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As FDA approves marketing for nicotine pouches, some doctors sound alarms

▶ Watch Video: Child psychologist breaks down the risks of ZYN and other nicotine pouches for young people

The U.S. Food and Drug Administration authorized marketing of four new flavored nicotine pouch products this week, bringing to 30 the number of such products the FDA has recently greenlit after considering the public health impact.

Tuesday’s decision on pouches from the brand “on!” is the latest in a series of steps by the Trump administration aimed at boosting this fast-growing sector of the industry. Last week, the White House TikTok account posted a video showcasing the nicotine pouch brand ZYN that included Joint Chiefs Chairman Dan Caine saying the U.S. military consumes “a lot of nicotine.”

In June, the FDA cleared the way for ZYN to market 20 of its products with the favorable new claim that “Using ZYN instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” The new labeling, which designates it as a “Modified Risk Tobacco Product,” was the first ever granted to a nicotine pouch brand.

Marketing nicotine pouch flavors like Rich Berry, Cappuccino, Citrus and Cinnamon raises particular concerns for health advocates because of their potential appeal to kids. 

The pouches create a “profound risk for a nicotine-naive person to get dependent and addicted,” said Dr. Brian King, executive vice president of U.S. programs at the Campaign for Tobacco-Free Kids.  

The brands covered by the FDA’s orders are manufactured by subsidiaries of two of the world’s largest tobacco companies: Philip Morris International, which makes ZYN, and Altria Group, for the “on!” brand.

Altria Group told CBS News in a statement: “No kid should ever use tobacco or nicotine products. Full stop.” They said, “Evidence shows that flavor variety can help make those smoke-free alternatives more appealing to adults seeking to transition away from cigarettes.” 

A U.S. spokesperson for Philip Morris International told CBS News, “ZYN is intended as a better alternative for current legal-age nicotine consumers who would otherwise continue to smoke—the most harmful form of consuming nicotine—or use other traditional tobacco products.” 

Nicotine pouches represent the fastest growing segment of the U.S. tobacco market. Between January 2023 and August 2025, monthly sales skyrocketed by 250%, CDC Foundation analysis found. Philip Morris International recently opened a $1.2 billion nicotine pouch manufacturing plant in Aurora, Colorado. 

Health concerns

Critics fear the products could be exposing a new generation to the risks of nicotine addiction and have urged more research. 

“Just because we don’t have evidence at this point doesn’t mean that there’s no harm,” said Dr. Purnima Kumar, chair of the Department of Periodontics, Oral Medicine, and Dental Hygiene at the University of Michigan. 

According to the World Health Organization, 16 countries have banned the sale of nicotine pouches. 

The legal age to buy nicotine pouches in the U.S. is 21 years old, but about 460,000 middle and high school students reported using them last year, according to the latest National Youth Tobacco Survey. That makes pouches the second most commonly used form of tobacco product for young people, behind e-cigarettes. 

Nicotine pouches contain a nicotine powder or salt that’s derived from the tobacco plant, as well as plant fiber, flavoring, and other chemicals. The nicotine salt allows the nicotine to cross the blood-brain barrier more easily, making higher levels of nicotine more palatable, according to King.

Dr. Bonnie Halpern-Felsher, a professor of pediatrics at Stanford University, warns that youth nicotine use can prime the brain toward addictive behavior. 

“You’re changing your brain,” Halpern-Felsher said. 

There are also cardiovascular concerns, according to Dr. Aruni Bhatnagar, director of the American Heart Association’s Tobacco Regulation and Addiction Center at the University of Louisville. He said nicotine causes elevated heart rate and blood pressure, and can constrict blood vessels. As a result, the heart is forced to pump faster and blood circulation is stressed.

“We know that there’s a strong link between [nicotine and] blood pressure and heart disease, and particularly heart attacks,” said Bhatnagar.

The area where the pouch sits, inside the mouth against the gums, has caught the attention of dentists and oral surgeons. 

Kumar said the lining of the mouth responds to physical irritation by thickening and whitening. Beyond the white patches, which disappear when pouch use stops, a lasting concern is gum recession, which is irreversible.

