Oral Nicotine Research Articles

Association of Perceived Neighborhood Disorder with Substance Use Behaviors and Retail Access Among Southern California Adolescents.

Neighborhood disadvantage is associated with a higher concentration of tobacco, cannabis and alcohol retailers and greater risk of certain substance use behaviors among youth. Less is known about the impact of subjective neighborhood disorder, which captures distinct exposures that may be relevant to substance use outcomes, including neighborhood social processes, safety, physical characteristics, and neighborhood drug use. Data are from two waves (Feb-Dec 2022) of a prospective cohort of Southern California high school students (n = 2,139; mean[SD] age = 15.7.[0.6]). We examined associations of perceived neighborhood disorder at baseline with (a) perceived ease of purchase (continuous scale 0-100) for alcohol, cannabis, e-cigarettes, cigarettes, hookah, cigars/cigarillos, and oral nicotine at baseline and follow-up, and (b) repeated measures of past 6-month and past-30-day alcohol, vaped cannabis, smoked cannabis, cannabis edibles, e-cigarette, cigarette, cigarillo, hookah, and oral nicotine use. E-cigarettes were perceived to be the easiest product to purchase. Participants in the highest (vs. lowest) quartile of neighborhood disorder reported greater mean ease of purchasing scores for all products (mean difference range = 5.43 [95%CI: 1.64-9.21] for mint/menthol oral nicotine products to 9.40 [95%CI: 6.16-12.64] for hookah) and greater odds of e-cigarette, smoked cannabis, edibles, vaped THC, and alcohol use (odds ratio range = 1.52 [95%CI: 1.05 to 2.18] for past 6-month alcohol to 5.40 [95% CI: 3.46 to 8.42] for 30-day smoked cannabis). Interventions that shape youth perceptions of their neighborhood and reduce youth retail access in disadvantaged neighborhoods are needed and may help to prevent youth substance use.

Characteristics of users of oral nicotine products according to smoking status in Denmark

Abstract Background Oral nicotine products e.g., snus, chewing tobacco, and tobacco-free nicotine pouches gain increasing popularity. The aim of the study was to estimate the prevalence of use of oral nicotine products in the Capital Region of Denmark in 2021, to describe associations with socio-demographic characteristics and to explore if smoking status moderated these associations. Methods The study was based on the Danish Capital Region Health Survey 2021 including 56,245 persons aged ≥16 years old (response rate 54.9%) which included self-reported information on use of oral nicotine products and smoking status. Information on socio-demographic characteristics were assessed in national registries. Descriptive analyses and multivariate logistic regression models including interaction terms with smoking status and weighted for survey-sampling and non-response were performed. Results In total, 3.5% used oral nicotine products. Men showed higher odds of using oral nicotine products compared with woman (OR = 3.70) while there were no associations with education and occupational affiliation when adjusted for sex and age. The associations with age and place of residence were moderated by smoking status. Among smoking participants, young persons aged 16-19 years showed the strongest association with use of oral nicotine products (sex-adjusted OR = 21.71) while persons aged 20-24 years showed the strongest association in non-smoking participants (OR = 11.08). Conclusions Especially men and young age were strongly associated with use of oral nicotine products. For age, the association was moderated by smoking status. Interventions should address these high-risk groups and pay attention to smoking status. Key messages • Sex and age play a siginificant role in use of oral nicotine products. • Interventions and public health campagins should adress high-risk groups

Tobacco Product Use Among Middle and High School Students - National Youth Tobacco Survey, United States, 2024.

Use of tobacco products in any form is unsafe, and nearly all tobacco product use begins during adolescence. CDC and the Food and Drug Administration (FDA) analyzed data from the 2024 National Youth Tobacco Survey to determine tobacco product use among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2024, current (previous 30-day) use of any tobacco product was reported by 10.1% of high school students (representing 1.58 million students) and 5.4% of middle school students (representing 640,000 students). Among all students, e-cigarettes were the most commonly reported tobacco product currently used (5.9%), followed by nicotine pouches (1.8%), cigarettes (1.4%), cigars (1.2%), smokeless tobacco (1.2%), other oral nicotine products (1.2%), heated tobacco products (0.8%), hookahs (0.7%), and pipe tobacco (0.5%). During 2023-2024, among all students, the estimated number who reported current use of any tobacco product decreased from 2.80 to 2.25 million students; e-cigarette use decreased (from 2.13 to 1.63 million students); and hookah use decreased (from 290,000 to 190,000 students). Among high school students, current use of any tobacco product decreased from 12.6% to 10.1% of students, and e-cigarette use decreased from 10.0% to 7.8%. Among middle school students, no statistically significant changes occurred. Evidence-based strategies can help prevent initiation and promote cessation of tobacco product use among U.S. youths.

