Which Nicotine Trend Worries Experts?

On World No Tobacco Day, CHC Mont Legia hosted the clinical nurse tobacco specialist Adrien Meunier to discuss the role of next-generation nicotine products in smoking cessation. The central question is: Do these alternatives genuinely help smokers quit, or are they simply a new gateway to combustible tobacco use?

Before presenting these next-generation nicotine products, Meunier dispelled the common myth that nicotine itself is not the cause of fatal diseases. The actual harm comes from thousands of toxic substances released during combustion, which are inhaled through cigarette smoke. These include tar, which is linked to lung, bladder, and pancreatic cancers, and carbon monoxide, which is associated with cardiovascular disease. In contrast, nicotine triggers the release of endorphins and dopamine in the brain, producing a sense of well-being that smokers seek.

“This clarification is essential because 79% of smokers believe nicotine is carcinogenic. Therefore, they are unlikely to use nicotine-replacement therapy when they try to quit, which heightens anxiety and potentially causes them to fail in their attempt,” Meunier said.

For many years, the tobacco industry has marketed products that deliver nicotine safely. However, several of these products remain problematic.

Device Debate

The most well-known of these are e-cigarettes. Invented in 2010 by a Chinese pharmacist independent of major tobacco companies, the first was a box mod. The earliest model, the box mod, heated liquid to a high temperature to transform it into vapor and inhale. 

Because there was no combustion, the highly toxic compounds found in cigarette smoke were avoided. The liquid consisted of vegetable glycerin, propylene glycol, water, alcohol, and nicotine.

“The problem is that the nicotine is very pungent and only present in small quantities,” Meunier explained. This pungency will displease some: They will quickly return to “classic” cigarettes. Those who are not bothered by the taste still do not get enough nicotine, so they vape constantly and consume massive amounts of liquid. However, there are hundreds of flavoring additives to give flavor, such as strawberries and watermelon, to this box mod. When heated, they release toxic furans, which are carcinogenic. Therefore, it is better to turn to neutral flavors, such as tobacco and mint.

The box mod should be avoided for smoking cessation. First, because of the potentially toxic substances generated when the liquid is heated, such as furans and carbonyl compounds, and on the other hand, because of the significant differences, for instance, much less nicotine and not the same type of inhalation compared to combustible cigarettes. In addition, box mods are quite expensive, costing 80-160 euros.

“The problem is that 67% of Belgian smokers who buy e-cigarettes to quit smoking turn to this form,” Meunier said.

A few years later, e-cigarettes evolved into pod form. “Pods have smaller batteries, and you cannot adjust the power output. The liquid heats at lower temperatures, which limits the release of toxic compounds,” Meunier said.

Another advantage of pod systems is that nicotine strength can be modulated. In addition, frequent coil replacement prevents heavy metal accumulation, which is a disadvantage of box mods.

Among other advantages, e-cigarettes with pods contain nicotine salts at the same pH as the nicotine present in combustible cigarettes. Thus, the smoker will be able to find peaks similar to those he has known. “For nicotine-dependent users, this is revolutionary: You get a large dose of smooth nicotine with much less vapor,” he said.

Currently, there are refillable pods.

“They are cheaper, so they can be interesting for patients with fewer resources. However, the longer you keep the same coil, the greater the risk of heavy metal accumulation,” said Meunier. As with box mods, it is best to choose the most neutral flavors available.

On price, pods represent a big price difference compared to e-cigarettes, with pods costing around 10 euros, while individual pods sell for only a few euros each.

How to Use a Pod-Based e-Cigarette in Smoking Cessation

Meunier strongly recommended the use of pod e-cigarettes to help patients quit smoking. The question remains as to how to proceed.

Each cigarette delivered approximately 1 mg of nicotine. Therefore, they will need to take patches equivalent to the amount of nicotine they usually consume. A smoker of 21 cigarettes per day should use a 21 mg nicotine patch to prevent withdrawal symptoms. However, patches provide a steady dose, while smokers require nicotine “hits.” That is where low-dose (1 mg) gum or lozenges fulfill minor cravings for smoking.

A pod-based e-cigarette using the highest nicotine salts, such as 10 mg for those smoking 10-20 cigarettes daily and 20 mg for heavier smokers, addresses the major urges.

“We are offering the full menu. The patch helps calm the patient, the tablets are used for small cravings, and the e-cigarette is used for large cravings. Since the patient will already have a good dose of nicotine, they will draw less on each cigarette and can stretch one pod over 5 or 6 days,” Meunier said.

