Triple Threat: The Hidden Dangers of E-Cigarettes, Oral Nicotine Pouches and Heat-Not-Burn Products

E-Cigarettes: Sweet Taste, Bitter Reality

While electronic cigarettes — also called e-cigarettes, e-cigs or vapes — have boomed in popularity in the U.S. during the past decade, they have been around a lot longer. E-cigarettes, invented in 1965, hit the U.S. market in 2007.

Since then, tobacco companies have developed and marketed various versions of the devices, from rechargeable units to disposable ones, along with thousands of kid-friendly flavors. E-cigarettes have been the most popular tobacco product among underage people since 2014. Among youths currently using e-cigarettes, nearly 90% use flavored products.

The Food and Drug Administration has regulatory authority over e-cigarettes and reviews product applications to determine which can legally be sold in the U.S. As of March 2024, the FDA has authorized marketing of 45 products, including 34 tobacco- and menthol-flavored e-cigarette products and devices.

But beyond these FDA-authorized e-cigarettes, an illicit market has exploded. The Centers for Disease Control and Prevention estimates that more than 6,000 different e-cigarette products are available for purchase in the U.S. So, most of the cigarette devices and flavors available in convenience stores, gas stations, smoke shops and other retail outlets — including many of the most popular brands — are being sold illegally.

To protect kids from flavored e-cigarettes, it is vital to address this illicit market.

Besides producing products with enticing flavors, including fruit, dessert and minty menthol, e-cigarette makers are adding engaging tech options to their products including touch screens, digital games and animated displays. On many products, consumers can access these extras only while actively using the e-cigarettes.

In addition, the devices’ most addictive ingredient — nicotine — could lead to even stronger dependency.

Nicotine is a highly addictive drug that can damage the heart and other vital organs. It increases blood pressure, heart rate and blood flow to the heart, while narrowing and hardening artery walls — a combination that can lead to heart attacks.

E-cigarette makers mix nicotine, extracted from tobacco or created in a laboratory, with flavorings, propylene glycol, glycerin and other substances. With the push of a button, the device heats this liquid mix, turning it into an aerosol that the user inhales. Studies show this aerosol can contain lead, cadmium, nickel, formaldehyde and hydrocarbons, toxic chemical elements and compounds whose uses include making nuclear reactors, preserving dead bodies and manufacturing batteries.

Despite the perception that e-cigarettes are less harmful than traditional cigarettes, they deliver significant amounts of these chemicals as well as nicotine. More research is needed to fully understand e-cigarettes’ long-term health effects, particularly on the cardiovascular system.

Oral Nicotine Pouches: A Growing Concern

A newer trend in nicotine use is the rise of oral nicotine pouches. Tobacco companies market these small, discreet pouches, sometimes called upper deckies or mouth pillows, as a safer alternative to cigarettes. While they may be tobacco-free and smokeless, the pouches still contain high levels of nicotine. Users place the pouches between their lips and their gums. Tiny capillaries in the mouth deliver the nicotine directly into the bloodstream.

Young people are particularly drawn to these products because of their bold flavors including mint or fruit, different nicotine concentrations, and because they can be used without adults noticing. Adults may like the pouches because they offer the “freedom” to be used anywhere, even in smoke-free places.

Nearly 500,000, or about 2%, of high-school and middle-school students report that they currently use oral nicotine pouches. Fewer than one-quarter of youths who use these products report doing so daily.

As with other emerging tobacco products, the different levels of nicotine and the option to use flavors in oral pouches continue to be attractive features, with more than 85% of people who use these products selecting a flavored one. Mint is the most popular flavor, followed by fruit flavor.

Oral nicotine pouch use has increased in recent years. Retailers sold more than 126 million units between August and December 2019; sales climbed to nearly 810 million units between January and March 2022.

Nicotine levels vary by product. Notably, sales of pouches with higher nicotine content (8 mg) increased faster than did those with lower levels (4 mg and 6 mg). And Altria recently announced it will release a new version of its On! nicotine pouches with higher nicotine concentrations than its current offerings.

While the long-term effects of these products are still being studied, their nicotine content raises concerns about addiction and other potentially harmful health effects.

Heat-Not-Burn Tobacco: A Looming Threat

Heated tobacco products, sometimes referred to as heat-not-burn products, come in various forms. Like e-cigarettes, they have electronic heating elements. Unlike e-cigarettes, which use e-liquid, heated tobacco products warm tobacco leaves.

These devices heat small “plugs” of tobacco to create an inhalable aerosol. The aerosol contains harmful contaminants and nicotine. The FDA has determined that one heat-not-burn product, IQOS, can be marketed as a “modified risk” tobacco product because it probably reduces the production of harmful chemicals, compared with traditional cigarettes.

Although relatively new in the U.S., heated tobacco products are already popular in countries such as Japan and Canada.