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Kent JT, Mok G, Austin E. Nicotine Toxicity From Repeat Use of Nicotine Pouches. Nicotine Tob Res 2024:ntae111. [PMID: 39087735 DOI: 10.1093/ntr/ntae111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/12/2024] [Accepted: 05/05/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Nicotine pouches have emerged as a novel way to administer concentrated nicotine and come as a white powder in flavored, microfiber pouches placed between the cheek and gums to dissolve without requiring spitting. While marketed as a safe alternative to smoking, nicotine pouches have the potential for toxic exposure to users. CASE PRESENTATION We present a case of a 21-year-old male with acute nicotine toxicity through repeated administration of nicotine pouches. Over the course of 12 hours, he consumed 15 extra-strength nicotine pouches (10.9 mg per pouch) as a study tool to prepare for the next-day exams. He presented to the emergency department with bizarre behavior requiring admission for persistent confusion and nausea which resolved after 24 hours. CONCLUSIONS This case represents the first case of acute nicotine toxicity secondary to nicotine pouch use. These pouches are emerging as a novel way to use nicotine and present a serious risk of inadvertent overdose and harm. IMPLICATIONS Nicotine pouches are emerging as a novel way to use nicotine, and second to e-cigarettes, are the most frequently used nicotine product among youth. These pouches, which lack clear warning labels, are promoted among social media forums and present a serious risk of inadvertent overdose and harm, especially among young adults. Healthcare professionals should be aware of this risk, especially from acute, repeated exposures, and should ensure the public is cautioned appropriately.
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Affiliation(s)
- Jessica T Kent
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Garrick Mok
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Emily Austin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Ontario Poison Centre, Toronto, Ontario, Canada
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Ruokolainen O, Ollila H, Härkänen T. Nicotine pouch use by sex, school type and tobacco product use among Finnish adolescents during the 2023 change in regulatory scheme with deregulated sales. Addiction 2024. [PMID: 38922776 DOI: 10.1111/add.16585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND AIMS In Finland, nicotine pouches entered the national market abruptly in 2023, following a change in April 2023 from medicinal product classification into less regulated tobacco surrogate status. This study aimed to measure adolescent nicotine pouch use and associated characteristics. DESIGN AND SETTING A cross-sectional, nationwide school-based survey among students in comprehensive schools (COMP), general upper secondary schools (GEN) and vocational institutes (VOC) in 2023 in Finland. PARTICIPANTS A total of 151 224 respondents aged 14-20 years (mean age 16.18 years, standard deviation 1.20 years). MEASUREMENTS Nicotine pouch use was used as the outcome variable. Demographics included age, sex, school type and tobacco product use (smoking, snus use and e-cigarette use). Covariates included parental education and parental smoking. All measures were self-reported. FINDINGS Unadjusted results showed that current nicotine pouch use was more common among boys (11.3%) than among girls (3.3%), adolescents in VOC (15.4%) compared with COMP (6.8%) and GEN (4.3%), whereas daily use of other tobacco and nicotine products was associated with current nicotine pouch use compared with never using such products and the association was especially strong for snus use. The fully adjusted estimates of current nicotine pouch use remained strong for daily use of other tobacco and nicotine products (snus use: adjusted prevalence ratio [aPR] = 74.95, 95% confidence interval [CI] = 65.65-84.25; smoking: aPR = 1.43, 95% CI = 1.36-1.50; e-cigarette use: aPR = 2.15, 95% CI = 2.04-2.27) and for sex (boys aPR = 1.53, 95% CI = 1.48-1.57). There was no clear evidence of differences in current nicotine pouch use by school type, age or parental factors in the fully adjusted model. CONCLUSIONS In Finland in 2023, during which the availability of nicotine pouches became less regulated, nicotine pouch use appeared to be more common among boys and adolescents who used other nicotine products.
