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Zamarripa CA, Dowd AN, Elder HJ, Czaplicki L, Tfayli D, Rastogi K, Thrul J, Strickland JC, Moran MB, Spindle TR. A comprehensive review on oral nicotine pouches: Available scientific evidence and future research needs. Exp Clin Psychopharmacol 2025; 33:123-132. [PMID: 39621395 PMCID: PMC11959675 DOI: 10.1037/pha0000755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2025]
Abstract
Oral nicotine pouches (ONPs) are an emergent class of tobacco products that, unlike conventional oral smokeless tobacco products, contain a nicotine powder instead of tobacco leaves. This review synthesizes available data on ONPs in key research domains including survey studies, marketing/advertising studies, chemical characterization and in vitro studies, and clinical studies. Research findings relevant for ONP regulations are summarized, including who uses these products and why, how marketing tactics influence appeal and use intentions, what harmful and potentially harmful constituents they contain, and what acute effects they have on humans. Taken together, the current data suggest that ONPs likely produce less harm to individual users than conventional tobacco products (e.g., moist snuff, cigarettes) and can acutely suppress nicotine/tobacco withdrawal symptoms among current cigarette smokers. Thus, ONPs may be a viable harm reduction option for individuals who switch completely to using them from conventional products. However, randomized controlled trials are needed to determine if established tobacco users would use ONPs long term, and more independent academic research is needed given that most ONP studies to date are tobacco industry-funded. Additionally, ONPs have qualities (e.g., flavors, marketing claims of "tobacco free") that could increase appeal among youth and young adults, and these products can deliver nicotine at levels sufficient to cause dependence; widespread adoption of ONPs among otherwise nicotine-naive individuals may reduce their net public health benefit. This review concludes by suggesting future research directions necessary to increase scientific understanding of ONPs and inform regulations for these increasingly popular products. (PsycInfo Database Record (c) 2025 APA, all rights reserved).
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Affiliation(s)
- C. Austin Zamarripa
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashley N. Dowd
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harrison J. Elder
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lauren Czaplicki
- Department of Health, Behavior and Society, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Dana Tfayli
- Department of Health, Behavior and Society, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Kriti Rastogi
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Justin C. Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan B. Moran
- Department of Health, Behavior and Society, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| | - Tory R. Spindle
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Renard K, Nishihara D, Nilsson J, Larroque S, Martinez J, Giles L. Characterization of the nicotine uptake and safety of Nordic spirit tobacco-free oral nicotine pouches: A randomized cross-over study. Psychopharmacology (Berl) 2025; 242:855-865. [PMID: 39578274 PMCID: PMC11890228 DOI: 10.1007/s00213-024-06721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 11/14/2024] [Indexed: 11/24/2024]
Abstract
RATIONALE Given the nascency of tobacco-free oral nicotine pouches (NPs) and the heterogeneity of commercially available NP brands, there is a need for scientific evaluation of different NP formulations. Nordic Spirit, novel NPs are distinguished by their unique composition. OBJECTIVES To characterize blood nicotine delivery, pharmacokinetics (PK), subjective and physiological effects and to monitor safety of three Nordic Spirit NPs (6 mg, 9 mg and 11.2 mg/pouch) compared with LD tobacco snus (11.2 mg/pouch) and Nicorette® gum (4 mg/unit) following single 30 min use. METHODS This was a randomized, open-label, ten-sequence, single-use, cross-over clinical study with 30 healthy adult Swedish snus users. RESULTS Peak nicotine concentrations (Cmax) ranged from 10.92 to 17.32 ng/mL for the three Nordic Spirit NPs, with a trend toward dose proportionality, and 8.18 ng/mL and 9.23 ng/mL for the LD snus and Nicorette® gum comparators, respectively. Peak concentration for Nordic Spirit NPs was reached (Tmax) after 30 to 38 min, and after 45 min for LD snus and Nicorette® gum. No notable safety concerns were observed after single use for any of the study products. CONCLUSIONS Delivery of nicotine from the three Nordic Spirit NPs appeared to be nicotine content-dependent, based on Cmax and AUC. The amount of nicotine extracted showed positive correlation with the reported Cmax and AUC. For Nordic Spirit NPs, Tmax was immediately after end of use. The characteristics of Nordic Spirit NPs were found to be favourable for profiling NP nicotine delivery and safety in human use, and for further product development. ISRCTN registry study no. ISRCTN75583947.
