Q&A: Nicotine pouches not as effective in curbing cravings as cigarettes

Key takeaways:

• Smokers rated 6 mg and 3 mg nicotine pouches as moderately appealing.
• An expert said nicotine pouches are far from being a first-line smoking cessation therapy.

Oral nicotine pouches did not relieve nicotine cravings as well as cigarettes after 5 minutes of use, according to a study published in Addiction.

“Nicotine addiction is a very real problem for many people, and most current smokers express wanting to quit but often fail because it is so challenging to stop — and to make it stick long term,” Brittney Keller-Hamilton, PhD, an assistant professor at The Ohio State University, said in a press release.

During the trial, which consisted of 30 adult smokers, the researchers found that nicotine cravings were significantly lower 5 minutes after smoking cigarettes (mean=1; 95% CI, 0.61-1.39) than using either 6 mg (mean=2.19; 95% CI, 1.6-2.79) or 3 mg (mean=2.25; 95% CI, 1.68-2.82) nicotine pouches.

Keller-Hamilton spoke to Healio about the study findings, the implications for primary care physicians and more.

Healio: Can you discuss the study and your findings?

Keller-Hamilton: We had participants from rural Ohio and Appalachia come up to our clinic for three visits. During two of the visits, they used a nicotine pouch that either had 6 mg nicotine per pouch or 3 mg nicotine per pouch, or they smoked one of their usual brand cigarettes.

For each of the products, we followed a standardized use protocol. So, for the nicotine pouches, every person in our study used them for 30 minutes, and for the cigarettes, every person in our study smoked one cigarette over the course of 5 minutes by taking a puff every 30 seconds.

While they were doing this, we asked them questions over the course of 90 minutes, and we did blood draws over the course of 90 minutes so that we could see how nicotine was being delivered to their blood over time, how it changed and differed between products, and how their feelings of withdrawal and craving symptoms changed over time as they were using the products.

We found that the cigarettes really delivered a lot more nicotine and delivered it faster than the two nicotine pouches we tested. We saw a spike in nicotine after 5 minutes of smoking a cigarette. It was much more gradual for the nicotine pouches to reach their maximum plasma nicotine levels.

The second main finding was that when we looked specifically at relief of craving symptoms, the cigarette smoking visit had the sharpest and steepest decline in craving symptoms compared to either nicotine pouch.

The third main finding was that participants rated the pouches as moderately appealing. Something that was surprising was that participants rated the two pouches very similarly on appeal. Even though we did see some differences in nicotine delivery, with a 6 mg pouch delivering more nicotine than the 3 mg pouch, participants liked them just the same. That’s kind of something we’ll need to unpack in future research.

Healio: What are the implications for PCPs?

Keller-Hamilton: PCPs at this stage should start to follow nicotine pouches a little more closely for a couple of reasons.

The first is that the sales of nicotine pouches are increasing really fast. The latest research I’ve seen that’s looked at sales data indicates that they’re growing at a rate of about 8% month over month. It’s just building more and more. Some of that uptake seems to be among young people and people who don’t use other forms of tobacco, which is obviously a public health concern. So, it’s probably time to start asking young people if they’re using nicotine pouches in addition to cigarettes, vapes and other tobacco products.

However, a lot of the uptake so far has been among adult tobacco users trying to quit or trying to just reduce their cancer risk. PCPs should also be ready for questions from their patients, where maybe a patient is trying to quit smoking or trying to smoke less and is interested in whether a nicotine pouch might work.

That said, the research isn’t out there yet. We don’t know how good they are helping people quit smoking, so it might be a case where a PCP refers a participant to their state tobacco quit line or encourages them to use nicotine replacement therapy and counseling.

If all those other measures fail, then maybe trying a nicotine pouch could be something that a PCP could explore with certain patients. But I don’t think it should be anywhere near the first line of smoking cessation therapy.

Healio: What do you plan to do with the $20 million grant for research on tobacco regulation that was awarded from the FDA to Ohio State University?

Keller-Hamilton: Big picture, the grant is trying to figure out how we can regulate e-cigarettes and nicotine pouches via FDA tobacco regulation to promote public health. We’re approaching this from two angles. Some of the projects are looking at how we can regulate these products so that they are too aversive and unappealing for young people or people without a preexisting nicotine addiction.

At the same time, we have some projects that are looking at how we can maximize the appeal of e-cigarettes and nicotine pouches for adults with a nicotine addiction. So, adults who are smoking cigarettes, adults are using traditional smokeless tobacco, who could see big health benefits of switching to these lower risk products.

The project I’m leading will focus on nicotine pouches. We will enroll a sample of smokers and smokeless tobacco users and have them try pouches that have different nicotine concentrations, different levels of pH — which affects how fast nicotine is delivered and how averse of the product is — and different nicotine sources, like whether it was nicotine that came from tobacco or nicotine that was made in the lab. That’s important because some of the lab-made nicotine doesn’t deliver as much to the user. It’s a milder product, which is the expectation.

So, that study will be directly comparing nicotine pouches that have these different characteristics to see how appealing they are, how they deliver nicotine, how they relieve withdrawal craving symptoms, and then we’re going to ask our participants to try to switch from cigarettes or smokeless tobacco to a nicotine pouch and compare how well participants can execute that switching behavior as it relates to differences in nicotine between the nicotine pouches.

References:

• Keller-Hamilton B, et al. Addiction. 2023;doi:10.1111/add.16355.
• Ohio State awarded $20M to put science behind tobacco product regulation. https://cancer.osu.edu/news/ohio-state-awarded-20m-to-put-science-behind-tobacco-product-regulation. Published Oct. 4, 2023. Accessed Dec. 5, 2023.
• Oral pouch products do little to curb addictive nicotine cravings. https://cancer.osu.edu/news/oral-pouch-products-do-little-to-curb-addictive-nicotine-cravings. Published Nov. 15, 2023. Accessed Dec. 5, 2023.