, and 34% have never smoked—a distribution that, in his view, contradicts the prevailing narrative that dual users make up the majority.

For Rodu, the persistence of dual use reflects less a failure of alternative devices and more a failure of institutional messaging. He argues that official campaigns have consistently equated the risks of vaping with those of combustion, conveying the idea that switching offers no meaningful benefits. This message, he contends, discourages full transition to lower-risk products and inadvertently sustains combined use.

Rodu’s perspective, though grounded in representative data analysis, is framed by a clearly defined outlook: it prioritizes harm reduction as the core of health policy—even if that means accepting some level of initiation among non-smokers. This approach, often at odds with the stringent precautionary principle embraced by figures like Wen, is built on the premise that the net benefits for the smoking population outweigh the potential cost of a new generation of users.

The disagreement, then, isn't settled by numbers—it’s ultimately a clash of regulatory philosophies. One seeks to minimize any emerging risk; the other focuses on displacing the greatest harm, even if total eradication remains a distant ideal.

Ultimately, the current debate over nicotine pouches isn’t just a technical dispute or a quantitative disagreement—it’s a battle over the framework through which we decide which risks to tolerate, whom to protect, and with what tools. Between the rigor of the precautionary principle and the pragmatism of harm reduction lies a tension that is irreconcilable, yet far from new. The recent history of tobacco control is shaped precisely by such inflection points: moments when the definition of the “enemy” shifts, transforms, or dons a new disguise.

The Curve and Its Inflections

In the 1990s and 2000s, the enemy was clear: the conventional cigarette. Among high school students, prevalence exceeded 30%. In 1991, the prevalence was approximately 27.5%. By 1997, this increased to 36.4%, before dropping to 21.9% in 2003 and further reducing to 19.5% in 2009.

Aggressive campaigns, high taxes, advertising bans, and restrictions in public spaces led to a steady decline through the early 2010s. Then came the meteoric rise of e-cigarettes, driven from 2014 onward by more sophisticated devices and flavors that extended well beyond tobacco and menthol.

Between 2017 and 2019, the National Youth Tobacco Survey (NYTS) recorded a sharp spike: recent e-cigarette use among high school students jumped from 11.7% to 27.5%. The regulatory response—partial flavor bans, deterrence campaigns—coincided with a cultural shift and the emergence of substitute products. Together, these factors helped reverse the trend.

By 2024, only 7.8% of high school students and 5.9% of all students reported recent e-cigarette use. Overall, tobacco product use dropped to 10.1% in high school and 8.1% across the student population—less than a third of the vaping peak.

But the statistics also cast shadows. The rise of pouches shattered the sense of control: among youth, they surpassed combustible cigarettes and cigars in usage, echoing—according to critics—the same seductive strategies that fueled the vaping boom.

For harm reduction advocates, however, the distinction is crucial: the risk vector is significantly lower, and the challenge isn’t to ban indiscriminately, but to regulate precisely—maximizing adult substitution while minimizing youth appeal.

The Battle Isn’t the Product. It’s the Narrative

At this juncture, bioethical principles collide and intertwine: beneficence, non-maleficence, autonomy, and justice. Smoking is unquestionably more harmful than using pouches—but if pouches fail to fully replace cigarettes, their potential benefits dissipate. Between unrestricted allowance and outright prohibition lies a narrow corridor requiring policies capable of closing dangerous doors for minors without sealing off vital exits for adult smokers.

Experiences like that of the United Kingdom—where vaping is actively promoted among smokers while youth-oriented marketing faces strict limits—suggest that balance isn’t just desirable, but possible.

For half a century, public health fought smoking with images of blackened lungs. It worked. It saved lives. But it also fused, in the public imagination, nicotine—addictive, yes, but not inherently lethal, with the combustion that kills. Today’s pouch controversy grows in that gap between chemistry and policy.

For some, pouches are a Trojan horse for youth initiation; for others, a bridge to safer ground. Both metaphors, ultimately, are rhetorical devices. Their meaning depends on the narrative frame from which the story is told.

Between alarmism and complacency lies a regulatory, ethical, and narrative path that demands not only solid evidence but a critical reexamination of the stories we tell about what threatens us. Sometimes, the substance matters less than the narrative that tames—or condemns—it.

The recent history of nicotine use among adolescents reveals a curve that doesn’t simply rise or fall—it branches, twists, and redefines itself. Every decline has been hailed as a triumph; every uptick, framed as a threat. But the slope isn’t just epidemiological—it’s also semantic, political, and ethical. What we understand as “risk,” and what we choose to fight, depends as much on the numbers as on the narrative built around them.

From combustible cigarettes to vaping, and now to pouches, public health has navigated a shifting landscape where once-clear categories—smoker, non-smoker, addict, protected—no longer suffice. What was once a clearly defined enemy has fragmented into products, practices, and narratives that defy the binary logic of ban or allow.

In this terrain, regulation can no longer afford to be reactive; it must anticipate, discern nuance, and calibrate with precision. It needs science, unquestionably—but also critical thinking, narrative sensitivity, and ethical courage. Because sometimes, the threat to health isn’t just the substance we inhale or absorb—it’s the story we tell about it.

The past three decades make it clear: the fight against tobacco isn’t a war of decisive victories, but a chain of displacements—from combustion to aerosol, from aerosol to pouch. Each step has marked a retreat from maximum harm and the emergence of new uncertainties. Trying to eradicate every new format with the same force once used against traditional cigarettes ignores an inconvenient truth: where demand persists, supply adapts.

Harm reduction embraces this reality and turns it into a strategy. It doesn’t stem from resignation, but from a proactive principle: to pull consumers away from smoke—where the greatest harm lies—without abandoning those who haven’t yet begun. It’s not indulgence; it’s regulatory pragmatism. It requires building a vigilant framework, with well-calibrated gates that regulate age of access, advertising limits, chemical composition, and taxation—each in proportion to the level of risk.

There is no perfect balance, but there can be a vigilant one—uncomfortable, perhaps, but more sustainable than the illusion of total eradication. Between the ideal and the possible lies a space that doesn’t reject ethics, but reshapes it into regulatory architecture. And in that space—as in all public health policy—what’s ultimately at stake isn’t just how we regulate a substance, but how we regulate a society.

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