One would expect that the Canadian Cancer Society, the Heart and Stroke Foundation and the Lung Association would welcome a new product that could reduce the cancer, heart attacks and lung disease caused by smoking. Instead, when such a product was first marketed in October 2023, these three major health charities worked with Action on Smoking and Health, Coalition québécoise pour le contrôle du tabac and Physicians for a Smoke-Free Canada to urge Health Ministers to ban the product and establish a moratorium on the approval of any similar products.
Cigarettes are unique in that they are a legal product that, even when used correctly, kills more than half of long-term users. About 125 Canadians die every day of a smoking-related illness –more than the total of all deaths due to alcohol, opioids, suicides, murders and traffic collision. Despite decades of health warnings, counselling, medical nicotine replacement therapy (NRT) and medications, 3.8 million Canadians still smoke.
We need new methods of smoking cessation to help those who have so far failed to quit. As a physician who has seen the damage that tobacco does to the human body, I was hoping nicotine pouches would offer adult smokers who had already tried and failed to quit using standard medical therapies a new, safe and effective option.
Nicotine pouches are dime-sized, porous, white cellulose bags that contain nicotine, flavouring and chemicals to control pH and humidity. They are placed between the teeth and the gum, and release nicotine into the bloodstream over about 30 minutes, reducing withdrawal symptoms and cravings in people who are trying to quit smoking. Because they do not contain tobacco, are not burnt and nothing is inhaled, they are 1,000 times safer than smoking and are also safer than medical NRT such as gums and lozenges
In randomized controlled trials, use of nicotine pouches reduced cigarette consumption by 42 per cent, compared to 33 per cent with the use of nicotine gum, and users preferred the pouches.
In July 2023, Health Canada, after almost two years of consideration, authorized one brand of nicotine pouch for sale in Canada, determining that “ZONNIC is a form of Nicotine Replacement Therapy. It can help you quit smoking by delivering nicotine to your body, temporarily relieving cravings and nicotine withdrawal symptoms. ZONNIC provides nicotine as part of a Nicotine Replacement Therapy program which increases the chances of quitting smoking successfully.”
Why were the Canadian health charities so opposed to this new product?
Firstly, like nicotine gum, it comes in a range of enjoyable flavours. Secondly, it is manufactured and marketed by Imperial Tobacco Canada (ITC), a wholly owned subsidiary of British American Tobacco. Thirdly, it is regulated as a “natural health product,” a category that includes nicotine gum and lozenges and imposes no age limit for sales. As a result, the Canadian Cancer Society could accurately state, in attention-grabbing headlines, that “Health Canada makes it legal for flavoured nicotine products from Imperial Tobacco to be sold to children.” It did not mention that 30 per cent of all cancer deaths are caused by smoking, or that Zonnic was a new, safe and effective way to quit.
Initially, ITC claimed it was excited to announce a new smoking cessation product. ITC’s President and CEO, Frank Silva, said, “Smoking is the cause of serious diseases, and we are committed to reducing the health impact of our business.”
Unfortunately, ITC seems to have made the business decision that there was more money to be made selling Zonnic to young adult Canadians, the vast majority of whom do not smoke, than as a cessation tool for older Canadians who smoke. Young people may continue to use the product for 50 years or more, but middle-aged smokers may only use it for a few months as a quitting tool. Accordingly, ITC promoted Zonnic on Instagram, with lifestyle advertisements that showed 20- to 30-year-olds enjoying Zonnic in social settings, such as eating out, watching TV together or dating.
Mark Holland, Canada’s Health Minister was outraged, claiming that he had been duped and that he would close the age-limit loophole. He told Big Tobacco to “Stay the hell away from our kids.”
ITC VP Eric Gagnon pushed back: “The actual loophole is the absence of a legal minimum age for purchasing NRTs in Canada.” Gagnon said that, after speaking with Health Canada, ITC had made changes, voluntarily removing parts of its advertising campaign featuring young people and placing the 18+ age label more clearly on its package.
He also stated that “It is irresponsible for governments to target a legal product that smokers are finding an effective way to quit, simply because they dislike the inconvenient fact that the manufacturer is a tobacco company.”