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Affiliation(s)
- Karine Renard
- JT International (JTI) SA, 8 Rue Kazem Radjavi, 1202, Geneva, Switzerland.
| | - Daisuke Nishihara
- JT International (JTI) SA, 8 Rue Kazem Radjavi, 1202, Geneva, Switzerland
- Scientific and Regulatory Affairs, Japan Tobacco Inc, 4-1-1 Toranomon Minato-Ku, Tokyo, 105-6927, Japan
| | - Johan Nilsson
- CTC Clinical Trial Consultants AB, Dag Hammarskjölds Väg 10B, 752 37, Uppsala, Sweden
| | - Sylvain Larroque
- JT International (JTI) SA, 8 Rue Kazem Radjavi, 1202, Geneva, Switzerland
| | - Javier Martinez
- JT International (JTI) SA, 8 Rue Kazem Radjavi, 1202, Geneva, Switzerland
| | - Lesley Giles
- JT International (JTI) SA, 8 Rue Kazem Radjavi, 1202, Geneva, Switzerland
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Travis N, Warner KE, Goniewicz ML, Oh H, Ranganathan R, Meza R, Hartmann-Boyce J, Levy DT. The Potential Impact of Oral Nicotine Pouches on Public Health: A Scoping Review. Nicotine Tob Res 2025; 27:598-610. [PMID: 38880491 PMCID: PMC11931220 DOI: 10.1093/ntr/ntae131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/30/2024] [Accepted: 05/14/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION Oral nicotine pouches (ONPs) are a new class of nicotine products. This scoping review summarizes evidence on ONPs and explores their potential public health impact. AIMS AND METHODS We conducted a structured literature search for empirical studies across three electronic databases through January 10, 2024. Outcomes included ONP product characteristics, use patterns, beliefs and perceptions, toxicity, and marketing and sales. RESULTS Sixty-two studies were included, 17 were industry-funded. Most studies were from the United States. While large variations across studies were observed in ONP youth prevalence estimates, nationally representative U.S. studies find current use at 1.5% and lifetime use below 2.5% through 2023. Between 35% and 42% of U.S. adolescents and young adults have heard of ONPs, and 9-21% of tobacco-naïve youth were susceptible to trying them. U.S. adult-use estimates varied widely (0.8%-3% current; 3%-16% lifetime use) and were limited to populations with a history of tobacco use. The chemical composition of ONPs suggests fewer harmful/potentially harmful compounds at lower levels than cigarettes and smokeless tobacco (SLT), except formaldehyde. Industry-funded studies find substantially less cytotoxicity compared to cigarettes and suggest that higher nicotine-strength ONPs can deliver nicotine at levels comparable to or higher than SLT or cigarettes, although with slower nicotine release than cigarettes. Evidence on the cytotoxicity of ONPs relative to SLT is mixed. CONCLUSIONS ONPs appear to be less toxic than cigarettes and deliver comparable nicotine, presenting an alternative for combustible product users, although key data are mainly available from industry-funded studies. Data from independent research is critically needed. Industry marketing of ONPs may encourage initiation in youth and situational and dual use in adults. IMPLICATIONS The review provides an initial assessment of the potential role of ONPs in harm reduction and aims to determine unintended consequences of their use (youth uptake and dual-use) and identify populations that disproportionately use the product. This information is essential for tobacco regulatory bodies in determining the net public health impact of nicotine pouches.
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Affiliation(s)
- Nargiz Travis
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC, USA
| | - Kenneth E Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Maciej L Goniewicz
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Hayoung Oh
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC, USA
| | - Radhika Ranganathan
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC, USA
| | - Rafael Meza
- Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jamie Hartmann-Boyce
- Department of Health Promotion and Policy, University of Massachusetts, Amherst, MA, USA
| | - David T Levy
- Lombardi Comprehensive Cancer Center, Georgetown Medical University, Washington, DC, USA
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de Granda-Orive JI, Jiménez-Ruiz CA, Gaga M. The New Tobacco Companies Offensive: The Nicotine Pouches. Arch Bronconeumol 2025; 61:65-66. [PMID: 39562253 DOI: 10.1016/j.arbres.2024.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Revised: 10/25/2024] [Accepted: 10/28/2024] [Indexed: 11/21/2024]
Affiliation(s)
- José Ignacio de Granda-Orive
- Department of Medicine, School of Medicine, Complutense University, Madrid, Spain; Respiratory Department, 12 of October University Hospital, Madrid, Spain.
