Do Ammonia Salts Pose a Health Risk for Hockey Players?

Hockey Quebec has banned the use of smelling salts, at least until the end of the season, after two minor league coaches were found to have given the ammonia-based inhalants to players aged 10 and 11 years, according to multiple reports in Canadian media.

The coaches are now suspended, and Hockey Quebec’s General Manager Stéphane Auger said that the organization plans to develop rules and a policy on the use of the product by next season.

He noted that Hockey Quebec is banning the use of ammonia and ammonium salts in federated activities, even though these substances are not considered doping products by the World Anti-Doping Agency.

In fact, smelling salts are marketed to athletes as an “energy boost,” and they’re a “common sight on the benches of National Hockey League teams,” according to CBC News.

What’s the harm?

‘False Sense of Energy’

“The Ordre des chimistes du Québec (OCQ) disapproves of the use of ammonium salts in sports,” OCQ President Michel Alsayegh told Medscape Medical News. The OCQ helps to protect the public by maintaining professional standards for chemists.

Ammonia must be handled with care, and its misuse in a sporting context poses a health risk, Alsayegh warned. “These salts have irritating properties that create a false sense of energy. The stimulating effect they produce is merely an illusion caused by their irritating properties.”

For hockey players, he said, “there may be a temporary stimulation of blood circulation and an increase in oxygen supply to the brain. However, I have not seen any study confirming that this product has any actual performance-enhancing effect beyond briefly waking someone up for a few seconds.”

Indeed, the authors of a small randomized controlled trial concluded that smelling salts may raise alertness and an individual’s perceived physical performance, “but not peak strength, power, or neuromuscular drive,” which are components of actual functional performance.

Furthermore, regular inhalation of ammonium salts “can cause respiratory irritation, headaches, and, in some cases, more serious complications,” said Alsayegh.

‘Masking a Medical Issue’

“If a child or an adult loses consciousness while playing sports, you shouldn’t be giving them smelling salts,” cardiologist Christopher Labos, MD, an affiliate member of McGill University’s Department of Global and Public Health in Montreal, Quebec, Canada, told Medscape Medical News. “There’s a reason that happened. Maybe it’s a benign reason, like they skipped breakfast and were a little bit hypoglycemic, and that’s why they felt faint and got a little woozy. That is easily fixable.

“But what you don’t want is a coach putting smelling salts on the nose and saying, ‘Okay, you’re fine. Get back in the game,’” he continued. “The real danger is that giving smelling salts may cover up what could be a very, very significant medical issue. And with kids, especially, and even in adults, we’re very worried about head trauma and the cumulative effect of putting them back into the game before they’ve fully recovered.”

Even for something like a concussion, return to play should be a much more gradual process than what was previously thought, he added.

Brian Schulz, MD, an orthopedic surgeon at Cedars-Sinai Orthopedics in Los Angeles and team physician for the Anaheim Ducks, a professional hockey team also based in California, said he has occasionally seen US National Hockey League players use smelling salts before a game. “But I would not say that it is commonly used on a professional level,” he told Medscape Medical News.

“If there was a serious issue with youth athletes using them or being encouraged to use them, then perhaps [Hockey Quebec’s] ban is appropriate,” he said. “There is no specific clinical or performative benefit, and any risk is unnecessary.”

In addition to irritating or burning the skin and eyes, smelling salts “could trigger bronchospasm in someone with a preexisting medical condition like asthma,” he noted. “As a medical professional, I personally would not use them for any medical situation — even if someone fainted, which is the most common use.”

‘Good Luck Charm?’

Despite the lack of evidence that smelling salts give a performance boost, YouTube and other social media outlets are rife with videos showing professional hockey players sniffing the salts before and during games. For some, it’s a ritual.

“The reason why this has become a health issue as opposed to something we laugh about, like having a good luck charm, which is benign but equally useless, is because it’s being done to kids,” Labos said. “With a lot of these products, without clear guidelines, people just use them in whatever way they want. That’s why it’s important to have an official line where we say, ‘No, this doesn’t work. Just because a celebrity does it doesn’t mean you should do it.’”

Commenting on the issue, Connie Klassen, Hockey Canada’s director of Prevention and Wellness, said, “It is a priority for Hockey Canada and our members to foster and provide a safe and healthy environment for our participants on and off the ice.

“Although we do not have a national policy pertaining to stimulant products such as ammonia-based smelling salts, there are concerns with their use when not medically prescribed,” she told Medscape Medical News. “The organization will continue to work with our members to better understand the availability and use of ammonia-based smelling salts and other stimulant products with hockey players across the country.”

Alsayegh, Labos, Schulz, and Klassen declared having no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.