It’s ‘just’ nicotine: What clinicians need to know about the rise of nicotine-only products

The health risks when it comes to smoking and vaping have been well-established through public health campaigns that have focused on the harms from inhaling smoke (or, in the case of vaping, the harmful chemicals present in the vaping liquid).But new products have entered the market, such as nicotine pouches and heat-not-burn tobacco, purporting to offer a safer way of delivering nicotine without any of the harmful smoke or chemicals—raising the question of how nicotine in and of itself can impact the body.Dr. Andrew Pipe, who had been the head of the smoking cessation program at the University of Ottawa Heart Institute, notes that nicotine is an “incredibly addictive substance.” “Addiction to nicotine occurs incredibly rapidly, and not only does that occur rapidly, but it's also a very tenacious form of addiction,” he said in an interview with the Medical Post. “Inevitably, people's intake of nicotine may increase, and they may also seek nicotine from other sources, particularly combustion products, which would be of great concern.”The addictiveness of nicotine is often paired with withdrawal symptoms, which can include irritability, restlessness, difficulty concentrating, anxiety and trouble sleeping. “Another huge side effect of the use of nicotine, which falls from its addiction, is that these products are going to suck enormous quantities of money out of your pockets over the years,” Dr. Pipe added.On top of that, nicotine is known to be a vasoconstrictor, which means it can impede circulation.“A number of emerging studies . . . have shown that individuals who use non-combustion nicotine products, and who undergo joint replacement have much higher rates of infection, joint complication,” said Dr. Pipe.Nicotine use during pregnancy can also disrupt placental structure and placental function, he added, impairing the flow of oxygen and nutrients to the fetus.On top of that, Dr. Peter Selby, head of the Nicotine Dependence Clinic at the Centre for Addiction and Mental Health in Toronto, says there’s “theoretical risk” of type-2 diabetes with nicotine, given the fact that it can increase insulin resistance. He also points out that researchers have found nicotine can potentially harm brain development and even act as a tumour promoter. The tobacco industry has also been working hard to downplay the harm that nicotine can cause. The “Unsmoke Canada” ad campaign funded by Canadian tobacco giant Rothmans, Benson & Hedges Inc. acknowledges that nicotine is addictive, but states that it’s “not the primary cause of smoking-related diseases. These are caused by the high levels of toxins released in tobacco smoke.”“It's always best to quit tobacco and nicotine completely, but smokers who don’t should know that smoke-free products that do not burn, produce smoke or ash exist in Canada today,” Unsmoke Canada’s website says. “However, many myths and misconceptions about nicotine are often preventing people from considering smoke-free alternatives over continued smoking. Clearing them up can help adult smokers make informed decisions for their health.”The last several years have also seen the rise of high-profile influencers promoting nicotine pouches to their largely young male audiences, such as the Nelk Boys, Joe Rogan, Andrew Huberman and Andrew Tate. Many of these influencers have made claims that consuming nicotine without smoke can actually elicit health benefits, such as improved focus, increased testosterone levels and weight loss. However, Dr. Selby notes that the supposed cognitive-enhancing benefits of nicotine are often found in people who are addicted to the substance because it gets rid of their withdrawal symptoms.“Everybody says, ‘I was feeling anxious, I couldn't focus, and I took a pouch, and I feel so much better. I can focus.’ Well, yeah, you were in withdrawal. That's why you couldn't focus. That's why you were anxious. And of course, when you take nicotine, you’re going to calm down,” he said.While nicotine has been known to be an appetite suppressant, no medical organization recommends the use any nicotine product for weight loss, given the litany of other health risks. The scientific evidence is also mixed when it comes to whether nicotine can increase or decrease testosterone levels, with much of the existing research focusing on cigarettes rather than smoke-free alternatives.“These sort of incidentally minimal attributes of nicotine use are dramatically outweighed by the other implications of nicotine use,” Dr. Pipe said.Zonnic, the only brand of nicotine pouches approved for sale in Canada, contains up to 4 mg of nicotine and is only offered in mint flavour. Under the ministerial order issued by then-Health Minister Mark Holland last year, 4 mg is the maximum amount of nicotine permitted for non-prescription pouches and flavours are not permitted, except for mint and menthol. The order also removed the products from gas stations and convenience stores, making them only available behind the counter at pharmacies.Yet, illicit pouches with much higher nicotine content and fruity flavours continue to be readily available for Canadians to purchase online, usually imported from the United States or Europe. For some illicit pouches, the nicotine content can be as high as 16.5 mg, which is more than four times the legal limit in Canada. Dr. Selby warns that particularly high doses of nicotine can result in nicotine poisoning, especially among children.This past August, the Canadian Task Force on Preventive Health Care put out their updated guidelines on smoking cessation and issued a conditional recommendation against e-cigarettes. However, nicotine pouches were not included in the analysis, despite the fact that these products are approved by Health Canada as a smoking cessation device. Dr. Selby, who served as an expert on the committee, says this is because of the limited randomized controlled trials that show whether they are an effective smoking cessation aid compared to established methods.“You’re living in a country where there’s science. That’s the science. Based on the science, that will be the recommendation,” he said.

It’s ‘just’ nicotine: What clinicians need to know about the rise of nicotine-only products

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