Smokeless Oral Nicotine: Many Unknowns, Potential Risks to CV Health

Smokeless oral nicotine products are skyrocketing in popularity but just like cigarettes and other tobacco products, they are addictive and can carry cardiovascular risks, cautions a new policy statement from the American Heart Association (AHA).

The document, published in Circulation, follows a prior AHA statement released in 2010. During the ensuing 14 years, “several varieties of tobacco-free oral nicotine products—including oral nicotine pouches; nontherapeutic nicotine gums, lozenges, and tablets; and nicotine gummies—have rapidly proliferated,” Cheryl R. Dennison Himmelfarb, PhD, RN (Johns Hopkins University, Baltimore, MD), and colleagues write.

“We’re seeing more and more of this, and particularly among youth and young adults,” Himmelfarb told TCTMD. “It’s this promulgation of these new products that drew the American Heart Association’s attention, and as a group we felt there was a need for an update.”

Nicotine in these recent arrivals can be either synthetic or derived from tobacco, or a mixture of both sources. It can even be derived from other plants in the nightshade family, like tomatoes. Also under the umbrella of smokeless oral nicotine are more traditional products, such as chewing tobacco, snuff, and snus, that contain actual tobacco.

Much like with vaping, the long-term cardiovascular risks of these products are not yet known and it’s unclear whether they are a useful way to help people quit smoking. Moreover, many contain carcinogens or other potentially harmful substances like sodium, artificial flavorings, and heavy metals.

“So while many of these tobacco companies are marketing these nicotine pouches as tobacco-free or safer alternatives to smoking combustible cigarettes, the reality is we don’t know,” said Himmelfarb. “More research is really needed to fully understand the short- and the long-term impact of these products.”

There’s also the concern that young people who start out with smokeless options may turn to combustible cigarettes. Nicotine, beyond being highly addictive, “can have a negative effect on the developing brain,” Himmelfarb noted.

The AHA statement delves into all these elements, detailing the evidence base on harms and trends in use. It also offers ideas for policy and regulatory changes to stem the tide.

Prevention First and Foremost

Himmelfarb stressed that for clinicians, the most important takeaway from the new paper is the need for prevention.

“What we really want to encourage clinicians to do is educate youth and the public about the dangers of tobacco products overall and to understand that nicotine is highly addictive,” she said. The goal is “to prevent tobacco use initiation and to support cessation through proven pharmacologic and behavioral therapies.”

Large-scale real-world research is also needed to compare the various options for cessation, including those that are already US Food and Drug Administration-approved, “with products such as oral nicotine pouches to assess efficacy in helping people on their journey to quit their tobacco and nicotine addiction,” according to the writing group. Such studies could be funded by the Patient-Centered Outcomes Research Institute, through federal funding, or via private/public partnership.

For the moment, “without data on the shorter- and long-term impact of these products, I think clinicians should be very hesitant to recommend them [as tools to quit smoking]. . . . We don’t have the evidence right now,” said Himmelfarb.

The concerns about nicotine use are too broad to be tackled on an individual level alone and merit changes at a policy level, she added.

One potential path is to rein in the marketing that “has evolved very rapidly as these products are coming out,” Himmelfarb said. Companies that manufacture smokeless oral nicotine products often use social media and other digital platforms to target youth and young adults, presenting an “important opportunity,” she added. “They’re engaging these brand influencers and having reward programs and branded swag. . . . Another key point that is of concern is that many of these products come in flavors and colorful packaging and can have like a candy-like appearance, which can make them also even more appealing to youth and possibly dangerous for children.”

Thus, the paper advocates for “stronger FDA regulation of tobacco product manufacturing [and] the design and marketing of these products,” including the smokeless varieties, said Himmelfarb.

Specific tools include laws related to purchasing, use, and possession of nicotine; warning labels and plain packaging; excise taxes; expanded funding for tobacco control and prevention; establishment of tobacco-free public environments; and restrictions on the number and location of retail outlets that can sell the products, among others.

Importantly, “clinicians should continue to screen for all nicotine use in all patients,” the AHA statement advises.