Smokeless Products Research Articles

Future of nicotine pouches – users’ perspective

Abstract Background Nicotine pouches (NPs) are gaining popularity. They are a rapidly developing category with little research or regulatory oversight. Studies have shown that the descriptor ‘tobacco-free’ may impact risk perceptions and the appeal of nicotine pouches among young adults and thus shape their position on the market. The aim of the study was to broaden the knowledge on NP users’ perspective about the future of this products. Methods Qualitative approach was utilized. In December 2022 there were seventeen structured In-depth Interviews (IDIs) conducted. The sample included of adults aged 18-22, both male and female. The respondents were asked how they see NPs in the context of aim group and competition with other nicotine products. Results We found that from NPs users’ perspective, these products are aimed at those who want give up smoking, do not want to play with electronic devices (such us e-cigarettes of heated tobacco products) or just seek for discretion (such as office workers who do want to go outside for a smoke or vape). Special aim group are children who want to hide their nicotine product use. Respondents believe that they will not force traditional cigarettes out of the market but will be a popular alternative for young people. Some suggest they need popularization to help exclude products that produce smelly smoke or vape. Conclusions Nicotine pouches as smokeless products will probably fill the market space with product aimed at young people who seek discretion of their nicotine addiction as well as those who do not want to inhale smoke. Key messages • Nicotine pouches users see value of these products. • Nicotine pouches future seems to be bright unless regulations disrupt their market development.

Estimating the weight of consumed tobacco product waste in various Indian states: a novel method to assess the potential burden of tobacco product waste

IntroductionThe direct morbidity and mortality caused by tobacco are well documented, but such products also contribute to a range of environmental pollutants resulting from tobacco product waste. No previous studies...

Harm Reduction in Tobaccoism : What Does the Scientific Evidence Say?

Smoking is considered a chronic disease caused by chemical dependence of nicotine. This is highly addicting, it in the brain system it influences our emotions, increases the feeling of pleasure/humor and reduces the anxiety. In a planet with about 8 billion people, around 1,36 billion are smokers. Cigarette smoking is the leading cause of preventable death in the world, around 8 million people die every year. A global public health problem, and those who smoke are vulnerable to 50 tobacco-related diseases, several kinds of cancer, lung diseases, cardiovascular disease, erectile dysfunction, female infertility and pregnancy complications. In 2020, according to data from the World Health Organization, 22,3% of the world population consumed tobacco, 36,7% of men and 7,8%of women. In Brazil, due to policies implemented to smoking control, we had a significant drop in the of period (1989 to 2019) from 34,8% of smokers to 12,6% and in 2021, the total percentage of smokers age 18 or over was 9.1%. All forms of tobacco consumption are harmful to health and there is no safe level. Cigarette smoke 4.720 different toxic substances such as nicotine, irritants, tar and carbon monoxide. In the last 15 years, new heated tobacco devices have arrived on the market with promises of less harm to health. In 78 countries this products are available, including Japan, The United States, Canada, Portugal, Australia, Italy and The United Kingdom. As they do not cause tobacco combustion, they created significantly lower levels of toxic substances, which is the strongest arguments made by defenders of those products. A systematic review of the literature in 2018 on heated tobacco products identified 31 studies randomly and blind over those devices, 11 independent and 20 funded by the products manufacturers, needing further long-term research. Another systematic review (relevant studies from 2015 to February 2021), both “in vitro” as alive has shown that the benefits of heated tobacco are controversial and more research is needed to the short-and-long term health effects. Another large concern is that availability of these smokeless products may encourage cigarette consumption, especially among young people and often with the combined use of traditional cigarettes and heated tobacco products.