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Affiliation(s)
- Otto Ruokolainen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Hanna Ollila
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Tommi Härkänen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
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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 2024:ntae131. [PMID: 38880491 DOI: 10.1093/ntr/ntae131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Cornacchione Ross J, Kowitt SD, Rubenstein D, Jarman KL, Goldstein AO, Thrasher JF, Ranney LM. Prevalence and correlates of flavored novel oral nicotine product use among a national sample of youth. Addict Behav 2024; 152:107982. [PMID: 38359494 PMCID: PMC10939726 DOI: 10.1016/j.addbeh.2024.107982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Flavored novel oral nicotine products (ONP), such as pouches, gum, lozenges, tablets, and gummies, have recently entered the US market but have not been authorized for smoking cessation. This study assessed the prevalence and correlates of ONPs in a national sample of youth who smoked little filtered cigars or cigarillos (LCCs) or were susceptible to LCCs. METHODS We conducted a national online survey from September-October 2022, as part of a study to develop cigar warnings among youth. Those aged 15-20 years old who reported using (ever or current) or susceptibility to little filtered cigars or cigarillos (LCCs) were eligible. Descriptive statistics and chi-square analyses assessed the prevalence of flavored ONP use and associations with other past 30-day tobacco product use and participant characteristics. RESULTS Approximately one-fifth (17.1 %) of the sample (n = 680) reported past month flavored ONP use. Any past month tobacco use was correlated with past month flavored ONP use (ps < 0.001), increasing from 17.1 % in the overall sample to 26.8 % among those reporting e-cigarette use, 41.4 % (LCCs), 47.8 % (waterpipe tobacco), 61.8 % (large cigars), and 69.1 % (smokeless tobacco). The number of products used in the past month was significantly associated with higher odds of ONPs in the past month in a multivariable logistic regression model (aOR2.26; 95 % CI: 1.92, 2.65). DISCUSSION Almost one-fifth of participants who use or are susceptible to cigar use in our national sample of youth use ONPs. Dual/poly use of other tobacco products and ONPs among youth suggests that many of these youth may be addicted to nicotine. Additional surveillance and regulation of ONPs that exhibit enticing characteristics, such as flavors, kid-friendly formulations, and targeted marketing/branding may be needed.
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Affiliation(s)
- Jennifer Cornacchione Ross
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Sarah D Kowitt
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dana Rubenstein
- Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC, USA; Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kristen L Jarman
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam O Goldstein
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Leah M Ranney
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zhang BY, Bannon OS, Tzu-Hsuan Chen D, Filippidis FT. Dual and poly-nicotine and tobacco use among adolescents in the United States from 2011 to 2022. Addict Behav 2024; 152:107970. [PMID: 38277994 DOI: 10.1016/j.addbeh.2024.107970] [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: 11/13/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Adolescent nicotine and tobacco product use remains common despite declining smoking rates in the United States, likely due to the emergence of novel products. Concurrent use of multiple products may increase the risk of nicotine dependency and subsequent substance use. AIM To identify patterns and trends of dual and poly nicotine and tobacco use among adolescents in the US and explore associations of dual and poly nicotine and tobacco use with sociodemographic factors. METHODS 12 years of annual National Youth Tobacco Survey data (2011-2022) from 242,637 respondents were used to examine prevalence trends of different combinations of nicotine or tobacco product use among adolescents in the US using weighted point estimates for each year. Poisson regression models examined sociodemographic factors associated with different patterns of dual and poly-product use from 2011 to 2022. RESULTS Overall, the prevalence of dual (i.e. at least two products) and poly (i.e. at least three products) use decreased between 2011 and 2021 (from 9.5 % to 2.8 % and from 5.1 % to 1.1 %, respectively), but showed signs of increase between 2021 and 2022 (3.7 % for dual and 1.7 % for poly use). The most common combinations included a combustible product with either a novel or noncombustible product. The risk for dual and poly-product use was higher among non-Hispanic Whites, males, and high school students. CONCLUSIONS Previously declining trends in the prevalence of tobacco/nicotine dual and poly use may have been reversed. Close monitoring and targeted tobacco control policies are essential to tackle multiple product use among adolescents.