“It is irresponsible for governments to target a legal product that smokers are finding an effective way to quit, simply because they dislike the inconvenient fact that the manufacturer is a tobacco company.”
The health minister has promised to take new action but it is not clear what he will do. He is talking about banning kid-friendly flavours, but Zonnic only comes in three flavours (Chill mint, Berry Frost and Tropic Breeze) while medical nicotine gum comes in five different flavours. He is also talking about removing nicotine pouches from convenience stores and other places where cigarettes are sold to a position behind the counter in pharmacies. This means that it will be quick, easy and convenient to continue to buy lethal cigarettes, but purchasing very much safer nicotine pouches will require a special trip to a pharmacy.
Instead of being promoted as a smoking cessation tool, Zonnic has been portrayed by the health minister and media as an attempt by Big Tobacco to addict a new generation of youth to nicotine. Its potential to save the lives of people who smoke has been almost completely lost.
The solution to this issue is very simple. Each organization needs to do its own job and do it properly.
- Health Canada needs to set a legal minimum age for all non-prescription nicotine products, and this needs to be enforced by the appropriate authorities.
- Imperial Tobacco Canada needs to actually do what it said it intended to do. It needs to use its extensive wealth and marketing savvy to effectively promote Zonnic as a smoking cessation tool for adult Canadians who are still smoking despite previous efforts to quit.
- Canada’s health organizations need to embrace all safer sources of nicotine and encourage smokers who cannot completely quit using nicotine to switch to much safer alternative sources such as vape, heat-not-burn products and nicotine pouches.
Nicotine pouches and vaping are more effective methods of reducing smoking or quitting than medical NRT. However, while the Ottawa Model for Smoking Cessation accepts sponsorship from the makers of medical NRT, it bans people associated with the vaping industry or with Zonnic from speaking at, sponsoring or even just attending its conference.
One of the major goals of the Canadian Cancer Society should be to reduce the 21,366 cancer deaths caused by smoking annually. If it wants to weigh in on adolescent medicine, maybe it should campaign against selling flavoured alcohol, a known carcinogen, to young people. There were 3,875 alcohol-induced deaths in 2021 in Canada.
The Heart and Stroke Foundation should be concerned about the 12,710 Canadians who die from heart disease due to smoking annually. About 20 per cent of all cardiovascular deaths are caused by smoking.
The Lung Association should worry about the 9,937 smokers who die from respiratory illness annually. In contrast, Health Canada reports no Canadians have died of vaping associated lung injuries.
The real and lethal risks to youth are alcohol, cannabis and opioids, not nicotine. The issue of illegal teenage use of nicotine products should be left to law enforcement and to appropriate organizations such as the Canadian Paediatric Society and the Centre for Mental Health and Addictions that are better qualified to address these issues.
People who smoke are entitled to medical care based on scientific evidence. There should be no “wrong” method to quit smoking. Nicotine pouches are a very safe source of nicotine that can help smokers reduce or quit smoking.
The possibility that some minors may choose to use nicotine recreationally should not prevent nicotine pouches from being readily available to adult smokers who are trying to quit. They should be available everywhere that cigarettes are sold. It doesn’t make sense to move nicotine pouches to pharmacies because they are thought of as dangerous, while leaving a product that is actually 1,000 times more dangerous on sale at every convenience store and gas station.
“Nicotine pouches present a promising option for smoking cessation, providing a safer alternative to smoking. Their effectiveness and safety could help many adult smokers who have struggled to quit using traditional methods. However, cranial nerves mnemonic it’s crucial that regulations ensure these products are marketed responsibly, with strict age restrictions and monitoring to prevent youth access and misuse. This balanced approach can help protect public health while offering smokers more choices to quit.”
RESPONSE TO JOHN POLITO – by paragraph
“Recreational” youth use of a “natural health product” that’s a “1,000” times safer and comes in 3 “kid friendly” and “enjoyable flavours,” if you were a gullible 17-year-old reading this article, what would be your takeaway? Absent is discussion of nicotine’s greatest harm, as permanent as alcoholism, the fact that it’s highly addictive; the likelihood that that next nicotine fix will become a teen’s highest priority from dawn to dusk for the rest of their life.
