By John Oyston
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.
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This post was previously published on HEALTHYDEBATE.CA and is republished under a Creative Commons license.
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