While decades of research have explored the health impacts of tobacco and nicotine, Kumar said the recent rise in popularity of oral nicotine pouches means the science is still catching up. 

“More studies are urgently needed,” she said. 

The U.S. spokesperson for Philip Morris International told CBS News the harm surrounding cigarette smoke is clear, and the company is “proud to responsibly provide less harmful modern nicotine alternatives to America’s 45 million legal-age nicotine consumers.” 

There are more than 7,000 chemicals in cigarette smoke, and more than 70 are linked to cancer. While the company acknowledged nicotine is addictive, it said, “It’s the other harmful chemicals in cigarette smoke that are the primary cause of smoking-related diseases.” 

An FDA spokesperson told CBS News that the government’s “modified risk” authorization for ZYN “does not mean these products are safe or risk-free.” 

Instead, the agency says it determined, “based on a rigorous scientific review,” that there is evidence the product helps smokers quit cigarettes, so it believes the decision is “appropriate for the protection of the public health under the statutory standard.” 

The FDA continues to warn “there is no safe tobacco product, and those who do not use tobacco products should not start.” 

King emphasized that if pouches initiate new users, “it could jeopardize the considerable public health progress we’ve made in addressing tobacco product use over the past several decades.” 

The FDA is requiring the owner of ZYN to “conduct postmarket surveillance and studies,” and its status as a “Modified Risk Tobacco Product” will expire in five years. The FDA wrote, “If at any point the agency determines that, among other things, the continued marketing of the products as MRTPs no longer benefits the health of the population as a whole, such as if there is a significant increase in youth uptake, the agency may withdraw the orders.”

This story has been updated to include a statement from Altria Group and to identify some additional flavors being used in nicotine pouch products.