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Affiliation(s)
- Baihui Y Zhang
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England, United Kingdom
| | - Olivia S Bannon
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England, United Kingdom.
| | - Daniel Tzu-Hsuan Chen
- Nuffield Department of Primary Care Health Science, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, United Kingdom
| | - Filippos T Filippidis
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, England, United Kingdom
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Clark SA, Baler G, Jarman KL, Byron MJ, Goldstein AO, Ranney LM. Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina. Tob Control 2024:tc-2023-058334. [PMID: 38307719 DOI: 10.1136/tc-2023-058334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/02/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches. METHODS We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis. RESULTS Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches. CONCLUSIONS Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.
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Affiliation(s)
- Sonia A Clark
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Guido Baler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kristen L Jarman
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Justin Byron
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adam O Goldstein
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leah M Ranney
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Vogel EA, Tackett AP, Unger JB, Gonzalez MJ, Peraza N, Jafarzadeh NS, Page MK, Goniewicz ML, Wong M, Leventhal AM. Effects of flavour and modified risk claims on nicotine pouch perceptions and use intentions among young adults who use inhalable nicotine and tobacco products: a randomised controlled trial. Tob Control 2023:tc-2023-058382. [PMID: 38148143 PMCID: PMC11199376 DOI: 10.1136/tc-2023-058382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Availability of flavours and potential modified risk tobacco product (MRTP) claims may influence young adults' (YAs') perceptions of and intentions to use nicotine pouches ('pouches'). METHODS YAs aged 21-34 years (N=47, M age=24.5, SD=3.1) with past-month nicotine/tobacco use (10.6% cigarette-only, 51.1% e-cigarette-only, 38.3% dual use) and no intention to quit were randomised to self-administer four Zyn 3 mg nicotine pouches in a 4 (flavour; within-subjects: smooth, mint, menthol, citrus) × 2 (MRTP claim on packaging; between subjects: present or absent) mixed-factorial design. After self-administering each pouch, participants reported appeal, use intentions and perceived harm compared with cigarettes and e-cigarettes. Three mixed-factorial analysis of variances (ANOVAs) examined main and interactive effects of flavour and MRTP claim on appeal, use intentions and comparative harm perceptions. RESULTS Mint (M=55.9, SD=26.4), menthol (M=49.7, SD=26.8) and citrus (M=46.6, SD=24.8) flavours were significantly more appealing than smooth (M=37.6, SD=25.4; p<0.001). MRTP claim did not significantly affect product appeal (p=0.376). Use intentions were greater for mint (M=2.6, SD=1.3) and menthol (M=2.0, SD=1.1) flavours than smooth (M=1.8, SD=1.0; p=0.002). Flavour did not affect comparative harm perceptions (p values>0.418). MRTP claims increased use intention (p=0.032) and perceptions of pouches as less harmful than cigarettes (p=0.011), but did not affect perceived harm relative to e-cigarettes (p=0.142). Flavour × MRTP claim interactions were not significant. CONCLUSIONS Flavoured (vs smooth) pouches were more appealing to YAs. MRTP claims reduced perceived harm of pouches compared with cigarettes; however, intentions to switch were low. To protect YAs' health, regulatory restrictions could target flavours and MRTP claims.
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Affiliation(s)
- Erin A Vogel
- TSET Health Promotion Research Center, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Alayna P Tackett
- Center for Tobacco Research, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jennifer B Unger
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Maria J Gonzalez
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Natalia Peraza
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Nikki S Jafarzadeh
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Michelle K Page
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Maciej L Goniewicz
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Melissa Wong
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
| | - Adam M Leventhal
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
- Institute for Addiction Science, University of Southern California, Los Angeles, California, USA
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