| | | | - Mina Gaga
- 1st Respiratory Medicine Department, Hygeia Hospital 4 Eritrou Stavrou, Athens, Greece
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Miluna-Meldere S, Vanka SA, Skadins I, Kroica J, Sperga M, Rostoka D. Oral mucosal changes caused by nicotine pouches: case series. Diagn Pathol 2024; 19:127. [PMID: 39300504 PMCID: PMC11412064 DOI: 10.1186/s13000-024-01549-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Accepted: 09/06/2024] [Indexed: 09/22/2024] Open
Abstract
Oral nicotine pouches are the latest products in the tobacco industry. They are manufactured by large tobacco companies and entice tobacco or nicotine addicts, although the products are presented as a 'harmless choice.' Nevertheless, dentists and oral health specialists worry about oral mucosal changes due to product interactions with the oral mucosa. Unfortunately, there are no case reports of oral mucosal changes from nicotine pouches that are also investigated histopathologically. The aim of the present study was to visually and histopathologically investigate oral mucosal changes in nicotine pouch users. An online retrospective survey regarding medical and dental health, dietary habits, and tobacco consumption habits was conducted (n = 50). Respondents were selected for further intraoral and histopathological investigation based on the inclusion criteria. All five respondents had oral lesions that were histopathologically analyzed. Visually, the lesions varied in form and intensity, but all appeared white at the location where the pouches were placed. Histopathological analyses revealed parakeratosis with acanthotic epithelium, intraepithelial and connective tissue oedema, and chronic inflammatory infiltration with lymphocytes and macrophages. Participants received information about nicotine cessation and oral health recommendations. In conclusion, nicotine pouches significantly impacted oral mucosa with white lesions that revealed important changes at the cellular level.
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Affiliation(s)
| | - Sarlote Agate Vanka
- Department of Biology and Microbiology, Riga Stradins University, Riga, Latvia
| | - Ingus Skadins
- Department of Biology and Microbiology, Riga Stradins University, Riga, Latvia
| | - Juta Kroica
- Department of Biology and Microbiology, Riga Stradins University, Riga, Latvia
| | - Maris Sperga
- Department of Pathology, Riga Stradins University, Riga, Latvia
| | - Dagnija Rostoka
- Department of Biology and Microbiology, Riga Stradins University, Riga, Latvia
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Avila JC, Maglalang DD, Nollen NL, Lee SC, Suh R, Malone M, Binjrajka U, Ahluwalia JS. Using Pod Based e-Cigarettes and Nicotine Pouches to Reduce Harm for Adults With Low Socioeconomic Status Who Smoke: A Pilot Randomized Controlled Trial. Nicotine Tob Res 2024; 26:1150-1158. [PMID: 38447095 DOI: 10.1093/ntr/ntae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Alternative Nicotine Delivery Systems (ANDS) such as e-cigarettes (EC) and oral nicotine pouches (ONP) may facilitate the substitution of smoking for those unwilling to quit. This pilot study assesses the harm-reduction potential of EC and ONP among smokers with low socioeconomic status (SES). AIMS AND METHODS Adults who smoked daily in the past 6 months, had a household income < 250% federal poverty level and had no intention of quitting smoking in the next 30 days were randomized 2:2:1 to 8 weeks of 5% nicotine EC; 4 mg ONP or assessment-only control (CC). The primary outcome was a within-group change in cigarettes per day (CPD) from Baseline to week 8. RESULTS Forty-five individuals were randomized (EC: N = 18; ONP: N = 18; CC: N = 9). Analyses included 33 participants who completed the week 8 visit. The mean age was 50.1 years (SD: 10.7) and the average CPD at baseline was 13.9 (SD: 10.1). For those randomized to EC, the average CPD decreased from 14.7 (95% CI: 10.3 to 19.1) at the Baseline to 2.9 (95% CI: .1 to 5.8) at week 8 (p-value < .001). For those randomized to ONP, average CPD decreased from 15.0 (95% CI: 5.0 to 24.9) to 8.3 (95% CI: 1.3 to 15.2) by week 8 (p-value = .01). In the EC and ONP groups, respectively, 4 (28.6%) and 1 (8.3%) participant fully switched from smoking to the ANDS product by week 8. CONCLUSIONS Individuals with low SES who smoke had lower CPD after switching to EC or ONP. These findings show the potential of ANDS in helping smokers switch to less harmful devices. IMPLICATIONS This study provides novel evidence that e-cigarettes and nicotine pouches can be a harm-reduction tool for individuals with lower SES who smoke and are not willing to quit smoking, contributing to reducing tobacco-related disparities in this population.Clinical Trials Identifier: NCT05327439.