GOP lawmakers keep trying to defang voters in their own states

(CNN) — The big headline out of Tuesday’s primaries was the slim victory of former public health official Abdul El-Sayed in Michigan’s Democratic Senate primary — proof that progressives are ascendant in the party, even in a key swing state.But two other results that barely registered in the national news chart another trend in US politics: the increasingly complicated relationship between Republican state legislatures and direct democracy.Voters in Kansas saw through a complicated ideaIn Kansas, voters rejected a proposal placed on the ballot by the state’s GOP-dominated legislature that would have taken the power to appoint state Supreme Court justices away from a merit board and the state’s governor, a Democrat.Instead, the amendment would have given voters power to elect state Supreme Court justices, who have been a thorn in the side of the GOP-dominated legislature. That might sound like voter empowerment, but the longer-term intent was to elect judges opposed to abortion rights so the court might eventually overturn the right to abortion in the state’s constitution, which was affirmed by voters in a 2022 ballot initiative.Bottom line: Anti-abortion rights activists hoped to use this amendment to overrule voters’ decision to uphold abortion rights. But voters understood this and rejected the move.Voters in Missouri protected their powerIn Missouri, voters rejected a measure placed on the ballot by the state’s Republican-dominated legislature that would’ve made it much harder to pass amendments placed on the ballot by citizens gathering signatures.Legislators’ goal was to create a two-tiered system: Constitutional amendments proposed by voters would have had to win in every congressional district in the state to pass, while amendments proposed by the state legislature would still need just a statewide majority.The important additional context is that Missouri’s GOP-dominated government has already drastically gerrymandered the state’s congressional districts to benefit Republicans, including by erasing a Democratic seat earlier this year.Functionally, the change would’ve given conservatives veto power over constitutional amendments proposed by Democrats or progressives, even if they were broadly popular.Missouri voters have routinely crossed their legislatureIt’s not just abortion rights that Missouri voters have endorsed in recent years, frustrating Republican legislators. They also expanded Medicaid and increased the state’s minimum wage.On taxes, Missouri voters on Tuesday rejected the legislature’s request to phase out the state’s income tax and, in theory, replace it with a sales tax, a priority of Republican legislatures elsewhere in the country.Take another look at abortion (but not the congressional maps)Missouri voters will not get the opportunity to weigh in on gerrymandering. The state’s top election official denied a citizen petition signed by hundreds of thousands of voters requesting a statewide vote on congressional districts enacted by the state’s GOP-dominated government. Supporters have promised to fight the decision in court.But voters will be asked to take another look at abortion rights. Missouri’s legislature is asking voters to repeal the citizen-initiated amendment they passed in 2024, but with a tweak, adding in the politically potent issue of banning transgender therapy for people under 18.Gerrymandering, the drawing of legislative maps for partisan gain, is frequently described as politicians picking voters instead of the other way around.Republicans won the redistricting war without input from votersIn fact, Republicans were able to get the upper hand in the unprecedented mid-decade gerrymandering war this year in part because they did not have to consult voters about their plans to erase Democratic districts.In California and Virginia, Democrats redrew maps, but only after consulting voters in statewide referendums, as their laws required. Voters in both states approved the concept of new maps, but only California’s will go into effect. In Virginia, state Supreme Court justices are appointed by the state legislature and a majority made up mostly of justices appointed in years when Republicans controlled the legislature threw the voter-blessed maps out, ruling they did not adhere to a strict process.There are stories like this all over the countryIn Florida, there’s already a supermajority requirement (60%) for citizen-initiated amendments to pass. That’s why, in 2024, solid majorities of voters supported restoring some abortion rights (57.2%) and legalizing cannabis (55.9%), but neither became law.Rather than face such questions again, the state’s GOP-dominated legislature and Gov. Ron DeSantis made it much more difficult and expensive for citizens to add initiatives to the ballot. The new rules, enacted earlier this year, make it a felony to gather more than 25 signatures in support of an initiative without first registering with the state as a petition circulator.When voters are given the opportunity, they tend to uphold abortion rightsIn the 17 states where voters have been asked to weigh in on abortion rights at the state level since Roe v. Wade was overturned, according to KFF, voters have supported abortion rights in all but three instances, in Nebraska and South Dakota, where majorities opposed abortion rights, and in Florida, where the supermajority requirement was not met.Five more abortion-related initiatives are currently expected to appear on statewide ballots in November.Citizen ballot initiatives vs. legislature ballot initiativesIn many of these instances, the divide is between ballot initiatives proposed by citizens and those proposed by the state’s legislature. Citizens have the ability to place initiatives on the ballot in about half of states, according to the National Conference of State Legislatures. CNN’s Fredreka Schouten wrote last year about the surge of efforts to put new hurdles in front of these efforts, which are frequently backed by liberal groups who feel locked out of power in red states.South Dakota voters will vote in November on whether to impose a 60% threshold on citizen-initiated ballot initiatives. South Dakota voters will also take another crack at Medicaid. In 2022, South Dakotans voted to expand the program offering health insurance to low-income people, bringing it in line with most of the rest of the country under Obamacare. This year, the legislature is asking the voters to drop that expansion if federal funding drops.Voters don’t always follow the scriptIf the trend is for left-leaning groups to use the initiative process to counter conservative legislatures, there are exceptions. California voters in 2024 narrowly rejected a state law that would have created an $18 per hour minimum wage.An initiative that would have raised the minimum wage in Oklahoma was rejected by voters earlier this year. Supporters of the initiative were frustrated that the state’s leaders moved the question to the June primary rather than the November general election. Voters in most states, given the chance, have supported minimum wage hikes, including in Arkansas and Missouri. Oklahoma’s vote means it will retain the federal minimum wage of $7.25 an hour, the product of a 2007 law. Look for Democrats to try to raise that floor the next time they hold majorities in Congress.Voters, ultimately, hold the power. They could throw out the legislators they disagree with. But that power is muted by gerrymandered legislative maps that feed hyper-partisanship in US politics. It could all get worse if, as expected, the redistricting war restarts next year and politicians do even more to pick their voters instead of the other way around.CNN’s Ethan Cohen contributed to this report.The-CNN-Wire™ & © 2026 Cable News Network, Inc., a Warner Bros. Discovery Company. All rights reserved.
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