Development and validation of a ddPCR assay to detect and quantify tobacco DNA in smoke and smokeless tobacco and tobacco-free products

The last decade, smoke and smokeless products claiming to be tobacco-free, including herbal cigarettes and herbal shisha, became available on the European market and gained popularity. This study proposes a new digital droplet PCR (ddPCR) method, designed based on a previously developed real-time PCR (qPCR) method being currently used by the U.S. Food and Drug Administration (FDA) to specifically detect the presence of tobacco DNA in targeting a sequence from the Nicotiana tabacum nia-1 gene. To ensure a harmonized and reliable control by enforcement laboratories, both of these qPCR and ddPCR methods were then evaluated and validated for their compliance to an international standard. First, the performance of these PCR-based methods was successfully assessed as specific and sensitive, and in line with minimum performance requirements from international standard. Secondly, the transferability to external laboratory was confirmed for these PCR-based methods. Finally, the applicability of these PCR-based methods was demonstrated using 7 ground tobacco reference materials from the Tobacco Research Center (TRC) Toronto University as well as 6 commercial smokeless and tobacco-free smoke and smokeless products. Based on this study, the previously developed qPCR method was confirmed as complying with international standard, ensuring a efficient and harmonize use by enforcement laboratories for tobacco control on the European market. Moreover, this study proposed to enforcement laboratories the possibility to use a ddPCR method, enabling the simultaneous detection and absolute quantification of tobacco DNA as well as a limited impact of PCR inhibitors.

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular riskAbout 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Tobacco Use and Associated Factors Among Men in Tanzania: Further Analysis of the 2022 Tanzania Demographic and Health Survey Data.

Background: Tobacco use is a significant public health challenge, contributing to preventable diseases and premature deaths globally. We aimed to determine the prevalence of tobacco use and associated factors among men in Tanzania. Methods: This was a cross-sectional analysis of data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey. The study population comprised men aged 15-49 years. Weighted logistic regression was performed to identify factors associated with tobacco use. Results:A total of 5763 men with a mean age of 28.6±10 years were included in the analysis. The overall prevalence of tobacco use was 11.1%, with 95% of users consuming smoked products, 17.1% using smokeless products, and 12.1% using both smoked and smokeless products. Older age was associated with increased odds of tobacco use, with odds of tobacco use increasing with each higher age group. Similarly, alcohol consumption was associated with greater odds of tobacco use. On the other hand, having a secondary education or higher, lack of occupation, being the head of the household, and owning a mobile telephone were associated with lower odds of tobacco use. Geographically, men from the Eastern zone and Zanzibar exhibited greater odds of tobacco use, while those from the Southern highlands zone had lower odds. Conclusion: This study revealed a significant prevalence of tobacco use among Tanzanian men and was associated with different individual, interpersonal, and community factors. The findings underscore the need for targeted interventions considering age-specific risk factors and geographical variations.

Marketing of nicotinamide as nicotine replacement in electronic cigarettes and smokeless tobacco.

In the United States, the Food and Drug Administration (FDA) requires tobacco product manufacturers to submit Premarket Tobacco Product Applications (PMTA) for new products, granting marketing approval only if deemed appropriate for the protection of public health. Historically, the tobacco industry has exploited loopholes in the Tobacco Control Act (TCA), especially related to the definitions of nicotine, tobacco product and characterizing flavors, to circumvent the PMTA requirement. In 2023, the industry introduced several 'PMTA-exempt' e-cigarette and smokeless products, including products containing 6-methyl nicotine, a synthetic nicotine analog that is pharmacologically more potent than nicotine. In late 2023 and early 2024, the major US e-cigarette suppliers Nicotine River and ECBlend introduced 'PMTA-exempt' products with the brand names 'Nixamide' or 'Nixodine' or 'Nixotine', with nicotinamide as the main active ingredient. Nicotinamide is a form of vitamin B3 with no known pharmacological activity at nicotinic receptors. Here, we report that the marketing claims for these products, suggesting them and be nicotine substitute products designed to target nicotinic receptors and provide the same experience as nicotine, is deceptive and misleading to consumers. We also inform that these products have evolved further to contain a combination of nicotinamide and 6-methyl nicotine. The regulatory implications of these newly introduced products are discussed.