Introduction of Nicotine Analogue-Containing Oral Pouch Products in the United States.

In 2023, 6-methyl nicotine (6MN), a synthetic nicotine analogue, was introduced in US-marketed electronic cigarette products advertised as exempt from regulation. It is unknown whether the use of 6MN has spread to the oral nicotine pouch product category that has become increasingly popular. Industry reports and the USPTO database were searched for informationon 6-methyl nicotine products. The search terms "Metatine", "Nixotine", "Imotine" and "pouches" were shortlisted and used to identify US-marketed pouch products. Ingredient contents were compared to popular products, and safety warnings and regulatory statements assessed in context with US state and federal regulations. Two US-based brands, "MG" and "Hippotine" pouches, were identified in August 2024, advertised to contain "Imotine"-trademarked 6MN. MG Pouches are marketed in four youth-appealing flavors. "Hippotine"-branded pouches are marketed in two flavors. 6MN contents ranged between 8mg - 25mg with almost identical ingredient lists otherwise. Products list extensive addiction and health warnings, including warnings not to operate vehicles. Vendors state that these are not a tobacco product, implicating that federal and state tobacco regulations do not apply. The spread of nicotine analogues to additional product categories such as oral pouches is concerning, especially given the high 6MN contents that exceed nicotine contents in popular US-marketed oral nicotine pouch products. Legislators and regulators need to provide certainty about the regulatory status of nicotine analogues to prevent further erosion of tobacco flavor bans and other regulations.

Oral mucosal changes caused by nicotine pouches: case series

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.

Evaluating the Forensic Inferences of Oral Nicotine Ingestion: Autopsy Case Review, Animal Experimentation, and Legal Implications

Nicotine, a highly lipophilic alkaloid derived from Nicotiana tabacum and Nicotiana rustica, can be lethal even in small doses when ingested in concentrated forms like e-cigarette liquids. This study examined a murder case in South Korea where a 52-year-old man was allegedly killed by oral administration of nicotine. Despite the absence of typical signs, such as chemical burns or vomiting, the case posed questions about the lethal concentration of nicotine and the presence of gastrointestinal symptoms in nicotine poisoning. Through literature review, autopsy analysis, and animal experiments, this study evaluated the forensic evidence presented in court. The results indicated that lethal nicotine levels could be lower than established previously, and death could occur without gastrointestinal injury or vomiting. Our findings supported the court's conviction decision, emphasizing the variability of symptoms in nicotine toxicity and the importance of scientific evidence in legal proceedings. The results of this study highlight the role of forensic medicine in clarifying scientific uncertainties in judicial contexts, particularly in cases involving toxic substances.

The safety of using oral nicotine pouche – consideration of their effects on general health, oral mucosa and periodontal diseases, comparing them to snus and other nicotinecontaining products

The safety of using oral nicotine pouche – consideration of their effects on general health, oral mucosa and periodontal diseases, comparing them to snus and other nicotinecontaining products

Oral Tobacco-Free Nicotine Pouches: a promising alternative or growing threat? – literature review

Oral Tobacco-Free Nicotine Pouches: a promising alternative or growing threat? – literature review

The Potential Impact of Oral Nicotine Pouches on Public Health: A Scoping Review.

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. 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. 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. 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. 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.

Impact of vanilla flavor on nicotine taste, choice, intake, and seeking behaviors.

Flavors can alter the orosensory properties of tobacco products. Specifically, flavors can serve as an oral cue for smokeless tobacco products. We aimed to investigate the impact of oral vanillin, the principal chemical of vanilla flavor in tobacco products, on nicotine's taste, and nicotine choice, intake, and seeking behaviors. Experiments were performed in young adult Sprague Dawley rats. We employed a two-bottle free-choice test (2BC) to measure the preference for different concentrations of vanillin and its effect on nicotine preference. To explore the long-term effects of early exposure to sweetened vanillin, we utilized a combined 2BC and intraoral self-administration (IOSA) model. We assessed the nicotine taking and seeking behaviors in the presence or absence of vanillin. We performed a taste reactivity test (TRT) to quantify liking (ingestive) and disliking (aversive) taste responses to oral nicotine with or without vanillin. In 2BC, female rats preferred vanillin containing solutions more than their male counterparts. In IOSA, vanillin alone and in combination with nicotine led to greater IOSA compared to water. Female rats self-administered vanillin plus nicotine more than male rats. Vanillin increased motivation to nicotine taking, but only in females. In TRT, vanillin increased nicotine's ingestive responses but blocked aversive responses in both sexes. These results indicate that vanilla flavor can increase oral nicotine intake. It can also increase liking and decrease disliking of nicotine's taste. Furthermore, the impact of vanilla flavor on nicotine taste and nicotine choice, intake, and seeking behaviors is concentration and sex dependent.

