With tobacco harm reduction products in general, Canada has taken an approach that is decidedly mixed, but nowhere near as draconian as in other parts of the world. However, until July 2023, Health Canada took a very dim view of nicotine pouches.

Calling them “buccal pouches,” the government department’s website said that “unauthorized buccal pouches may pose serious health risks.” It recommended that nicotine pouches “should not be used by anyone.” 

This was unjustifiable. Nicotine pouches contain nicotine, flavoring and preservatives, but no tobacco. They are placed in the mouth, and do not involve combustion or inhalation. They fall very low on the risk spectrum, similar to nicotine gum or lozenges. And they can help people quit smoking. Research has shown that nicotine pouches reduce smoking more than nicotine gum, and that people who smoke prefer nicotine pouches to gum.  

Then, in July 2023, after almost two years of consideration, Health Canada for the first time authorized the sale of a brand of nicotine pouches as a smoking cessation tool: Zonnic. 

While Health Canada warned, “Do not use if you are under 18,” there is no legal minimum age to purchase natural health products.

Health Canada had changed its tune. It now said that Zonnic “can help you quit smoking by delivering nicotine to your body, temporarily relieving cravings and nicotine withdrawal symptoms.” Cessation through Zonnic could happen “immediately or gradually,” it added. It even noted that while smoking cessation “is preferable,”  Zonnic could be used to reduce the number of cigarettes you smoke, or for “when you need to temporarily refrain from smoking, for example, around others, in smoke-free areas, airplanes, or in other situations.” 

Zonnic was classified as a “natural health product,” in the same legal category as nicotine replacement therapy (NRT). And while Health Canada warned, “Do not use if you are under 18,” there is no legal minimum age to purchase natural health products.

Zonnic is manufactured by Imperial Tobacco Canada (ITCAN), and after obtaining authorization, the company launched sales in October 2023. It described itself as “excited to launch a smoking cessation product.”

Accompanying Instagram posts showed videos of young adults enjoying the pouches while partying, dining out, dating and weightlifting. These videos were rapidly moved to an age-gated website, though stills from them are still being used on Instagram. 

It was a strange marketing choice. The vast majority of Canadians who smoke are 35 and older, and smoking is most common in the 50-64 age cohort. Those over 50 are at the most acute risk of death from smoking-related diseases. Very few Instagram users are in that age group.

The reaction from certain public health groups was predictable. 

The cancer organizaton did not mention that 30 percent of cancer deaths in Canada are caused by smoking, and that nicotine pouches are a proven way to quit. 

The Canadian Cancer Society and five other health charities—Action on Smoking and Health, Canadian Lung Association, Coalition Québécoise Pour le Contrôle du Tabac, Heart and Stroke Foundation and Physicians for a Smoke-Free Canada—quickly signaled their outrage in coordinated press releases. 

“Health Canada makes it legal for flavoured nicotine products from Imperial Tobacco to be sold to children,” declared the Canadian Cancer Society in a typical message.

That’s factually correct. But the cancer organizaton’s release made no mention of the fact that 30 percent of cancer deaths in Canada are caused by smoking, and that nicotine pouches are a proven way to quit. 

The health charities demanded that health ministers either classify nicotine pouches as prescription-only products or suspend sales altogether, in addition to imposing a temporary ban on approval of any more pouches.

There was even a parliamentary petition to the same effect.

The media response to all that was even more predictable, along the lines of “save our kids!” 

CTV, in one of the more restrained examples, recently asked: “Is your teen using nicotine pouches? In light of health concerns, we want to hear from you.” The network issued no such invitation to adults who had used nicotine pouches to avoid exponentially more serious health concerns.  

A number of politicians then responded in the way we’ve come to expect. “We were duped,” claimed Minister of Health Mark Holland. “It would seem that their intention is to addict new young people to nicotine, which is disgusting,” he said of the manufacturers. “We want to shut down this loophole.”

“There was no loophole in the way Zonnic’s license was granted,” Eric Gagnon of ITCAN shot back in a February press release. “Health Canada did its due diligence and now Canadians who smoke have a new and effective way to quit.” He added that “there is no legal minimum age set for NRTs. That is the real problem.” 

Claiming that “the company has gone above and beyond to ensure Zonnic is only marketed and sold to adults,” he concluded: “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.”

Provinces moved to impose restrictions. From the start, Quebec only allowed the sale of Zonnic in pharmacies. In February, British Columbia followed suit, and removed Zonnic from convenience stores and other places where cigarettes are sold—successfully leaving dangerous products far more accessible than safer substitutes. 

A banner read, “Help Hope Bloom.” In another world, this might have referred to hope for Canadians who smoke.

BC Premier David Eby made the announcement from a podium, displaying some Zonnic pouches and surrounded by daffodils, the symbol of the Canadian Cancer Society. A banner read, “Help Hope Bloom.”  

In another world, this might have referred to hope for Canadians who smoke, thanks to the availability of a new, safe, legal and enjoyable nicotine alternative that would greatly reduce their risk of dying from cancer, as nearly 50,000 do each year.  