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Affiliation(s)
- Jaqueline C Avila
- Department of Gerontology, University of Massachusetts Boston, Boston, MA, USA
| | - Dale Dagar Maglalang
- Silver School of Social Work, New York University, New York, NY, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nicole L Nollen
- Department of Population Health, School of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sangah Clara Lee
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Riley Suh
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Mona Malone
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Urvi Binjrajka
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Jasjit S Ahluwalia
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Németh O, Sipos L, Mátrai P, Szathmári-Mészáros N, Iványi D, Simon F, Kivovics M, Pénzes D, Mijiritsky E. Snus Use in Adolescents: A Threat to Oral Health. J Clin Med 2024; 13:4235. [PMID: 39064277 PMCID: PMC11277688 DOI: 10.3390/jcm13144235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/29/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Snus consumption is increasingly popular, mainly among the youth, due to the promotion of the tobacco industry and the lack of knowledge regarding its adverse effects. Even though some of its systemic complications are common knowledge, the oral consequences are rarely known. Aim: Therefore, the objective of this study is to evaluate the oral health effects of snus consumption among a highly exposed group of adolescent athletes. Design: Participants received an interactive presentation, followed by interviews and dental screenings by young doctors to establish trust. They were categorized into groups based on the frequency of snus usage. The oral hygiene habits and status, snus consumption habits, and awareness about its adverse effects were evaluated. Results: Statistically significantly (p < 0.05), more regular snus users experience gum bleeding while tooth brushing than nonusers (60% and 37%, p = 0.004). Snus consumption and poor oral hygiene have a cumulative effect on oral health. Some young athletes experience ulcerous oral mucosal lesions coinciding with snus placement. Nonusers exhibit greater awareness of the adverse effects of snus than regular users (27% and 49%). Conclusions: Regular snus use negatively affects oral health, especially the gums. Early education is of the utmost importance in preventing snus usage by raising awareness.
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Affiliation(s)
- Orsolya Németh
- Department of Community Dentistry, Semmelweis University, 1088 Budapest, Hungary (M.K.); (D.P.)
- Centre for Translational Medicine, Semmelweis University, 1088 Budapest, Hungary
| | - Levente Sipos
- Doctoral School of Health Sciences, University of Pécs, 7624 Pécs, Hungary
| | - Péter Mátrai
- Institute for Translational Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
| | | | - Dóra Iványi
- Department of Community Dentistry, Semmelweis University, 1088 Budapest, Hungary (M.K.); (D.P.)
| | - Fanni Simon
- Department of Community Dentistry, Semmelweis University, 1088 Budapest, Hungary (M.K.); (D.P.)
| | - Márton Kivovics
- Department of Community Dentistry, Semmelweis University, 1088 Budapest, Hungary (M.K.); (D.P.)
| | - Dorottya Pénzes
- Department of Community Dentistry, Semmelweis University, 1088 Budapest, Hungary (M.K.); (D.P.)
| | - Eitan Mijiritsky
- Department of Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, School of Medicine, Tel-Aviv University, Tel Aviv 64239, Israel
- Goldschleger School of Dental Medicine, Faculty of Medicine, Tel-Aviv University, Tel Aviv 39040, Israel
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Mallock-Ohnesorg N, Rabenstein A, Stoll Y, Gertzen M, Rieder B, Malke S, Burgmann N, Laux P, Pieper E, Schulz T, Franzen K, Luch A, Rüther T. Small pouches, but high nicotine doses-nicotine delivery and acute effects after use of tobacco-free nicotine pouches. Front Pharmacol 2024; 15:1392027. [PMID: 38841367 PMCID: PMC11150668 DOI: 10.3389/fphar.2024.1392027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024] Open
Abstract
Tobacco-free nicotine pouches are new nicotine products for oral consumption. They can contain very high nicotine amounts that have not been addressed with clinical studies yet. Thus, nicotine delivery, effects on craving, and side effects were assessed using pouches with up to 30 mg nicotine. In this single-center, five-arm, crossover study, 15 regular cigarette smokers consumed tobacco-free nicotine pouches from different brands with 6, 20, and 30 mg for 20 min. Comparators were nicotine-free pouches and tobacco cigarettes. At baseline and predefined time points over a study period of 240 min, plasma nicotine concentrations, effects on cigarette craving, and side effects were assessed. Cardiovascular parameters including arterial stiffness were measured using a MobilOGraph. Consumption of 30 mg nicotine pouches has led to a higher nicotine uptake compared with the cigarette (Cmax: 29.4 vs 15.2 ng/mL; AUC: 45.7 vs 22.1 ng/mL × h). Nicotine uptake in the acute phase was rapid during use of the 30 mg pouch and cigarette. Extraction rate of nicotine differed between pouches. Use of all products has reduced acute cigarette craving, even the nicotine-free pouch. During consumption of the cigarette and the pouches with 20 and 30 mg, heart rate increased about 27, 12, and 25 bpm, respectively. Parameters for arterial stiffness were elevated and all pouches have induced mouth irritations. The pouches with 30 mg nicotine had overall the strongest side effects and may induce addiction. As craving was also reduced by products with less nicotine, it is questionable whether such high nicotine contents should be allowed on the market. A limit of nicotine content is warranted. The nicotine release rate varies across products and needs to be known to estimate the nicotine delivery.
