A 200-plus page report from the National Center on Addiction and Substance Abuse states that despite the lack of a firm consensus on the risks and benefits of non-cigarette nicotine products, strict government regulation and concerted prevention targeting e-cigarettes and other products are necessary to reduce the threat of widespread addiction.
The report, Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implications for Tobacco Control, states that the Food and Drug Administration's (FDA's) move last year to exercise regulatory authority over all nicotine products “is a critical first step in helping to ensure that the current proliferation of non-cigarette nicotine products do not become our nation's next public health crisis.”
The report synthesizes existing research on electronic cigarettes, smokeless tobacco, hookah, and other non-cigarette products containing nicotine. It examines patterns in their use and how the government has regulated the products.
Spearheaded by the center's director of policy research and analysis, Linda Richter, PhD, the report clearly takes the position that governments have dropped the ball on regulating non-cigarette products up to now.
“Historically lax regulation and oversight of the manufacture, marketing, and sales of these products already have resulted in sharp increases in their use, especially among youth, and in sharp reductions in perceptions of their harm or risk,” center president and CEO Samuel A. Ball, PhD, wrote in a statement accompanying the report.
The report adds that while there has been support for using e-cigarettes as a tool for smoking cessation, there also has been evidence that using e-cigs can lure more nonsmokers into trying cigarettes for the first time. The center points out that the United States Preventive Services Task Force has concluded that current evidence does not support use of electronic delivery systems for tobacco cessation.
Richter tells Addiction Professional that the research appears to demonstrate that most nicotine products are less harmful than cigarettes, unless used frequently and heavily. “Still, regardless of the device through which it's delivered, nicotine is not harmless,” she says. “A major concern about the use of non-cigarette nicotine products is that, in many cases, they tend to lead to or perpetuate cigarette smoking, rather than curbing it or promoting quitting.”
The center's report analyzed data from the Centers for Disease Control and Prevention (CDC) on nicotine product use in adolescents (2014) and adults (2013-14). Current use of a non-cigarette nicotine product was reported in an estimated 16% of adults and 15% of middle and high school students.
Of even greater concern was the finding that 38% of adults and 50% of middle and high school students indicated that they have tried more than one nicotine product, which raises alarm about the risk of other concurrent substance use and possible addiction.
Asked about the relative risks of nicotine products, Richter described a continuum with cigarettes at the most harmful end and FDA-approved nicotine replacement products the least harmful. She indicates that smokeless tobacco “snus” products, which are popular among men in Sweden and have been credited with lower rates of lung cancer there, “are less strictly regulated in the U.S. than in Sweden and contain more carcinogens. ... While safer than cigarettes, unless they replace the use of cigarettes in long-term addicted smokers, they should not be considered a safe alternative to cigarettes.”
A Swedish manufacturer of snus products available in the U.S. has so far been unsuccessful in an attempt to gain a modified risk product designation for its nicotine products here.
Advice for providers
The report advises healthcare professionals to educate patients of all ages about the risks associated with nicotine use, and to provide screening and brief intervention services. It adds that individuals who are engaging in nicotine product use should be screened further for alcohol and other drug use.
Richter adds that addiction treatment professionals need to be aware of the increased risk of relapse to alcohol and other drug use in patients who continue to use nicotine. “Too often, addiction treatment professionals see nicotine product use as low down on the list of health concerns for their clients, and many mistakenly believe that encouraging cessation will interfere with recovery from alcohol or other drug addiction,” she says. “The evidence shows that this assumption is largely inaccurate.”