Instead, the tagline on the podium was “Keeping Kids Safe.” Selling Zonnic only in pharmacies would prevent kids from accessing it, Eby suggested, without mentioning that it would also make the product less visible and less available to people who smoke.

Federal Health Minister Holland strongly supported BC’s new policy in an impassioned speech in March. “Stay the hell away from our kids,” he told tobacco companies. He plans national legislation to restrict the sale and advertising of Zonnic and other nicotine pouches. 

Exact details are unclear, but one aspect of this legislation would be a ban on flavors deemed to attract youth. Zonnic is sold in three flavors: Chill mint, Berry Frost and Tropic Breeze. The entirely uncontroversial Nicorette brand of nicotine gum comes in five flavors: Spearmint, Extreme Chill Mint, Ultra Fresh Mint, Cinnamon and Fresh Fruit. Why the first set should be more appealing to children than the second beats me.

More pertinently, flavor options in tobacco harm reduction products help people quit smoking. Banning flavors in vapes or nicotine pouches makes it less likely they’ll quit and increases their chances of dying. It also encourages an entirely unregulated illicit market without product standards, public revenue from taxes or age restrictions.

So that’s where our fiasco now stands. Serious mistakes from all sides led us here.

If there’s any upside, it’s this: It has at least ensured that large numbers of Canadians who smoke have now heard of nicotine pouches for the first time.

Health Canada had almost two years during which it could have set a legal age limit for nicotine pouches had it wished to do so. But it didn’t.

ITCAN could easily have foreseen the reaction to marketing that appeared to portray Zonnic as a lifestyle product for young adults, given years of high-profile past examples. But it didn’t.  

The health charities could have recognized that by far the most substantial health impact of nicotine pouches is improving the hearts, lungs and cancer risk of people who currently smoke. But they wouldn’t.

The media might have shown interest in the benefits for adults who smoke, rather than fueling the outcry around youth use. But alarmism sells.

And the health minister bowed to pressure from the health charities and media, and seems set on making it as hard as possible for people who smoke to access a very low-risk harm reduction alternative. He seems proud of it.

If there’s any upside to our unedifying national controversy, it’s this: It has at least ensured that large numbers of Canadians who smoke have now heard of nicotine pouches for the first time. But if they decide to switch despite all the noise, they’ll find it increasingly difficult to obtain products that might very well save their lives.

Photograph (cropped) by Ted Callander via Flickr/Creative Commons 2.0

The Influence Foundation, which operates Filter, has received unrestricted grants from Reynolds American, Inc., which, like Imperial Tobacco Canada, is a subsidiary of British American Tobacco. Filter‘s Editorial Independence Policy applies.

The post Predictable, Avoidable and Harmful: Canada’s Nicotine Pouch Fiasco  appeared first on Filter.

Despite decades of work on tobacco control, the World Health Organization reports that tobacco use causes over 8 million annual deaths. The number of tobacco users, most of whom smoke cigarettes, is only declining very slowly, from 1.36 billion in 2000 to 1.25 billion in 2022. 

What is going wrong, and what could we do better?

As a physician, I would suggest that the medicalization of smoking cessation therapy is one reason why so many people continue to smoke. Quitting smoking would be easier if it were principally regarded as a consumer choice, not a medical procedure.

Physicians have created a clinical condition called “tobacco use disorder.” Its manifestations include: 

*Persistent desire/unsuccessful efforts to stop using  

*Failure to fulfill major role obligations due to use 

* Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by tobacco

This medicalization of tobacco use means that physicians can label people who consume combustible tobacco products as patients needing treatment for a medical problem, and may consider them to be irrational “addicts,” unable to control their own actions.

These statements seem designed to reinforce a lack of autonomy and create a long-term reliance on medical care.

Where I live in Toronto, the Centre for Addiction and Mental Health runs a Nicotine Dependence Clinic. The organization states that “Nicotine dependence (also called tobacco addiction) involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit.” 

“Medications and behavioral counseling are the two main types of tobacco cessation treatment,” it adds. “The more time a person spends in counseling, the more likely that they will succeed in quitting tobacco use.”

These statements seem designed to reinforce a lack of autonomy and create a long-term reliance on medical care.

One problem with medical smoking-cessation therapy is that it requires people who smoke to consider themselves as sick patients in need of advice from a trained medical professional. Many people who smoke do not consider that they have a disorder, and are uncomfortable around people in white coats. 

Pharmaceutical companies play into this too, encouraging physicians to prescribe their medications by funding smoking-cessation conferences, for example. 

This all creates employment for health care workers and profits for pharmaceutical companies, but therapy and medication have very limited effectiveness at helping people quit smoking.

If 100 people try to quit smoking without using any kind of medication or nicotine, this is likely to work for just six of them, according to Cochrane.

If they use drugs, the success rate is between 12-16 percent with varenicline (Champix); between 10-18 percent with cytisine; and about 9 percent with bupropion (Wellbutrin). At least two of the medications also have unwelcome side effects.