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Affiliation(s)
- Nadja Mallock-Ohnesorg
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
- Institute of Legal Medicine, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Andrea Rabenstein
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Yvonne Stoll
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Marcus Gertzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Benedikt Rieder
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Malke
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Nestor Burgmann
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
| | - Peter Laux
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Elke Pieper
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Thomas Schulz
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Klaas Franzen
- Medical Clinic III, Campus Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
- Airway Research Center North, Member of the German Center for Lung Research (DZL), Großhansdorf, Germany
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Tobias Rüther
- Department of Psychiatry and Psychotherapy, LMU University Hospital, LMU Munich, Munich, Germany
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Keller-Hamilton B, Alalwan MA, Curran H, Hinton A, Long L, Chrzan K, Wagener TL, Atkinson L, Suraapaneni S, Mays D. Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study. Addiction 2024; 119:464-475. [PMID: 37964431 PMCID: PMC10872395 DOI: 10.1111/add.16355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/29/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND AND AIMS Oral nicotine pouches (ONPs) probably offer reduced harm compared with cigarettes, but independent data concerning their misuse liability are lacking. We compared nicotine delivery and craving relief from ONPs with different nicotine concentrations to cigarettes. DESIGN This was a single-blind, three-visit (≥ 48-hour washout), randomized-cross-over study. Participants were encouraged to complete all study visits in less than 1 month. SETTING The study took place in Rural/Appalachian Ohio. PARTICIPANTS Participants comprised 30 adults who smoke cigarettes. Participants (meanage = 34.5) were 60% men and 90% White. INTERVENTION Participants who were ≥ 12-hour tobacco-abstinent used: (1) a 3-mg nicotine concentration ONP, (2) a 6-mg nicotine concentration ONP and (3) usual brand cigarette in separate visits. ONPs (wintergreen Zyn) were used for 30 minutes; cigarettes were puffed every 30 sec for 5 minutes. MEASUREMENTS Plasma nicotine and self-reported craving were assessed at t = 0, 5, 15, 30, 60 and 90 minutes. The primary outcome was plasma nicotine concentration at t = 30 minutes. A secondary outcome was craving relief at t = 5 minutes. FINDINGS At t = 30, mean [95% confidence interval (CI)] plasma nicotine was 9.5 ng/ml (95% CI = 7.1, 11.9 ng/ml) for the 3 mg nicotine ONP, 17.5 ng/ml (95% CI = 13.7, 21.3) for the 6 mg nicotine ONP and 11.4 ng/ml (95% CI = 9.2, 13.6 ng/ml) for the cigarette. Mean plasma nicotine at t = 30 minutes differed between the 3- and 6-mg nicotine ONPs (P = 0.001) and between the 6-mg nicotine ONP and cigarette (P = 0.002). Mean (95% CI) craving at t = 5 minutes was lower for the cigarette (mean = 1.00, 95% CI = 0.61, 1.39) than either the 3 mg (mean = 2.25, 95% CI = 1.68, 2.82; P < 0.0001) or 6 mg nicotine (mean = 2.19, 95% CI = 1.60, 2.79; P < 0.0001) ONP. CONCLUSIONS Among adult smokers, using 6-mg nicotine concentration oral nicotine pouches (ONPs) was associated with greater plasma nicotine delivery at 30 minutes than 3-mg ONPs or cigarettes, but neither ONP relieved craving symptoms at 5 minutes as strongly as a cigarette. Accelerating the speed of nicotine delivery in ONPs might increase their misuse liability relative to cigarettes.
