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Evidence supporting the causal relationship of both passive and active exposure to tobacco smoke with the development of atherosclerosis and cardiovascular morbidity, beginning as early as fetal life, has been found in a wide array of studies, including those using direct measurement of atherosclerosis in humans and animals, noninvasive measurement of injury to cardiovascular end organs, and measurement of associations with biomarkers known to be associated with atherosclerosis and other forms of cardiovascular disease

A 2023 study in Tobacco Control found that flavoring chemicals in pouches impair periodontal immune responses and increase penetration of nitrosamines the flavors themselves may cause harm independent of nicotine

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Risk of nicotine addiction The Centers for Disease Control and Prevention has warned that bidis contain higher levels of nicotine, tar and carbon monoxide than conventional cigarettes