Oral tobacco-free nicotine products: Quality and safety during storage

Oral non-tobacco nicotine products have gained enormous popularity in recent years. The countries of the Eurasian Economic Union also produce and sell this type of innovative but poorly studied goods. As a result, the safety profile and quality of such products as nicotine poaches require urgent comprehensive research. This study featured the changes in quality of nicotine poaches during storage, i.e. nicotine content, water activity, and microbiological index. The research featured nicotine poaches of several popular brands. The authors used standard research methods; the experiments were performed in the laboratory for chemistry and quality control, Institute of Tobacco, Makhorka, and Tobacco Products, Krasnodar, and at the Department of Bioorganic Chemistry and Technical Microbiology, Kuban State Technological University, Krasnodar. The water activity was 0.8911–0.9502 Aw at the initial stage and remained stable in most samples even after six months of storage. Velo Freeze was the only brand to show significant variations in water activity. The nicotine content was 10.115–12.950 mg/g at the initial stage. Only four samples maintained the initial values after six months of storage. The fluctuations of nicotine content were also mentioned by the manufacturer. The microbiological profile remained stable during the six months of storage and met the requirements for similar products, i.e., chewing gum and unglazed caramel. The project needs further research because the qualitative characteristics of nicotine poaches provided rather unambiguous results. Our study will help develop state standards for oral nicotine products. The results obtained will be used to formulate proposals to the organizations responsible for the future Technical Regulations of the Eurasian Economic Union for nicotine products.

Evaluating the Role of Nicotine Stereoisomer on Nicotine Pouch Abuse Liability: A Randomized Crossover Trial.

Many oral nicotine pouch (ONP) brands use synthetic nicotine, which typically contains a racemic (50:50) mixture of nicotine's two stereoisomers: S-nicotine and R-nicotine. Because tobacco-derived nicotine contains more than 99% S-nicotine, the effects of R-nicotine in humans are not well known. We compared systemic nicotine exposure and product appeal of ONPs containing more than 99% S-nicotine versus racemic nicotine. N = 18 adult smokers (Mage = 45 years, 66.7% male, 77.8% White) enrolled in a three-visit single-blind, randomized crossover study. During each visit, participants used one wintergreen-flavored, 3mg nicotine ONP for 30min following at least12h nicotine abstinence. Study ONP #1 contained more than 99% S-nicotine and the other two study ONPs contained racemic nicotine (collapsed for analyses). Plasma nicotine assessments and measures of withdrawal relief occurred at t = 0, 5, 15, 30, 60, and 90min; measures of product appeal were assessed following ONP use. Using the ONP with more than 99% S-nicotine resulted in greater plasma nicotine concentration from 15 to 90min (p < .0001) and greater maximum plasma nicotine concentration than the ONPs with racemic nicotine (M = 9.9ng/mL [SD = 2.5] vs. M = 5.7ng/mL [SD = 2.8], respectively; p < .0001). Product liking and withdrawal relief were similar across ONPs, although participants reported more "bad effects" when using the ONP with more than 99% S-nicotine. Participants reported few subjective differences in ONPs according to nicotine stereoisomer, but plasma nicotine concentration was greater for ONPs using more than 99% S-nicotine. ONPs with more than 99% S-nicotine (vs. racemic nicotine) might be better substitutes for cigarettes, but research into other ONP characteristics (eg flavors, freebasenicotine) is needed to inform regulation. Little is known about the effects of racemic (vs. S-) nicotine in humans. In a sample of adults who smoke cigarettes, we identified that oral nicotine pouches containing racemic nicotine exposed participants to less nicotine than oral nicotine pouches containing only S-nicotine, but both types of oral nicotine pouches held similar, moderate appeal. Additional research evaluating the roles that flavorings, total nicotine concentration, and freebase nicotine play in the abuse liability of oral nicotine pouches would inform comprehensive product regulations to support public health.

