Q&A: Youths’ use of new tobacco-free nicotine products and their awareness of risks

Rosaria Galanti is Professor Emerita of Epidemiology at GPH, whose research interests include tobacco use and the use of new tobacco-free nicotine products among young people. New products such as white snus are often marketed as “tobacco-free” despite containing high doses of nicotine, which is produced from tobacco and are often marketed as a fresher alternative to snus with appealing flavors.

We asked Rosaria a few questions to find out more about young people‘s use, and risk awareness.

How aware are young people of the risks of the ‘new’ tobacco-free products?

In general, I would say that young people (and not only!) are downplaying the risks with the use of the novel nicotine products, just because their marketing heavily stresses the “tobacco free” characteristic, implying a low risk of the negative health consequences that people generally attribute to tobacco smoking. A study from 2022 indicated that among Swedish people the endorsement of “low risk” behavior may be even more pronounced than among people from other European countries.

Although it is logical to suppose that risks with non-combustible products containing nicotine are lower than with combustible tobacco products, nicotine is not risk-free. I believe that knowledge about the potential negative consequences of nicotine alone (including acute toxicity) is not as established as that of tobacco smoking. The only well-known consequence of chronic use of nicotine is the development of dependence, which is a risk usually disregarded by adolescents and young adults.

The truth is that we lack reliable information to be disseminated to these young users, because of the lack of longitudinal studies on the medium- long term risks with the use of nicotine products in a naturalistic population setting.

Are there any specific groups where you think more work is needed to increase risk awareness among young people?

Again, not much is known on the socio-demographic or psycho-social characteristics of the young users of nicotine products. In my research group we just started using data from population surveys to this end. However, it is very clear that e-cigarettes and nicotine pouches (aka “white snus”) have gained an enormous popularity among girls and young women.

Just to give an idea, based on the 2023 survey conducted by CAN among students in the 9th grade (15–16 years old) 22% of the girls and 13% of the boys reported use of e-cigarettes in the past 30 days. The use of nicotine pouches seems to be similar between genders, at odds with tobacco snus that has been traditionally much more frequent among men.

How do young people get information about these products?

Some qualitative investigations conducted both internationally and in Sweden indicate that the information to young people comes mainly from social media, that in turn reflects the narrative of the producers “fresh, healthy, modern” etc.

What role does social media play?

This is really a field that warrants deeper investigations. Narrative reports indicate that the role of social modeling (that was once upon a time confined to peer encounters and relationships) to date is partly taken up by the s.c. “influencers” on social media. I am personally not very acquainted with most social media, but it is enough to open YouTube to find plenty of clips with “promoters” of “white snus” in particular.

One recurrent theme in these videos is the taste. Novel nicotine products exist in an increasing number of appealing flavors. It is well documented that flavors play a very important role in determining continued use and dependence.

What are the most promising strategies or interventions to reduce the use of tobacco and nicotine products among young people?

This is perhaps the field where evidence is so scant that one does not dare to give any advice. It is generally assumed that interventions that have been successful to curb smoking can also be successfully employed with these new products. But this may not prove true.

In fact, there are at least three reasons that make these novel products difficult to target with individual-level prevention: 1. The diffuse perception of “safety” paired with the lack of authoritative knowledge on the actual risks; 2. The high social acceptance of the behavior, at odds with the use of traditional tobacco products; 3. The wide accessibility (e.g., the possibility to buy via internet).

It has been proposed that messages to be passed on to young people should include a critical view of the manipulative strategies employed by the producers to increase the consumers’ population (for instance, the flavoring additives).

I personally believe that the most promising strategies should be monitoring the market and in particular the accessibility of the products to young people.