Emerging non-therapeutic nicotine products: What health professionals need to know

Professor Michelle Jongenelis

Professor Michelle Jongenelis has expertise in health promotion, intervention development and evaluation, behavioural science, and clinical psychology. She works across multiple and diverse health-related behaviours including tobacco and alcohol control, nutrition, and physical activity. Michelle is internationally recognised for her research exploring emerging issues relating to tobacco and nicotine products. She sits on the Australian Council on Smoking and Health, and the World Federation of Public Health Associations' Tobacco Control Working Group. She is also Deputy Chair of the Thoracic Society of Australia and New Zealand's Tobacco and Other Products SIG and co-convenes the Public Health Association of Australia's Alcohol, Tobacco, and Other Drugs SIG.

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• Further reading: InDepth 18C Nicotine pouches and other non-therapeutic oral nicotine products - Tobacco in Australia
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[00:00:00] Paulette: This Quit Insights clinical series podcast is recorded on Wurundjeri Woi-Wurrung Country. We acknowledge the traditional custodians and pay our respects to elders past and present, and we extend that respect to those on the lands where you're listening today. This podcast is intended for health professionals and is for educational and informational purposes only. The content discussed does not constitute medical, legal or professional advice and should not replace your own clinical judgment. Welcome. I'm Paulette Trevena and this is a Quit Insights Clinical Series podcast for health professionals. Each of our episodes will bring you in-depth information and insights from professionals who are experts in smoking and vaping cessation. Our guest today is Professor Michelle Jongenelis, who is director of Melbourne Centre for Behaviour Change at the University of Melbourne. Michelle is a public health expert with over a decade of experience in tobacco control. Michelle works as a researcher and consultant for a broad range of organisations in the not-for-profit and government sectors. Michelle sits on the Australian Council on Smoking and Health and the World Federation of Public Health Associations Tobacco Control Working Group. She is also deputy chair of the Thoracic Society of Australia and New Zealand's Tobacco and Other Products Special Interest Group and Co-convenes the Public Health Association of Australia's Alcohol, Tobacco and Other Drugs Special Interest Group. Welcome, Michelle, and thank you for being our podcast guest today. 

[00:01:33] Michelle: Thanks for having me. 

[00:01:34] Paulette: So in this episode, we'll be exploring emerging Non-therapeutic nicotine products, the latest National Drug Strategy Household Survey data from the Australian Institute of Health and Welfare shows that while daily e-cigarette use has stabilised, emerging non-therapeutic and non-smoked nicotine products like oral nicotine pouches and snus are growing fast among young adults. So what are these emerging non-therapeutic nicotine products that we're hearing more about? 

[00:02:04] Michelle: Yeah. So they're essentially nicotine products that have not been approved by the Therapeutic Goods Administration. They're essentially industry created products that are designed to addict a new generation to nicotine. 

[00:02:17] Paulette: Right. So talking about nicotine pouches, snus, etc., how do these products work? 

[00:02:25] Michelle: The snus and nicotine pouches, they're quite similar. They look like a tea bag about a third of the size of a tea bag. And they contain various substances. So nicotine obviously is the addictive substance. But then there's a whole bunch of other chemicals that go into these products. And the idea is that you put the pouch between your lip and your gum, and the nicotine and the other chemicals get absorbed into your bloodstream. And that creates the sort of effect that you would normally get. Now, the difference between snus and nicotine pouches. Snus contains tobacco. Nicotine pouches do not. That doesn't mean that nicotine pouches are safer than snus because like I said, both products contain chemicals, but you'll often hear the term used interchangeably. But the difference is that snus is a tobacco and oral nicotine products don't contain tobacco. 

[00:03:13] Paulette: Right. And what's the main difference between these products and nicotine replacement therapy or NRT designed for cessation? 