Fluoride as a potential contributory factor in pathogenesis of oral submucous fibrosis: A novel hypothesis

Oral submucous fibrosis (OSMF) is a chronic premalignant condition of the oral cavity characterized by progressive submucosal fibrosis and high malignant transformation risk. Areca nut chewing is an established aetiological factor, but OSMF's sporadic incidence in nut users indicates other contributing cofactors. This paper propose a novel hypothesis on the potential role of fluoride exposure in OSMF pathogenesis. Evidence in the literature demonstrates fluoride readily accumulates in oral tissues upon topical exposure and can elicit oxidative stress, chronic inflammation, collagen changes, and muscle degeneration through various mechanisms. We hypothesize chronic topical fluoride exposure from gutkha, areca nut or other smokeless tobacco products, along with other aetiologic factors, may induce an aberrant microenvironment in the oral mucosa, initiating and propagating submucosal fibrosis. Resultant repetitive injury coupled with fluoride's interference in collagen metabolism and wound healing may culminate in OSMF pathogenesis. We further speculate that chronic ingestion of dietary fluoride especially from drinking water and food may predispose individuals to OSMF when it interacts synergistically with direct contact of gutkha or other smokeless products. In addition, it is also speculated that the cellular effects of fluoride in a dose-dependent manner, could contribute to dysplastic changes and malignant transformation in severe OSMF cases. Further research should systematically investigate fluoride levels in OSMF cohorts and correlate with disease severity and malignant transformation rates. Confirming the aetiopathologic role of fluoride as a promoting factor would highlight public health efforts to limit its topical exposure from oral habits and diet to combat this oral potentially malignant disorder.

Longitudinal Assessment of Association Between Tobacco Use and Tobacco Dependence Among Adults: Latent Class Analysis of the Population Assessment of Tobacco and Health Study Waves 1-4.

With increasing tobacco product varieties, understanding tobacco use (TU) profiles and their associations with tobacco dependence (TD) has also become increasingly challenging. We aimed to identify TU profiles and their associations with TD over time, and to identify subgroups with high risk of TD. We included 3463 adult recent tobacco users who had complete TU and TD data across waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. We used a composite index of TD and a summed TD score from an established 16-item TD measure. We applied a latent class analysis to identify TU profiles based on participants' usage of eight common tobacco product groups at each survey wave and to check the stability of the TU profiles over time. We then used generalized estimating equations regressions to evaluate the longitudinal TU-TD association, adjusting for potential confounders. We identified three distinct TU profiles that remained consistent across four survey waves: Dominant cigarette users (62%-68%), poly users with high propensity of using traditional cigarettes, e-cigarettes, and cigars (24%-31%), and dominant smokeless product users (7%-9%). Covariate-adjusted models showed that TD was significantly lower among the poly users and the dominant smokeless users, compared to that among the dominant cigarette users. Both TU profiles and their associations with TD were stable over time at the population level. Poly users and smokeless product users were consistently associated with lower TD than cigarette-dominant users, suggesting the need for tailored tobacco cessation interventions for users with different TU profiles. The finding of consistent TU profiles across four survey waves extends the current literature in capturing TU patterns in an evolving tobacco product landscape. The finding of the overall higher level of TD among the cigarette-dominant users compared to the other TU latent profiles (the Cig+eCig+Cigar dominant poly users and the dominant smokeless product users) can help identify high-risk groups for potential interventions. Our application of innovative statistical methods to high-quality longitudinal data from the PATH study helps improve the understanding of the dynamic TU-TD relationship over time.