Comment: Yes, nicotine is dependence forming. Youth should be deterred. The fact of the matter is that the Zonnic product is covered by the contract between Imperial and vendors which states: “Sell to underage and you no longer get Zonnic from us to sell.” This is rarely mentioned in the emotional discussion of pouches. Do alcohol suppliers act so ethically? The final sentence ..” from dawn to dusk for the rest of their life.” Wow. Most kid use is experimental, some is daily.
The author pits smoking’s long-term harms against current youth collateral damage. While the establishment of a statutory minimum nicotine purchase age is obvious, so is the need to relocate the sale and marketing of all nicotine products into stores that deny access to those below the minimum age.
Comment: Will you do the same for alcohol – a carcinogen? Pouches are not carcinogenic. And for gambling – those lottery terminals above the candy at the checkout – will they go too? Is this “obvious”?
What is the cure for the cure? Having devoted the past 25 years to helping facilitate nicotine dependency recovery, I submit that the quest for quitting industry profits has obliterated the beauty and speed of harm elimination via abrupt nicotine cessation.
Comment: “The beauty and speed of harm elimination via abrupt nicotine cessation.” What a glorious statement. If only the frequency of such heroic behaviour were anything close to the success of non-combustible nicotine products. The established fact is that vaping is the most successful antidote to smoking since the invention of the factory-rolled cigarette. See the Cochrane Library.
Whether a light or heavy user, whether cigs, vapes or pouches, nicotine’s roughly two-hour half-life doesn’t discriminate. Within 72 hours, a nicotine-free brain has no choice but to begin the process of restoring natural neuronal sensitivities. The worst behind you, what’s amazing is watching fear and dread melt into like or even love, normally within 2-3 weeks. But just one hit of nicotine and it’s back to square one. We’re simply not that strong.
Comment: most underage nicotine use is experimental. US data indicate that 1.5% of middle and high school kids experimented with pouches in the preceding 30 days. Hardly an epidemic. Kids, like adults, who suffer from mental health disorders, individuals who are part of the LGB+ community, people with schizophrenia etc: should they all quit nicotine if it provides them with solace? Or should we hector the underprivileged with the glory and heroics of an instant quit? I say, let them consume nicotine in a safer form.
While plenty of hints here and there, the most fundamental quitting question of all largely remains unanswered. How do most addicted to nicotine successfully arrest their chemical dependence?
Comment: The truth is that a huge percentage of society is dependent on substances: gambling, cannabis, alcohol, nicotine, prescription drugs. Nicotine in non-combustible form is the least harmful of these products, even if dependence is difficult to break. If society bans or over-regulates these goods they will be supplied in more dangerous form by the illegal market. We must adopt an adult approach to the consumption of these products – meaning that we try to get them consumed in a low-harm form. Individuals have rights to consume products that are unhealthy. Obesity will kill millions while nicotine in pouch or vape form will not. Should we put all fat and sugar products in adult only stores?
In the quest for objectivity, I encourage journalists to put nicotine shell games into perspective. Missing and needed is an accurate population-level nicotine dependency recovery picture. Why? Because common sense shouts that cold turkey quitters don’t join clinical trials dangling weeks or months of free dopamine agonists or partial agonists as study recruiting bait.
Comment: Do we need a cigarette quit program or a nicotine quit program? If oral tobacco is about 1% as dangerous and is a substitute for cigarettes, let’s get it to as many adult smokers as possible. Why not get the government to distribute it free in return for smokers exchanging a pack of cigarettes? Let’s focus on where the harm originates – combustion.
I think you’ll discover that harm reduction is built upon the fiction that nicotine is medicine and its use therapy. A divide and conquer agenda, it’ll eventually hit you that abrupt nicotine cessation books, counseling, insights, apps, and support groups don’t change the underlying quitting method, that reading Allen Carr’s Easy Way or Joel Spitzer’s Never Take Another Puff is like putting condiments on a burger or hotdog.
Comment: Nicotine is a pleasurable dependence forming drug. If its harms are small let’s be adults and minimize our risk. Should we never drive a car or should we drive and wear seat belts?
It’s often said that harm reduction is for smokers who can’t quit. But is it true? Is it that they can’t quit or that profit-driven harm reduction has zero incentive to teach them how? While I’m confident that the vast majority of harm reductionists would agree that harm elimination should take priority, try to locate any who have openly shared with smokers how most successfully arrest their chemical dependence upon nicotine.