Using Pod Based e-Cigarettes and Nicotine Pouches to Reduce Harm for Adults With Low Socioeconomic Status Who Smoke: A Pilot Randomized Controlled Trial.

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). 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. 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. 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. 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.

Objective Characteristics and Subjective Responses of 18–24-Year-Olds to U.S. nationally Televised Tobacco Advertisements

Background: Restrictions on televised tobacco ads do not apply to vaping and oral nicotine products. Several campaigns are currently active on U.S. national television. This research examines the extent to which objective ad features are associated with ad, brand, and product appeal and use intentions among 18-24-year-olds. Methods: We identified seven unique campaigns for Vuse, Velo, and JUUL from the Mintel Comperemedia database, coded for youth-appealing content, and then randomly assigned among N = 1450 18-24-year-olds. Following exposure to one 15-second ad, participants completed a survey assessing their subjective responses. Results: Youth-appealing content was prevalent across these ads to varying degrees. Mixed effects regression analyses showed a positive association between features from the Content Appealing to Youth (CAY) index and pro-social brand perceptions, positive attitudes, reactions, and perceived effectiveness of the ad, and positive use perceptions. Moreover, themes related to customization of the device and environmental sustainability were associated with similar positive perceptions, including that using the product would be cool, as well as behavioral intentions to try, use occasionally, and use daily. Conclusions: Regulators need to update tobacco advertising restrictions to accurately reflect the current tobacco product landscape. This study contributes to the research on tobacco promotion strategies by examining the current marketing landscape for newer tobacco products and their appeal to youth. Findings from this study inform comprehensive tobacco marketing regulations, recommending the FDA update its guidelines and apply current marketing restrictions to e-cigarettes and oral nicotine products.

Prevalence and correlates of flavored novel oral nicotine product use among a national sample of youth

BackgroundFlavored 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. MethodsWe 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. ResultsApproximately 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). DiscussionAlmost 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.

Examination of empathy-like behaviour in nicotine-preferring rat lines

Aim Addiction is an important global health issue, impacting also addicts environment and society. Empathy plays crucial role in establishing successful social relationships and is a fundamental component of social life. The aim of this study is to investigate how nicotine preferring (NP) strain and oral forced nicotine administration affects empathy-like behaviour in rats, with gender differences. Materials and Methods Sprague-Dawley NP rats (10 males/10 females) and wild-type control rats (10 males/10 females) were used. Behavioural tests were administered to all rats before and after oral forced nicotine administration. The behavioural tests were completed in the fourth week of nicotine administration. Anxiety levels that could affect empathy-like behaviour were evaluated with open field, elevated plus maze tests and with blood cortisol levels. Oxytocin receptor and arginine vasopressin (AVP) levels, which have been shown to be related to empathy-like behaviour, were examined in the prefrontal cortex and amygdala regions using the enzyme-linked immunoassay method. Results It was observed that males from the NP strain showed less empathy-like behaviour than all other groups, and nicotine administration did not cause a significant change in the results. Higher levels of locomotor activity (LA) were found in control females than in all other groups. Blood nicotine and corticosterone levels were higher in NP rats. No significant differences were found in AVP and oxytocin receptor levels in the prefrontal cortex and amygdala. Conclusions It was found that coming from an addicted strain particularly reduces empathy-like behaviour in males.

Tobacco market trends in 97 countries between 2007 and 2021.

Analysis of the tobacco market can provide valuable insights for developing tobacco control strategies. This study examines the market trends of cigarettes, cigars/cigarillos, smoking tobacco, smokeless tobacco, e-cigarettes, heated tobacco products (HTPs), and tobacco-free oral nicotine, across 97 countries between 2007 and 2021. We obtained annual tobacco retail value data from Euromonitor Passport and calculated the market share for each type of tobacco product. The research examined trends in retail value and market share globally, stratified by national income level, as well as in individual countries. From 2007 to 2015, the growth of the global tobacco market was primarily driven by cigarette sales. However, starting in 2016, emerging products, including e-cigarettes, HTPs, and tobacco-free oral nicotine, as well as non-cigarette combustible products, including cigars/cigarillos and smoking tobacco, have been mostly responsible for the increases in the global tobacco retail value. High-income countries experienced the greatest increase in the retail value of emerging products, while middle- and low-income countries still observed rises in cigarette sales. Trends in the retail value of different tobacco products varied widely during the study period, with distinct trends observed in different income levels and within individual countries. These trends can supplement prevalence data and be used to inform local tobacco control policies.