Subsequently, the patches, lozenges, and pods should be tapered gradually so that the withdrawal process remains comfortable. Since nicotine is highly addictive — more so than cocaine or heroin — abrupt cessation can cause irritability and compensatory behaviors, such as excessive sugar intake. Meunier recommended two patches for each dosage: 42 days at 21 mg, 42 days at 14 mg, and 42 days at 7 mg.

Youth Trend

Another product that has emerged among adolescents is puffs. According to a study conducted in Belgium in 2024, 92% of young people aged 11-24 years were aware of puffs, and 39% reported using them — 81% with nicotine, often at 20 mg. “Puffs are inexpensive, colorful, flavored, and disposable, leaving no trace for parents that can be detected,” Meunier said.

Similar to e-cigarettes, puffs contain vegetable glycerin and propylene glycol; however, their nicotine salts are synthetic. Being tasteless, young consumers go unnoticed. However, they are also more addictive. “It makes them dependent for life and causes developmental problems, such as hyperactivity or learning disorders. Moreover, puffs are a steppingstone to smoking,” Meunier warned.

Slick social media marketing and a wide range of appealing flavors, such as cola, red berries, cookies, and popcorn, can give young people the impression that they are inhaling something as harmless as candy. Meanwhile, major tobacco companies are taking it a step further with new tactics such as smart vapes. This device combines nicotine addiction with elements of gambling: The more a person vapes, the more virtual currency they earn, allowing them to climb the leaderboard of other users. Recently, a new device called a puff has emerged. One version, nicknamed “Tamagotchi,” requires users to vape to keep a virtual pet alive.

Although their sales have been banned in Belgium since the beginning of the year, young people still manage to hold them. In a recent survey, many high school students said that they could easily obtain these products. They are readily available on social media and are often disguised in makeup boxes or candy bags to avoid detection by parents.

“These products are often manufactured in China under poor conditions, using low-quality components. In addition to the elevated levels of nicotine and carcinogenic substances in the liquid, the devices themselves contain harmful materials such as lead and arsenic,” added Meunier.

Study Findings

e-Cigarettes are less risky than combustible cigarettes but should be avoided by nonsmokers. Precise assessment of their harm is complex because studies rarely differentiate them by device type or flavor. Long-term health effects remain unknown, as e-cigarettes have existed for only 15 years, and most users are former cigarette smokers. 

“We know the risks associated with ingesting propylene glycol, vegetable glycerin, and especially flavorings, but we do not know what happens when they are inhaled. We also know that we must be careful of the carbonyl compounds produced when heating to too high a temperature,” Meunier said.

Recent studies show that 28% of patients who use e-cigarettes quit smoking within 6 months compared with 16% who rely on patches and lozenges alone. However, many then struggle to give up e-cigarettes because of their habitual use and nicotine dependence.

“First-line therapy, it is best to try patches and lozenges alone. If that fails, add pod-based e-cigarettes with neutral flavors,” Meunier advised.

Avoided Products

Meunier concluded his lecture by presenting new-generation products other than the various variants of e-cigarettes.

It began with heated tobacco devices that are now entering Belgium. These devices heat real tobacco without burning it and therefore produce no smoke. However, some patients mistake e-cigarettes for containing tobacco.

“In reality, these arguments are false. This system emits smoke, which contains all the toxic and carcinogenic constituents present in combustible cigarettes. The Superior Health Council of Belgium is clear that heated tobacco cannot be used as part of a smoking cessation program. Is clear: Heated tobacco cannot be used for cessation,” he said.

Another product more popular among young people than puffs is nicotine pouches, placed between the gum and lip, delivering up to 10 mg of nicotine per pouch, with some containing 50 mg, which is lethal to young children. Attractive packaging targets the youth.

“Nicotine pouches are common in football and hockey clubs for their stimulant effect. They are banned in Belgium; however, young people manage to get their hands on them through a parallel market. And it is even worse since they contain arsenic and lead,” Meunier said. 

He also raised concerns about a new molecule that arrived recently in Belgium, 6-methyl-nicotine. “It is a synthetic version of nicotine and is believed to be even more addictive,” he said. It is sold under various names, such as NoNic and metatine, and can be found in disposable vapes and sachets aimed at young people.

“As you can see, it is the Wild West. Manufacturers deliberately create confusion to slip through the legal net and continue to distribute nicotine in the most attractive way possible,” concluded Meunier.

This story was translated from MediQuality.