Nicotine products: Separating facts from fiction

Progress towards a Smoke-Free Sri Lanka that addresses the needs of the nicotine consumers whilst advocating for potentially reduced-risk alternatives will depend on replacing misperceptions with balanced, evidence-based dialogue. Regulation of tobacco-free, smokeless products and public education must be firmly grounded in science and evidence

By: Dr. R.S Mowjood

Two common characteristics of the twenty-first century smoker are: (1) they are well aware of the health-risks associated with their habit of choice; and (2) they have repeatedly tried to quit but somehow found themselves back at the mercy of a smoke.

Being as technologically and medically advanced as we are, it is hard to believe that we have been unable to come up with solutions to an issue that over a billion people across the world are facing. It begs the question – is it a problem-solving issue, or a messaging issue centred around misinformation?

Objective research

The good news is that objective research suggests that it is the latter. Innovation has created a plethora of options for smokers looking to quit. Today, a range of smokeless, reduced-risk alternatives to cigarettes exists, including oral nicotine pouches and vapour products. The challenge, however, is that discussions around these alternatives are often shaped by myths and misinformation. 

Just like how fiction moves faster than fact in a school library - as with many new entrants to old markets, sensationalised tales of caution spread faster than research-based information. The same can be said for oral nicotine pouches and vapour products – product categories that provide the consumer with an alternative to access nicotine without tobacco or combustion. 

As someone who works in the medical field, it is almost muscle memory at this point, to separate facts from fears. In that spirit, here is research-based narrative that is probably less entertaining, but far more lifesaving.

Myth: All nicotine products pose the same level of harm. 

Fact: Not all nicotine products are equally harmful, because they differ in their composition and nicotine delivery mechanisms

The perception that all nicotine-containing products carry the same risk is inaccurate. In fact, when we look at the major drivers of smoking-related diseases - cancer, heart disease, lung disease - the overwhelming scientific consensus indicates that nicotine itself is not the primary driver. Instead, most of the harm associated with smoking-related diseases comes from the thousands of toxicants emitted when the tobacco is burned. 

This understanding has shaped how leading public health bodies, including the US Food and Drug Administration (FDA), view tobacco and oral nicotine products along a continuum of risk - with combustible cigarettes at the highest end and non-combustible or smoke-free products potentially presenting lower risk for adults who would otherwise continue to smoke. The FDA notes that such products, when scientifically substantiated, “may significantly reduce exposure to harmful chemicals.”

This is the principle behind oral nicotine pouches and vapour products. They contain no tobacco and involve no combustion. Without burning, research shows a substantial reduction in the levels of harmful chemicals compared with those produced in cigarette smoke.

It is also worth flagging in-line with that, that, not all oral nicotine products are alike. Tobacco-free nicotine pouches do not contain tobacco and consist of food-grade ingredients. In contrast, other traditional oral products such as chewing tobacco which is widely used in the agricultural community of Sri Lanka, paan, and gutka include tobacco and/or betel nut, slaked lime, and other additives which impact on their toxicant levels. 

Myth: Smokeless products, including oral nicotine pouches and vapour products, have no role in tobacco harm reduction.

Fact: Smokeless products, including oral nicotine pouches and vapour products, can play a role in tobacco harm reduction.

Epidemiological evidence from Sweden provides a clear example of the tobacco harm reduction potential smokeless products can have. Sweden has permitted access to oral tobacco and nicotine pouches for adult smokers for more than 5 decades. And as a result, with a daily smoking prevalence of 5.4% (as of 2024), they are on track to become the first smoke-free country in the EU. It also reports some of the lowest rates of smoking-related diseases, including lung cancer and heart disease, in the EU. 

New Zealand is another good example. Between 2016 and 2023, adult daily smoking declined from 14.5% to 6.8%, putting them on track to achieving the smoke-free goal (defined as having a smoking prevalence to less than 5% of the population by the end of 2025). This success has been largely attributed to the introduction of vapour products as adult consumer products and policies enabling smokers to switch by providing accessible, diverse, and quality-controlled options of the product category. Importantly, vapour alternatives have been recognised as a harm reduction tool, rather than a public health concern, helping many smokers move away from combustible cigarettes.

Myth: Oral nicotine pouches have the same level of toxicants as cigarettes. 

Fact: Oral nicotine pouches emit significantly fewer and substantially lower levels of harmful chemicals compared to those found in cigarette smoke. 

Oral nicotine pouches do not contain tobacco, involve no combustion, and produce no tar. Consequently, studies show they expose users to substantially fewer and lower levels of toxicants compared with combustible cigarettes. According to Johns Hopkins (a major FDA research partner) nicotine pouches eliminate exposure to combustionrelated toxicants, which are responsible for most smokingrelated disease.

Ultimately, progress towards a Smoke-Free Sri Lanka that addresses the needs of the nicotine consumers whilst advocating for potentially reduced-risk alternatives will depend on replacing misperceptions with balanced, evidence-based dialogue. Regulation of tobacco-free, smokeless products and public education must be firmly grounded in science and evidence. By empowering policymakers, regulators and public health stakeholders with the robust evolving body of scientific evidence on tobacco-free, smoke-free alternatives, we can help create the conditions for pragmatic, forward-looking policy aligned with long-term public health goals.

(The author is a Chest Physician)