Literature Review on Nicotine’s Role in Human Health

Summary Background Next generation of nicotine/tobacco products (NGPs) include electronic cigarettes (ECs), heated tobacco products (HTPs), oral nicotine pouches (NPs) and smokeless tobacco (SLT) products (in particular snus). These products commonly contain nicotine and are intended to replace combustible cigarettes (CCs) and thus can be regarded as tobacco harm reduction products. To fulfill this role, it is essential that nicotine, which has well established addictive properties, is not causally related to health risks upon chronic use. Objectives The purpose of this review is to evaluate the scientific literature to answer the question, whether nicotine is involved in the development of any diseases or disorders associated with the acute, short, mid- and long-term use of NGPs. Appropriate results from studies with nicotine replacement therapy (NRT) products (gum, patches, inhalers, lozenges) are included as reference basis for inferring the health effects of NGPs. Furthermore, suggestions for filling identified gaps and for avoiding or minimizing limitations and weaknesses in study design are provided. Methods Literature databases such as MEDLINE, Google Scholar and an in-house ABF library (containing about 180,000 articles) were searched for relevant articles. Furthermore, pertinent monographs (such as the US Surgeon General Reports) and recent reviews were screened for further publications. Inclusion criteria were: all human studies investigating the association between use (preferably chronic use) of the nicotine/tobacco products mentioned above and health effects, including diseases, disorders, changes in biomarkers of biological effect (BOBEs). In vivo (animal) and in vitro studies were also considered, provided effects of NGPs in the presence and absence of nicotine or in relation to the nicotine exposure dose were reported. Also, reference lists of recent suitable articles were screened. In total, about 500 articles were retrieved by this approach. The role of nicotine was evaluated by considering the article authors’ statements and their cited references as well as by own judgement of reported results. Human studies are presented in a standardized table format. Results In total, 183 human studies were evaluated, with cardiovascular diseases (CVD) ranking highest (N = 75 studies), followed by respiratory diseases (43), oral health disorders (23), cancer (10), metabolic syndrome (7), reproduction disorders (5) and several other diseases (&lt; 5). The majority of studies do not provide evidence for a participation of nicotine in the pathogenesis. Some (weak) evidence was found that nicotine might be involved in some CVD-related effects and metabolic syndrome. This would be also supported by results from animal and in vitro studies. Discussion Human studies showed some severe limitations and weaknesses with respect to the study design and time of availability of NGPs on the market. A severe flaw is the insufficient consideration of dual use (NGP + CC), particularly in studies on chronic use, which could have led to erroneously increased risks for NGPs with direct consequences also for the role of nicotine. Additionally, prior effects from using CC have an impact. Both circumstances could have led to inaccurate conclusions in terms of elevated risk levels, which require changes in method designs. Suggestions for methodological improvements are provided for future studies. Conclusions A final evaluation of the role of nicotine in disease development in NGP users is currently not possible because use durations are too short. Chronic studies often suffer from insufficient separation between NGP only and dual use together with CCs, which may falsely increase the observed health risk. There is some limited evidence that nicotine may be involved in CVD-related effects, which, however, has to be verified in well controlled long-term studies. The potential involvement of nicotine in other patho-mechanisms also requires further research.

Commentary on Keller-Hamilton et al. : Oral nicotine pouches provide a less controversial route for tobacco harm reduction than electronic cigarettes.

Commentary on Keller-Hamilton et al. : Oral nicotine pouches provide a less controversial route for tobacco harm reduction than electronic cigarettes.

Sports, Gigs, and TikToks: Multi-Channel Advertising of Oral Nicotine Pouches

Oral nicotine pouches, which contain fewer harmful constituents than traditional tobacco products, are being increasingly marketed and sold. In this paper, we use images we collected in Great Britain between 2021 and 2023, along with a social media scan of Instagram and TikTok in 2023 to analyse the marketing strategies of these pouches on three key marketing channels — online media, sports sponsorships, and out-of-home advertising. Findings reveal the extensive use of visually appealing content, influencer partnerships, and event sponsorships that are potentially targeting young and naive audiences. Despite this, survey data indicates that nicotine pouch use in Great Britain remains minimal. However, a notable shift in public health impact could arise if these marketing efforts start to bear more fruit. The study underscores the need for balanced policy measures that increase access to reduced harm alternatives for existing tobacco and nicotine users while minimising exposure to youth and non-users. Continuous monitoring and regulatory adjustments are essential to address the evolving landscape of nicotine pouch marketing.