Evaluation & Comparison of Nicotine quantification in smokeless tobacco products

Introduction: Smokeless tobacco products (STPS) represent a significant health risk and have been associated with oral and pancreatic cancers, oral lesions, coronary artery and peripheral vascular disease and adverse pregnancy outcomes. So, the aim of the present study is to perform quantitative determination of nicotine, the main alkaloid of smokeless product (Gutkha) available in Vadodara, Gujarat. Method: Collection of sample was done from local tobacco selling shopkeeper from Vadodara i.e. vimal, RMD, pan vilas, rajnigandha and raag. All the samples included in the study the same products available everywhere in Gujarat. The quantification of nicotine was done by High Performance Thin Layer Chromatography (HPTLC) using the mobile phase toluene: ethyl acetate: Diethylamine (6:4:0.5). Spectrodensitometric measurement was carried out at absorption maximum 254 nm. Results: Five different smokeless tobacco samples were estimated using HPTLC method. Nicotine content was found to be 2.45% in Vimal, 3.11% in RMD, 2.60%- Pan Vilas, 3.06%- Rajigandha,3.32%- Raag. Conclusion: A considerable variation of nicotine content was found among the five investigated smokeless tobacco product where sample raag revealed the highest amount of nicotine than the other samples. The nicotine concentration of commercially available chewing tobacco products was found to be much lower than that of the smoking form of tobacco, but the higher average daily consumption made it comparable to the smoking form.

Quick nic: novel smokeless nicotine products and pediatric trends.

The development and marketing of smokeless nicotine products in recent years have become increasingly popular among adolescents. In addition to well known conventional inhaled nicotine products, noninhaled products, such as nicotine toothpicks, orbs, lozenges, strips, and more, have dangerously captivated a new youth audience. Although smokeless nicotine products may seem to be less threatening than conventional inhaled nicotine products, there are significant risks associated with the use of these products, including addiction and severe health issues. The purpose of this review is to provide up-to-date information about alternative nicotine products currently on the market that may appeal to youth, and the dangers of nicotine use for pediatric populations. Smokeless nicotine products appeal to minors with their varying flavors and discrete packaging. These products may lead to nicotine toxicity as well as severe health problems, such as cancer, issues with reproduction, and heart attacks. Nicotine is extremely dangerous for young children; in fact, using nicotine products before the age of 18 years can lead to addiction and is linked to an increased likelihood of experimenting with stronger nicotine products or illicit drugs. The development of inconspicuous nicotine packaging has led to increasing concerns for accidental nicotine exposure and overdose in youth. Greater knowledge regarding current nicotine products on the market, specifically smokeless nicotine products, will help clinicians be more aware of the dangers associated with these products. Clinicians will be better able to provide their patients and families with proper guidance to avoid nicotine addiction, further drug use, and detrimental health issues. Caregivers and medical professionals must recognize novel and inconspicuous nicotine products commonly used among youth, understand the signs of nicotine abuse and dependence, and take measures to address possible nicotine-related health risks.

CO135 Clinical and Economic Outcomes Associated with Transitions of Tobacco Use Among a Cohort of Adult Male Smokers Using U.S. Real-World Data

Real-world data on the clinical and economic impact of switching from cigarettes to non-combustible (NC) tobacco products are lacking. This study describes select clinical outcomes and healthcare costs among adult males who continued to use combustible cigarettes (CS), switched to non-combustible smokeless products (ST), or quit tobacco (NT).

Awareness regarding the antitobacco laws and perceptions regarding interventions for effective tobacco control among young adults of Haryana, India.

Tobacco is one of the major behavioral risk factors for noncommunicable diseases in India. Tobacco control depends on public awareness regarding prevalent antitobacco measures. The present study documents the understanding of young adults (<25 years) regarding the antitobacco laws and their perception regarding interventions for effective tobacco control. A cross-sectional study was conducted in two districts of Haryana. A semistructured questionnaire was used to assess tobacco use, participants' awareness of sections 4, 5, 6 (a), and 8 of the Cigarette and Other Tobacco Products Act (COTPA, 2003), sources of information about antitobacco laws, and their implementation. The perception of participants about the effectiveness of laws and provisions was assessed using a three-point Likert scale. Of the 1470 participants, 517 (35.2%) smoked or used smokeless products. They reported the media (84.6%) to be the most critical source of information about antitobacco laws, followed by the health department (57.6%) and family/peer group (44.9%). Most participants were aware of the prohibition of smoking in offices or banks, educational institutions, hospitals, and other public places. Both tobacco users and nonusers perceived health education programs to be an effective intervention to reduce tobacco use (P < 0.01). The awareness regarding COTPA has increased among the general population. The media could be a powerful tool to counteract the pro-tobacco cues in society. The need of the hour is to focus on improving compliance with antitobacco laws at the population level to achieve a tobacco-free India.