[00:03:21] Michelle: Yeah. Well, like I mentioned earlier, these products were created by the tobacco industry. So obviously we've done an excellent job over the last few decades of bringing down smoking rates. But the problem that leads to for the tobacco industry is that they are obviously seeing a fall in their profits. And so they've developed these products sort of outside of that to addict a new generation to nicotine. So they have, you know, lifelong customers. So the difference between these products and nicotine replacement therapies is that nicotine replacement therapy are products that have been approved by the Therapeutic Goods Administration, and they are registered on the Australian Register of Therapeutic Goods, which means they've undergone rigorous testing for safety, quality and efficacy. And the TGA can say we've tested these products. They do what they say they're going to do. They do help people quit. There's evidence behind them. We know that these products that we've tested are safe, and these particular products are then going to be put on the registry and you can access them from, you know, pharmacies. But also there's a lot of products on the registry that you can access through Coles and Woolworths, for example. These nicotine pouches, snus, there is no product at the moment on the Australian market that has been approved by the TGA. So these are completely unapproved goods. And so that's the main difference is we have no idea how harmful these products are, whether these products actually work for smoking cessation. There has been some research done the Cochrane Review recently, which found that, you know, there's actually very low level certainty evidence that these products help with smoking cessation or are any better than tobacco cigarettes. So really early stages of the research at the moment, but we're not finding any evidence that these are actually helping people at all. 

[00:05:00] Paulette: And are they legal? 

[00:05:01] Michelle: Not in Australia. No. So initially when you know these products first came on the market, you were allowed to access them, provided you had a prescription from your medical practitioner and you then took it to a pharmacy and the pharmacy would dispense these products. However, very recently, again, because of the lack of evidence that these products actually do anything other than addict young people, there were changes made, and now these products are prohibited in Australia altogether. 

[00:05:25] Paulette: Right. Okay. How common is their use and who are the main people using them? 

[00:05:30] Michelle: So mainly young people using these products at the moment. So we're still getting some very early information around prevalence data. You mentioned the AIHW National Drug Strategy Household Survey which found that at the overall level. So 14 plus use is still quite low. Less than 2%. But when you look at it by age group, what we're finding is that 18 to 24-year-olds are the around 8.4% who have said that they've used it in the last year. So when it comes to the National Drug Strategy Household Survey, we don't necessarily look at singular points in time. We like to sort of look at, you know, how often are they being used over the last 12 months? How often are they being used over the last month? So because they've only just been around, the only question that they could ask for the survey was, have you used it in the last 12 months? We don't know whether that means using it daily or whatever. But 8.4% for the 18 to 24 year olds. So definitely a market among younger people and particularly men as well. So we're finding in the research that those people who are most likely to use these products are younger people, men, and those people who either smoke or vape. 

[00:06:34] Paulette: Okay. So is the promotion of these products targeted at certain groups? 

[00:06:38] Michelle: Yeah. So we've run some focus groups and there's been some focus groups that have been done in the UK. And one of the findings from both those focus groups was this sense that men are being targeted with these products. So for the last few years, these products have been put in the hands of influencers or athletes specifically sort of targeting the male demographic. So English Premier League soccer players, English Premier League managers would be using these products on the sidelines. So that's sort of how it filtered down to sort of the men more than women. But then we're also hearing that they're appearing on podcasts. So you might get a podcast host who would be saying, oh, look, this is what we're using today. So they're not necessarily promoting the product, obviously, but it's quite subtle advertising that makes it seem as if it's a very organic way of promoting the product. Right? Very passive. But a lot of the people who we did our focus groups with could really see through that and said, look, this doesn't seem right. It's obvious that they're getting paid by the companies to promote the product. So very much targeting young men. And we're seeing this also this disturbing trend on social media as well, where we're seeing fitness and wellness influencers talking about how nicotine is a natural substance that actually is health promoting. Now, obviously that's very problematic. And we're keeping our eye on that because it's an addictive substance. But you can imagine how that sort of a message can get across to younger people who are perhaps wanting to improve their well-being. 

[00:08:05] Paulette: So from your research and your experience, why do people use the product? 