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Affiliation(s)
- Brittney Keller-Hamilton
- The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Mahmood A. Alalwan
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Hayley Curran
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Alice Hinton
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Lauren Long
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Kirsten Chrzan
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Theodore L. Wagener
- The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Leanne Atkinson
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University College of Public Health, Columbus, OH, USA
| | - Sriya Suraapaneni
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University College of Arts and Sciences, Columbus, OH, USA
| | - Darren Mays
- The Ohio State University College of Medicine, Columbus, OH, USA
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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10
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Grandolfo E, Ogden H, Fearon IM, Malt L, Stevenson M, Weaver S, Nahde T. Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review. Cureus 2024; 16:e54228. [PMID: 38496069 PMCID: PMC10944327 DOI: 10.7759/cureus.54228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but may involve continued use of nicotine and/or tobacco. Next-generation products (NGPs) are a THR alternative as they do not burn tobacco or produce smoke and deliver nicotine and have fewer and substantially lower levels of harmful chemicals compared to cigarettes. Tobacco‑free nicotine pouches (TFNPs) are an emerging category of nicotine‑containing oral products that do not combust or contain tobacco leaf. Similar to Swedish snus, TFNPs are placed between a user's lip and gum, and nicotine is absorbed through the oral mucosa rather than being inhaled. The aim of this scoping review was to systematically collate and evaluate published scientific evidence (cut‑off of 31 May 2023) identified from bibliometric databases investigating the potential of TFNPs to contribute to THR. Overall, studies examining chemical constituents indicated that the use of TFNPs may result in lower exposure to toxicants than other tobacco or nicotine-containing products, both combustible and non‑combustible. This reduction in toxicant exposure has been demonstrated by multiple human biomarker studies and in vitro toxicological assessments to translate to harm reduction potential in smokers switching to TFNPs. However, further study is warranted. At present, there is some evidence from human behavioral research that TFNPs can support either transitioning away from smoking or reducing cigarette consumption. Furthermore, TFNP use appears very much limited to current users of traditional tobacco products, and youth uptake has been limited. In conclusion, the findings of this review indicate that TFNPs have the potential to support THR efforts and may help inform evidence‑based regulation.
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Affiliation(s)
- Erika Grandolfo
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, GBR
| | - Henry Ogden
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, GBR
| | - Ian M Fearon
- Scientific Research, whatIF? Consulting Ltd., Harwell, GBR
| | - Layla Malt
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, GBR
| | - Matthew Stevenson
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, GBR
| | - Sarah Weaver
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, GBR
| | - Thomas Nahde
- Group Science and Regulatory Affairs, Reemtsma Cigarettenfabriken, Hamburg, DEU
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Back S, Masser AE, Rutqvist LE, Lindholm J. Harmful and potentially harmful constituents (HPHCs) in two novel nicotine pouch products in comparison with regular smokeless tobacco products and pharmaceutical nicotine replacement therapy products (NRTs). BMC Chem 2023; 17:9. [PMID: 36869349 PMCID: PMC9985244 DOI: 10.1186/s13065-023-00918-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 02/15/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Tobacco-free nicotine pouches is a novel category of oral nicotine-delivery products. Among current tobacco users such pouches may serve as a low-risk alternative to cigarettes or conventional, tobacco-based oral products e.g., snus and moist snuff. In the United States (U.S.), the market leading nicotine-pouch brand is ZYN®. However, no data on the chemical characteristics of ZYN have been published. METHODS We screened for 43 compounds potentially present in tobacco products in seven oral nicotine-delivery products: ZYN (dry and moist), snus (General®), moist snuff (CRP2.1 and Grizzly Pouches Wintergreen), and two pharmaceutical, nicotine replacement therapy products (NRTs, Nicorette® lozenge and Nicotinell® gum). Thirty-six of the tested compounds are classified as harmful and potentially harmful constituents (HPHCs) by the Center for Tobacco Products at the U.S. Food and Drug Administration (FDA-CTP). Five additional compounds were included to cover the GOTHIATEK® product standard for Swedish snus and the last two compounds were chosen to include the four primary tobacco specific nitrosamines (TSNAs). RESULTS The tested products contained nicotine at varying levels. The two ZYN products contained no nitrosamines or polycyclic aromatic hydrocarbons (PAHs) but low levels of ammonia, chromium, formaldehyde, and nickel. In the NRT products we quantified low levels of acetaldehyde, ammonia, cadmium, chromium, lead, nickel, uranium-235, and uranium-238. The largest number (27) and generally the highest levels of HPHCs were quantified in the moist snuff products. For example, they contained six out of seven tested PAHs, and seven out of ten nitrosamines (including NNN and NNK). A total of 19 compounds, none of which were PAHs, were quantified at low levels in the snus product. NNN and NNK levels were five to 12-fold lower in snus compared to the moist snuff products. CONCLUSIONS No nitrosamines or PAHs were quantified in the ZYN and NRT products. Overall, the number of quantified HPHCs were similar between ZYN and NRT products and found at low levels.