Tobacco use profiles by respiratory disorder status for adults in the wave 1-wave 4 population assessment of tobacco and health (PATH) study

Limited evidence exists on the association between electronic nicotine delivery systems (ENDS) and chronic respiratory disorders. This study examines the association of combustible tobacco and ENDS use with chronic respiratory disorders among US adults. Public-use data from the Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013–2014), Wave 2 (2014–2015), Wave 3 (2015–2016), and Wave 4 (2016–2018) were pooled. Analyses focused on adults with W1–W4 respiratory disorder data and current tobacco use at W4, as well as youth entering the adult cohort at W2 through W4 (N = 26,072). We fit weighted multivariable logistic regression models for each respiratory outcome (asthma, COPD, bronchitis) using W4 longitudinal weights. Cigarette smokers (adjusted odds ratio [AOR] = 0.8, 95 % CI 0.7–0.9) were less likely to report an asthma diagnosis (p = 0.013). In contrast, ENDS users (AOR = 6.5, 95 % CI 3.7–11.5), cigarette smokers (AOR = 6.1, 95 % CI 4.0–9.1), dual users of cigarettes and ENDS (AOR = 5.4, 95 % CI 3.4–8.7), current users of non-cigarette combustible, smokeless, and polytobacco products (AOR = 4.4, 95 % CI 3.1–6.4), and former users of any product (AOR = 3.0, 95 % CI 1.9–4.7) had significantly elevated odds of reporting a diagnosis of COPD (p < 0.001). Similar patterns to COPD were observed for bronchitis (p < 0.001). Current and former tobacco use, including ENDS, were significantly associated with prevalence of self-reported COPD and bronchitis after controlling for demographic and psychosocial confounders.

Use of new approach methodologies (NAMs) to meet regulatory requirements for the assessment of tobacco and other nicotine-containing products.

Regulatory frameworks on tobacco and other nicotine-containing products (TNCP) continue to evolve as novel products emerge, including electronic nicotine delivery systems (e.g., electronic cigarettes or vaping products), heated tobacco products, or certain smokeless products (e.g., nicotine pouches). This article focuses on selected regulations for TNCPs that do not make health claims, and on the opportunities to use new approach methodologies (NAMs) to meet regulatory requirements for toxicological information. The manuscript presents a brief overview of regulations and examples of feedback from regulatory agencies whilst highlighting NAMs that have been successfully applied, or could be used, in a regulatory setting, either as stand-alone methods or as part of a weight-of-evidence approach to address selected endpoints. The authors highlight the need for agencies and stakeholders to collaborate and communicate on the development and application of NAMs to address specific regulatory toxicological endpoints. Collaboration across sectors and geographies will facilitate harmonized use of robust testing approaches to evaluate TNCPs without animal testing.

Toward an ontology of tobacco, nicotine and vaping products.