For nicotine replacement therapies (including patches and gum), Cochrane reports a success rate of just 8-9 percent with a single form of NRT, which delivers too little nicotine, too slowly. 

Vapes, like other harm reduction options, can be made available to all adults at retail outlets, allowing access on a vast scale. 

Other research shows that “In addition to having slower delivery, NRT only offers 30% to 75% of the amount of nicotine that would be acquired from smoking.” However, the same authors state that “use of emerging nicotine delivery systems, such as e-cigarettes, should continue to be discouraged.”  

This is curious, when Cochrane, in 2023, found “high certainty evidence that nicotine e-cigarettes are more effective than traditional [NRT] in helping people quit smoking.” Further research has found vapes to be almost twice as effective as NRT. 

Assessing respective quit rates is often a minefield, when the duration of abstinence from cigarettes that’s measured—together with how this abstinence is verified—varies from study to study. The earlier Cochrane source I cited puts the success rate of nicotine vapes at 10-19 percent—a wide range but not, to be sure, dramatically better than some of the medications.

In continuing to scrutinize such data, however, we must not lose sight of a critical distinction. 

Vapes, like other harm reduction options that deliver nicotine more safely than cigarettes, can be made available to all adults at retail outlets, allowing access on a vast scale. 

Prescribed medications, requiring doctors and appointments, will never be available at a comparable scale. This dramatically curtails their population-level effectiveness, even if they do demonstrate comparable quit rates among study participants.

Instead of treating people who smoke as patients, how about considering them as rational and intelligent consumers?

To take a real-world example, look at the United Kingdom, where, by 2023, 2.7 million people had switched entirely from cigarettes to vapes, which they can buy anywhere from gas stations to supermarkets. 

No smoking-cessation medication has ever had a remotely comparable impact.

Instead of treating people who smoke as patients, how about considering them as rational and intelligent consumers, who are merely confused and misinformed about the available consumer nicotine options?  

That’s the opposite of what the World Health Organization wants us to do. In the runup to its COP10 global tobacco control meeting, currently taking place in Panama, the agency urged governments to ban vapes or to treat them purely as medical devices, as in Australia.

We should ignore the WHO. There are many safer alternatives to smoking which, instead of being delivered through a pathologizing system, can be satisfying, enjoyable and widely available for people to choose for themselves, without medical supervision. 

Which is best for a particular person depends on why they smoke and what they are looking for from a “smoke break.”  

If they want something to do with their hands, something to put in their mouths, and the opportunity to inhale, then they could switch to vaping, which is about 20 times safer than smoking (despite all the media scare stories).

If they like the smell and taste of tobacco, and want a small portion that will last about five minutes, then they could use a heat-not-burn device. As the tobacco is heated to produce vapor without combustion, these products are about 10 times safer than smoking.

However, if the main reason they smoke is that they want the psychological effects of nicotine, then oral nicotine products such as snus (made with tobacco) or nicotine pouches (with no tobacco) may be the best option. These products are placed under the gum, where they release nicotine over the course of about 30 minutes. They are about 100 times safer than smoking.

Physicians seem to have an irrational objection to safer nicotine products, perhaps because they compete with medical programs, or because of a sense that non-medical use is immoral.

Different nations have permitted widespread adoption of vapes, heated tobacco products or oral products—resulting in dramatic population-level declines in cigarette smoking in each case. 

Yet physicians and health care workers seem to have an irrational objection to safer nicotine products, perhaps because they compete with medical smoking-cessation programs, or because of a sense that any non-medical use of nicotine is dangerous and immoral.

They’re far from alone in this opposition. In 2023, when Zonnic became the first nicotine pouch authorized for sale in Canada, tobacco control lobby groups focused on an unfortunate legal loophole that allowed it to be purchased by minors. They made no mention of the health benefits for people who switch from combustible tobacco. 

It is ironic that the Canadian Cancer Society is one of the ring-leaders, when smoking causes about 30 percent of all cancer deaths. No reliable evidence links pouches and vapes, which replace cigarettes, to cancer in humans.

Current regulation of safer nicotine products is based on politics, not science. Different countries authorize, tolerate or outright ban different options. 

In a rational world, vapes, heated tobacco devices and oral products would all be available—and sold wherever people can buy cigarettes. They should come in a range of enjoyable flavors, with tax rates set to incentivize switching. Then you just need to ensure that consumers are honestly informed, and let them judge each nicotine product on its merits. 

Sadly, that scenario has yet to be fully realized anywhere in the world.

In Canada, for example, the Tobacco and Vaping Products Act specifically forbids people who are selling vaping equipment from saying that vaping is safer than smoking. It is a senseless suppression of the truth, and costs lives.

With accurate information, the 1.25 billion people who currently smoke could take control of their own health by switching to far less harmful nicotine products. This would ultimately prevent hundreds of millions of deaths.  

Quitting should primarily be a matter of consumer choice, not medical intervention.

Photograph by Kiwiev via Wikimedia Commons/Public Domain

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