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Affiliation(s)
- Susanne Back
- Regulatory & Scientific Affairs, Swedish Match AB, Box 17037, S-104 62, Stockholm, Sweden.
| | - Anna E. Masser
- Regulatory & Scientific Affairs, Swedish Match AB, Box 17037, S-104 62 Stockholm, Sweden
| | - Lars E. Rutqvist
- Regulatory & Scientific Affairs, Swedish Match AB, Box 17037, S-104 62 Stockholm, Sweden
| | - Johan Lindholm
- Regulatory & Scientific Affairs, Swedish Match AB, Box 17037, S-104 62 Stockholm, Sweden
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Shaikh SB, Newton C, Tung WC, Sun Y, Li D, Ossip D, Rahman I. Classification, Perception, and Toxicity of Emerging Flavored Oral Nicotine Pouches. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4526. [PMID: 36901533 PMCID: PMC10002198 DOI: 10.3390/ijerph20054526] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Oral Nicotine Pouches (ONPs) are the new form of nicotine pouches that have become a type of emerging smokeless tobacco product sold by various tobacco companies. These smokeless tobacco products are marketed for usage all over as snus containing tobacco-derived nicotine (natural) or as tobacco-free nicotine (synthetic) as substitutes for other tobacco products. Based on perception and socio-behavioral aspects, ONPs have become popular tobacco products among adolescents/young adults, and over 50% of young adult users of ONP use flavored ONPs, such as menthol/mint, tobacco, dessert/candy, and fruity, which are the most popular flavors. Various new ONP flavors are currently popular locally as well as in the online market. Tobacco, menthol, and fruit-flavored ONPs could motivate cigarette smokers to change to ONPs. METHODS We expanded our knowledge on natural/synthetic ONP flavor wheels to available data on ONPs, describing, in detail, their flavors and brands (US and Europe) in both natural and synthetic ONP categories. We classified over 152 snus and 228 synthetic ONPs into the following flavor categories: "Tobacco", "Menthol/Mint", "Fruity", "Candy/Deserts", "Drink", "Aroma", "Spices", and "Mixed Flavors". RESULTS Based on total numbers, we found the most popular ONP flavors, sold as tobacco and menthol, to be among natural ONPs; among synthetic ONPs, fruity and menthol are the most prominent flavors, with varying concentrations of nicotine and other flavoring chemicals, including coolant WS-23. We also showed possible molecular targets and toxicities, due to exposure to ONPs, activating several signaling cascades such as AKT and NF-kappaB, which might possibly lead to apoptosis and epithelial mesenchymal transition (EMT). CONCLUSIONS Considering the marketing of ONP products with various flavor profiles and with most of these products containing tobacco/menthol/fruit flavor, it is likely to have regulation and a marketing disclaimer on some of these products. Further, it would be logical to determine how the market reacts in terms of compliance and non-compliance with flavor restrictions by the regulatory agencies.