Comment: Reduced harm in alcohol use is to consume low-alcohol beer rather than high-content spirits; reduced harm in cannabis is what? Does it exist now that so many products have sky-high THC content? Reduced harm in gambling is going to bingo night rather than Las Vegas. Reduced harm in drug consumption takes place at needle exchanges. Is nicotine in low-harm form the only one of these products to receive the treatment you propose? Let’s adopt the principle of horizontal equity – which means tolerance across the board. It will also restrict the illegal sector.
I am a professor in economics at Concordia University in Montreal. I have worked for government and the private sector in the field of nicotine.
Ian Irvine
“Recreational” youth use of a “natural health product” that’s a “1,000” times safer and comes in 3 “kid friendly” and “enjoyable flavours,” if you were a gullible 17-year-old reading this article, what would be your takeaway? Absent is discussion of nicotine’s greatest harm, as permanent as alcoholism, the fact that it’s highly addictive; the likelihood that that next nicotine fix will become a teen’s highest priority from dawn to dusk for the rest of their life.
The author pits smoking’s long-term harms against current youth collateral damage. While the establishment of a statutory minimum nicotine purchase age is obvious, so is the need to relocate the sale and marketing of all nicotine products into stores that deny access to those below the minimum age.
What is the cure for the cure? Having devoted the past 25 years to helping facilitate nicotine dependency recovery, I submit that the quest for quitting industry profits has obliterated the beauty and speed of harm elimination via abrupt nicotine cessation.
Whether a light or heavy user, whether cigs, vapes or pouches, nicotine’s roughly two-hour half-life doesn’t discriminate. Within 72 hours, a nicotine-free brain has no choice but to begin the process of restoring natural neuronal sensitivities. The worst behind you, what’s amazing is watching fear and dread melt into like or even love, normally within 2-3 weeks. But just one hit of nicotine and it’s back to square one. We’re simply not that strong.
While plenty of hints here and there, the most fundamental quitting question of all largely remains unanswered. How do most addicted to nicotine successfully arrest their chemical dependence?
In the quest for objectivity, I encourage journalists to put nicotine shell games into perspective. Missing and needed is an accurate population-level nicotine dependency recovery picture. Why? Because common sense shouts that cold turkey quitters don’t join clinical trials dangling weeks or months of free dopamine agonists or partial agonists as study recruiting bait.
I think you’ll discover that harm reduction is built upon the fiction that nicotine is medicine and its use therapy. A divide and conquer agenda, it’ll eventually hit you that abrupt nicotine cessation books, counseling, insights, apps, and support groups don’t change the underlying quitting method, that reading Allen Carr’s Easy Way or Joel Spitzer’s Never Take Another Puff is like putting condiments on a burger or hotdog.
It’s often said that harm reduction is for smokers who can’t quit. But is it true? Is it that they can’t quit or that profit-driven harm reduction has zero incentive to teach them how? While I’m confident that the vast majority of harm reductionists would agree that harm elimination should take priority, try to locate any who have openly shared with smokers how most successfully arrest their chemical dependence upon nicotine.
It’s important to debate this topic, so I appreciated the article, Dr. Oyston. I was involved in tobacco control in the 1990s and early 2000s, and like to keep up-to-date on these issues.
Two questions regarding nicotine pouches that don’t seem to have been adequately addressed, at least in the mainstream press:
1) Is there concern adolescents who use nicotine pouches will go on to smoke tobacco cigarettes?
2) It’s clear people enjoy nicotine for its stimulant properties, but what exactly are the risks? Is nicotine like a caffeine type of product, or something much more harmful, especially if used for many years?
Thanks for your comments.
There is a legitimate concern that pouches could be a gateway to smoking. However, youth vaping has led to historic declines in youth smoking. If you can enjoy nicotine fairly safely with pouches orvape, you would ve an idiot to start snoking.
In general nicotine is pretty safe. Thats why uts available in pharmacies without prescription. I has mild CV effects similar to caffeine. It is more addictive in cigarettes than it is in other formats like gum or pouches. In rodent experiments it impairs brain develooment. This effect has not been shown in human smokers.