[00:08:10] Michelle: Yeah, so they're very discreet. So unlike tobacco cigarettes where, you know, you're using them, there's a very pungent smell. There's a smoke cloud that comes up vapes as well, vapes. The smell is less pungent because they obviously come in those fruity flavours. But you see this massive plume of aerosol that comes out. So it's quite obvious when someone's using them, whereas with nicotine pouches they're very discreet. So something that we're hearing from the kids and the adults in our focus groups was they were saying, well, it's really discreet to use. I can use it when I'm in a lecture theatre and nobody knows, you know, if I have to sit a three hour exam and I can't use my vape, I can just pop one of these in and I'm fine, I can use it on an airplane. I can use it when I'm going to a concert, when I'm going to the football where smoking and vaping is banned. So the ability to use it in places where you can't use other products is a big one. They're discreet nature, so teachers can't pick up that they're using it. Their parents can't pick up that they're using it. 

[00:09:04] Michelle: But we're also hearing from some younger people that they're using these products because, you know, it gives them a kick. They like the fact that the nicotine is giving them a head spin, and also that it potentially helps moderate their anxiety. So emotion regulation, they might be feeling a bit stressed and they pop one of these things in. But of course, you know, they're also recognising the negative effects of it. So we had a lot of participants in our groups who said, look, either I have noticed this when I've used it or I've seen my friends, you know, if they don't use it, I've seen peers use it where, you know, they're vomiting straight away or they're passing out from using these products. A lot of oral health issues as well. So there's a bit of a mix where they appreciate that there are these clear harms associated with it, but there's also this sort of drive to use it, particularly for those who are already addicted to nicotine or already using vapes. And they're looking for like a gap to be able to use these products where they can't use vape or cigarettes. 

[00:09:58] Paulette: So there's co-use happening there. 

[00:10:00] Michelle: A lot of co-use. Yeah. And actually, one of the concerning big findings from the National Drug Strategy Household Survey was that the percentage of people who are using more than one product has actually increased quite a bit. So we're no longer seeing people who are just smoking or just vaping or smoking and vaping. We're seeing people smoking, vaping, and using nicotine pouches or other sort of forms of nicotine. Now you can imagine the sort of entrenchment of addiction that then happens if you're using nicotine in all those different environments. 

[00:10:29] Paulette: Yeah for sure. So what do we know about the risks of these products? What's the evidence around that? 

[00:10:35] Michelle: Yeah very little - because they're so new. What we do know from independent testing and I say independent because the industry, like I said, developed these products. And what the industry does is; it floods the scientific evidence base with its own research. So if you look at a study that says, you know, these products aren't harmful or they're way less harmful than tobacco cigarettes, and they can help you quit. If you look at who's funded that study, it's almost always the tobacco industry. Or it might be that they funded the researchers. They might not have funded the research itself, but they're sort of funneling funds to the researchers. So we always look at the independent evidence. We don't look at those papers. And the independent evidence has started to find that there are carcinogens. So cancer causing chemicals in these products, as well as a whole bunch of other obviously not so great chemicals that we want to be ingesting into our bloodstream. But in terms of the sort of medium and longer term effects, still very early days because they haven't been around long enough. But like I mentioned earlier, we do have young people who are saying, you know, short term effects, they're vomiting, they're dizzy, they're passing out. But the oral health effects seem to be particularly concerning. And we are starting to see some research emerge in that space where people are saying, you know, we've had kids say, I took the product out of my mouth and my gum just came off with it. Like it's literally peeling gums or my gum now have a hole in my gum from where the product has been sitting or my gum has is like black and bruised. So definitely seeing some oral health issues more so than other issues at this point in time. 

[00:12:03] Paulette: Right. Okay. So how can health professionals support their patients who are using non-therapeutic nicotine products? 