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Affiliation(s)
- Sadiya Bi Shaikh
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Chad Newton
- College of Professional Studies, Bethel University, McKenzie, TN 38201, USA
| | - Wai Cheung Tung
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Yehao Sun
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Dongmei Li
- Department of Clinical and Translational Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Deborah Ossip
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Irfan Rahman
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
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Ye D, Rahman I. Emerging Oral Nicotine Products and Periodontal Diseases. Int J Dent 2023; 2023:9437475. [PMID: 36819641 PMCID: PMC9937772 DOI: 10.1155/2023/9437475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/29/2022] [Accepted: 01/18/2023] [Indexed: 02/12/2023] Open
Abstract
Oral nicotine pouches are emerging as a new "modern oral" nicotine product. These prefilled pouches contain nicotine, flavorings, and filling agents that dissolve in the mouth. Nicotine can be derived from tobacco leaf or chemical synthesis. Traces of TSNAs and toxic chromium were detected in the pouch products. This raises the concern about general and periodontal health. This review aims to update the current oral nicotine products research relating to periodontal disease and its relevance in periodontal inflammation. Nicotine interacts with host cells and affects inflammatory responses to microbial challenges. It may directly or indirectly deteriorate periodontal tissues by activating nicotinic acetylcholine receptors, repressing PDL fibroblasts cells, increasing cellular ROS and cytokines/chemokines, growth factors, breaking microbiota balance, and dysregulating miRNAs expression. Studies show that appealing flavorings contained in nicotine pouches pose harm to periodontal innate immune responses and increase penetration of nitrosamines. In addition, flavored ONPs increase the risk of dual or poly-tobacco products among young adults, stacking up detrimental effects on the periodontium. Given the recent growth of users, further studies are needed to elucidate the impact of ONPs, even poly-tobacco use, on systemic and periodontal health. Moreover, policymakers should ensure to avoid generating a new wave of nicotine addiction among youths in the U.S.
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Affiliation(s)
- Dongxia Ye
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Irfan Rahman
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY, USA
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Shaikh SB, Tung WC, Pang C, Lucas J, Li D, Rahman I. Flavor Classification/Categorization and Differential Toxicity of Oral Nicotine Pouches (ONPs) in Oral Gingival Epithelial Cells and Bronchial Epithelial Cells. TOXICS 2022; 10:660. [PMID: 36355951 PMCID: PMC9696007 DOI: 10.3390/toxics10110660] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
Oral nicotine pouches (ONPs) are a modern form of smokeless tobacco products sold by several brands in the U.S., which comprise a significant portion of non-combustible nicotine-containing product (NCNP) sales to date. ONPs are available in various flavors and may contain either tobacco-derived nicotine (TDN) or tobacco-free nicotine (TFN). The growth in popularity of these products has raised concerns that flavored ONPs may cause adverse oral health effects and promote systemic toxic effects due to nicotine and other ONP by-products being absorbed into the circulatory system through oral mucosa. We hypothesized that flavored ONPs are unsafe and likely to cause oral and pulmonary inflammation in oral and respiratory epithelial cells. Before analyzing the effects of ONPs, we first classified ONPs sold in the U.S. based on their flavor and the flavor category to which they belonged using a wheel diagram. Human gingival epithelial cells (HGEP) were treated with flavored ONP extracts of tobacco (original, smooth), menthol (wintergreen and cool cider), and fruit flavor (americana and citrus), each from the TDN and TFN groups. The levels of ONP-induced inflammatory cytokine release (TNF-α, IL-6, and IL-8) by ELISA, cellular reactive oxygen species (ROS) production by CellRox Green, and cytotoxicity by lactate dehydrogenase (LDH) release assay in HGEP cells were assessed. Flavored ONP extracts elicited differential toxicities in a dose- and extract-dependent manner in HGEP cells 24 h post-treatment. Both fruit TDN and TFN extracts resulted in the greatest cytotoxicity. Tobacco- and fruit-flavored, but not menthol-flavored, ONPs resulted in increased ROS production 4 h post-treatment. Flavored ONPs led to differential cytokine release (TNF-α, IL-6, and IL-8) which varied by flavor (menthol, tobacco, or fruit) and nicotine (TDN vs. TFN) 24 h post-treatment. Menthol-flavored ONPs led to the most significant TNF-α release; fruit TFN resulted in the most significant IL-6 release; and fruit TDN and tobacco TFN led to the highest release of IL-8. Subsequently, human bronchial epithelial cells (16-HBE and BEAS-2B) were also treated with flavored ONP extracts, and similar assays were evaluated. Here, the lowest concentration treatments displayed increased cytotoxicity. The most striking response was observed among cells treated with spearmint and tobacco flavored ONPs. Our data suggest that flavored ONPs are unsafe and likely to cause systemic and local toxicological responses during chronic usage.
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Affiliation(s)
- Sadiya Bi Shaikh
- Department of Environmental Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Wai Cheung Tung
- Department of Environmental Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Cortney Pang
- Department of Environmental Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Joseph Lucas
- Department of Environmental Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Dongmei Li
- Department of Clinical and Translational Science Institute, School of Medicine and Dentistry, University of Rochester, Rochester, NY 14642, USA
| | - Irfan Rahman
- Department of Environmental Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA
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