In its statement responding to the FDA's approval of Zyn nicotine pouches for marketing in the United States, the American Lung Association blasted the FDA and called for the removal of all flavored nicotine products from the market. This includes flavored nicotine gum but not flavored NRT nicotine gum.
The ALA argued that flavored nicotine products appeal to youth and could cause addiction, and therefore should be removed from the market. However, the ALA was only referring to products the FDA classifies as "tobacco products," which does not include NRT nicotine gum.
What justification is there for the American Lung Association to want flavored non-NRT nicotine gum to be removed from the market but not flavored NRT nicotine gum? Why the distinction?
There are 4 possible justifications:
First, if non-NRT nicotine gum came in flavors that could attract youth while NRT nicotine did not.
Second, if non-NRT nicotine gum were more hazardous than NRT nicotine gum. The main concern here is the potential presence of carcinogens, specifically tobacco-specific nitrosamines.
Third, if non-NRT nicotine gum was used by a substantially greater proportion of youths compared to NRT nicotine gum.
Fourth, if non-NRT nicotine gum contained much higher levels of nicotine than NRT nicotine gum and was therefore more addictive.
Let's examine each of these.
1. Flavors
This is not a distinguishing factor between non-NRT nicotine gum and NRT nicotine gum because NRT nicotine gum comes in at least the following flavors:
Mint, Spearmint, and White Ice Mint
2. Tobacco-Specific Nitrosamines
There is little evidence that non-NRT nicotine gum contains substantially higher levels of tobacco-specific nitrosamines than NRT nicotine gum. Existing studies show that both contain either non-detectable or trace levels and so nicotine gum should not pose any significant carcinogenic risk.
3. Prevalence of Youth Use
According to 2024 data from the FDA, the prevalence of use of all oral nicotine products not including nicotine pouches (lozenges, sticks, and gums) was 1.2%. Thus, the prevalence of non-NRT nicotine gum use among adolescents appears to be around 1%.
Unfortunately, data on use of NRT nicotine gum among adolescents is difficult to find. The only estimate I could find was that every day use of NRT nicotine gum in one sample of students was approximately 1%.
It does not appear that there is a substantial difference here, and I have not seen any data to support the contention that there is a substantial difference.
4. Amount of Nicotine
NRT nicotine gum typically contains either 2mg or 4mg of nicotine. Most non-nicotine NRT gum appears to contain either 2mg or 4mg of nicotine, although I was able to find one brand that contained 8mg of nicotine.
The Rest of the Story
If the American Lung Association truly believes that any flavored nicotine product that may appeal to youths and pose a risk of addiction should be removed from the market, then why are they not calling for all flavored nicotine gum to be removed from the market?
One logical reason could be that the American Lung Association doesn't want to remove from the market a product that is helping many smokers to quit. However, if that is the case, then it is a strong argument for keeping other nicotine gum products on the market as well, since there are many smokers who are using these products in an attempt to quit.
It's not clear to me that the primary motivation here is to help smokers. If that were the case, then the ALA would certainly want to balance the benefit of flavored nicotine products in helping adult smokers quit with the potential harms to youth. This is exactly what the FDA did in its consideration of Zyn, and its finding was that the balance is clearly in favor of its benefits. It appears that the ALA and many other tobacco control organizations are not even considering the potential benefits of non-tobacco nicotine products in helping millions of smokers to quit. Instead, they have a sole focus on the use of any flavored nicotine product by youth. Well, any flavored nicotine product that is not manufactured by a pharmaceutical company.
I have been struggling to understand why the ALA wants to selectively ban all flavored nicotine gum except for those made by Big Pharma. The only answer that I have come up with is this:
I believe that the American Lung Association and many other tobacco control groups simply cannot tolerate the fact that someone might be using nicotine and getting pleasure from it without suffering severe health effects and thus not being punished for their bad decision. After all, these groups are not calling on states to ban the sale of real cigarettes. Apparently, it is OK for adults to use cigarettes recreationally because they are going to be punished for their poor decision. But as soon as someone is using a relatively safe nicotine product, it must immediately be removed from the market.
From a broader perspective, why are so many health groups calling for a ban on any flavored nicotine product that may appeal to youths, but not calling for a ban on the sale of flavored alcohol? To be sure, flavored alcohol products are causing much more harm to the lives of adolescents than electronic cigarettes or nicotine pouches. And unlike these much safer products, flavored alcohol use has been shown to be a gateway to problem drinking behaviors.
I'm afraid that the tobacco control movement's nearly sole focus on what is probably the safest form of youth substance use is diverting attention from much more hazardous forms of youth substance use like alcohol. When is the last time you heard the American Cancer Society call for a ban on flavored alcohol products, which are used by many more youths than nicotine pouches and which actually do cause cancer?
I'm not calling for a ban on flavored alcohol but if it's not reasonable to ban flavored alcohol then it's much less reasonable to ban flavored reduced risk nicotine products.
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