Ontologies are ways of representing information that improve clarity and the ability to connect different data sources. This paper proposes an initial version of an ontology of tobacco, nicotine and vaping products with the aim of reducing ambiguity and confusion in the field. Terms related to tobacco, nicotine and vaping products were identified in the research literature and their usage characterised. Basic Formal Ontology was used as a unifying upper-level ontology to describe the domain, and classes with definitions and labels were developed linking them to this ontology. Labels, definitions and properties were reviewed and revised in an iterative manner until a coherent set of classes was agreed by the authors. Overlapping, but distinct classes were developed: 'tobacco-containing product', 'nicotine-containing product' and 'vaping device'. Subclasses of tobacco-containing products are 'combustible tobacco-containing product', 'heated tobacco product' and 'smokeless tobacco-containing product'. Subclasses of combustible tobacco-containing product include 'cigar', 'cigarillo', 'bidi' and 'cigarette' with further subclasses including 'manufactured cigarette'. Manufactured cigarettes have properties that include 'machine-smoked nicotine yield' and 'machine-smoked tar yield'. Subclasses of smokeless tobacco product include 'nasal snuff', 'chewing tobacco product', and 'oral snuff' with its subclass 'snus'. Subclasses of nicotine-containing product include 'nicotine lozenge' and 'nicotine transdermal patch'. Subclasses of vaping device included 'electronic vaping device' with a further subclass, 'e-cigarette'. E-cigarettes have evolved with a complex range of properties including atomiser resistance, battery power, properties of consumables including e-liquid nicotine concentration and flavourings, and the ontology characterises classes of product accordingly. Use of an ontology of tobacco, nicotine and vaping products should help reduce ambiguity and confusion in tobacco control research and practice.

The role of smoking in the development of strokes at a young age

Stroke in young patients is a disease based on a number of known specific non-modifiable factors (extracranial artery dissection, thrombophilia, open oval hole, etc.) and modifiable factors (alcohol abuse, drug use, smoking, etc.), in combination leading to the development of pathology. Smoking is a generally recognized modifiable risk factor for stroke, which is directly proportional to the number of tobacco-containing products smoked. Quitting smoking is the basis of prevention, an integral part of the treatment and rehabilitation of stroke patients. If it is impossible to completely give up smoking combustible cigarettes, it is advisable to switch to alternative smokeless products. This article presents the results of current studies on the comparative assessment of the risk of stroke in young people when using combustible cigarettes and smokeless analogues.

Online Tobacco Advertising and Current Chew, Dip, Snuff and Snus Use among Youth and Young Adults, 2018–2019

Objective: To understand the relationship between exposure to online tobacco advertising and current smokeless tobacco use in the context of tobacco control policies. Methods: Three waves of a national probability-based sample of (n = 15,985) youth and young adults were used. Analysis consisted of GEE logistic models controlling for social media use, demographics, tobacco use, average price of smokeless tobacco inclusive of taxes, smoke-free indoor air laws (SFIA) and state tobacco control expenditures. Results: Frequent exposure to tobacco advertising on social media is associated with greater odds of current smokeless use (aOR: 2.05, 95% CI: 1.62, 2.60). Higher prices and SFIA coverage were associated with reduced current smokeless use when examined separately from other tobacco policy variables (aOR: 0.79, CI: 0.73, 0.85; aOR: 0.44, CI: 0.28, 0.70). Conclusions: Greater exposure to tobacco advertising online is associated with greater odds of smokeless use among surveyed youth and young adults. This effect of social media marketing exposure on smokeless use outweighs the mitigating impact of existing tobacco control policies. The findings underscore the need for strong advertising regulation of evolving tobacco products, including smokeless products, on social media and surveillance of digital marketing tactics to young people.

EFFECT OF ORAL TOBACCO ON VITAL DATA

Chewing Tobacco is a global public Health hazard. oral and nasal smokeless products have been used in many countries for centuries. Smokeless tobacco use has been associated with oral cancer and leukoplakia at the site of application of tobacco . .Nicotine is cardio active , changes in heart rate, temperature respiratory rate blood pressure were observed . At present cross-sectional study was done between September 2020 to February 2021 on apparently healthy individuals of age group 20 to 40 years who have the habit of tobacco chewing for more than 2 years. Oral use of smokeless tobacco is widely prevalent in India. On chewing tobacco in any form, nicotine is released into bloodstream which in turn has effect on sympathetic nervous system Hence the present study was conducted to study the effect of oral tobacco on heart rate , respiratory rate , blood pressure and temperature

Cheaper tobacco product prices at US Air Force Bases compared with surrounding community areas, 2019

IntroductionIn March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to ‘prevailing prices’ in the ‘local community’ adjusted for...