[00:12:10] Michelle: Well, I think it's about understanding why they're using it to begin with. So there's a difference between I'm using this because my friends use it compared to I'm using it because I'm addicted to nicotine, and I'm using this product because I can't vape in a lecture, for example, versus I'm using this product because I'm really anxious and I'm trying to manage my anxiety. So understanding why is really important to begin with, because that'll help determine what your treatment is. Because something that I, I'm a clinical psychologist by trade, something I always think about is never tear down a wall before understanding why it's being built in the first place. And so if a teenager or an adult comes to you and they are using these products to manage their anxiety, and you suddenly take this product away from them, there are going to be a lot of issues there. So making sure that before you take that product away, you understand the anxiety, you're providing them with more appropriate regulation, emotion regulation strategies, you're helping them cope with those stressors. And then you can gradually think about how do I wean this product off this person? And the same goes for addiction. We never want to sort of cut potentially cold turkey. There might be certain situations where it's best to, especially if they're using so many different products to wean them down and gradually reduce the nicotine content before coming to zero, before sort of just cutting everything cold turkey. 

[00:13:29] Paulette: Mhm. Do you think there's an understanding among a lot of health professionals about these products, or do you think this is really early days in terms of those things? 

[00:13:37] Michelle: I think it's really early days. Even with vapes, we're finding that health professionals are still very unsure what to do. So, you know, there's been a bit of research where we've asked health professionals, how confident are you addressing vaping cessation or smoking cessation. And what we've found in our research, but also in other research is most health professionals are asking about smoking, right? It's been in the form, It's been as part of clinical guidelines. It's absolutely standard. Whereas with vaping, they are not asking about that as much because they're not confident about it. What happens when a patient says yes, I don't know what the guidelines say. And actually the guidelines in Australia are for vaping cessation are still really unclear. So you can imagine a health professional goes well, if someone says yes, I don't know what to do. So I'm just not going to ask to begin with. And so we're finding that with vapes, and they've been on the market now for 10 to 15 years. Right. So when it comes to nicotine pouches, that's a whole other ball game. I think it'd be quite some time before we even get our health professionals asking about nicotine pouches and knowing what to do when the answer is yes. Having said that, like I said earlier, nicotine pouch use is very, very rarely happening in isolation. Yes, there are some kids who haven't used any nicotine product who are trying these pouches, but most often it's people who are using these products are also vaping and they're also smoking. So when thinking about sort of what health professionals can do, it's about understanding that this product is happening amongst a whole bunch of other product use and seeing it as part of that, rather than, how do I deal with this nicotine pouch use in isolation, because it's very rare that you're going to be dealing with it in isolation. 

[00:15:12] Paulette: So it can be quite complex. Complex use. 

[00:15:14] Michelle: Yeah, absolutely. And the whole nicotine landscape has become more complex these days because there are just so many products out there. Yes. We've obviously been focusing on nicotine pouches today because that's an area that I've researched. But you mentioned earlier in the segment, snus, there's also nicotine toothpicks, nicotine pearls that, you know, people are getting online. So obviously not available necessarily in Australia just yet, but you can still bring them in online. And so there's a variety of these products. And it's difficult for clinicians and for health professionals to sort of be across every single product. And so the sort of recommendation is, well, you don't necessarily need to be across every product, but just be across the fact that there's a lot of different nicotine products. The primary mechanism is the same across all of them. It's the delivery of nicotine. So basically, the way that you're meant to be treating is around, well, what's the nicotine addiction and how do I deal with that. 

[00:16:06] Paulette: For sure. Okay. And I'll remind health professionals that they can access resources to help support their patients at quitcentre.org.au. 

[00:16:14] Michelle: Yeah. Great resource. 

[00:16:15] Paulette: Thank you. Okay. Thank you so much to our guest today, Professor Michelle Jongenelis, for sharing a wealth of information and insights on this topic, which is definitely a current subject of interest to health professionals. We invite listeners to visit the Quit Centre website at quitcentre.org.au for more information and resources for health professionals. And thank you for listening today. Please listen in for future episodes of the Quit Insights Clinical Series podcast. 

This podcast is intended for health professionals and is for educational and informational purposes only. The content discussed does not constitute medical, legal, or professional advice and should not replace your own clinical judgment.