Misunderstanding nicotine delivery: a discussion on nicotine pouches. PMI's Carrie Wade and Gizelle Baker discuss the problems with comparing nicotine content of pouches with combustible tobacco. #GFN25 Science Lab discussions
Transcription:
00:05 - 00:28
[Karin Jacobson]
Gizelle Baker is the Vice President of Global Scientific Engagement at PMI. She is responsible for the scientific engagement strategy and ensures the company's scientific communications are accurate, transparent, and always based on the latest evidence. And the title of her presentation is Misunderstanding Nicotine Delivery, a Discussion on Nicotine Pouches.
00:34 - 01:18
[Carrie Wade]
So thanks, Gizelle. I wanted to talk today about nicotine pouches. I know there's so much confusion that's going on around nicotine pouches, nicotine delivery, attempts to compare nicotine pouch content to cigarettes. It became clear that just the conversation is probably a bit unusual for a GFN5, but makes more sense in this context. Before we start, I just want to read one quote, which is from the American Lung Association, talking about nicotine pouch content compared to cigarettes. And one of the quotes is the average user consumes about a half can per day or eight to 12 nicotine pouches. This is equivalent to about one to three packs of cigarettes a day, depending on the nicotine pouch milligram amount used. I just want to know if anything strikes you about this.
01:18 - 02:53
[Gizelle Baker]
Well, I think the first thing that strikes me is based on the quote that you found, I can tell exactly when you found that quote. The interesting thing I think we have to point out is when you look at the ALA website on this, when they first came out with this quote, it was half a pack or eight to 12 is about three packs of cigarettes, where they were looking at the six milligrams in a pouch, multiplying that by about 10 and coming to 60 milligrams of nicotine. content in there. And then for the cigarettes, they went and they took the amount of nicotine yield, the amount of nicotine in the smoke of a cigarette, one mig, times by 60, 60 migs of nicotine. Half a pack? three packs, totally with the purpose of scaring people. I mean, for me, even when I read that at first, I was like, oh my gosh, how is this possible? But when you start to break it down, you have to realize that they're comparing apples to oranges. They're comparing content. to yield, not content to content. When you compare content to content, you don't come to the same conclusion. If you compare what's extracted from a pouch to what's extracted from a cigarette, don't come to the same conclusion. So over time, we watched their quote change to one to three packs. And even that was really alarming because you still have the three. But if you look at it today, it now says between one and one and a half packs, which is still probably a little high, but a little bit more reasonable.
02:53 - 03:26
[Carrie Wade]
And considering how they present this and the change in how they present this over time, you'd think that it might become clear that making a direct comparison simply isn't that easy. It instills a bit of fear mongering that just puts up one more barrier for people to consider switching away from cigarettes. Personally, if I were smoking, I would think that one pouch giving me as much nicotine as four or five cigarettes would be a bit of a turnoff, and I probably would be a little bit scared. And we know these comparisons are incorrect. We know that even a comparison of content from one product doesn't really capture the whole story. Do you have any thoughts about that?
03:26 - 05:47
[Gizelle Baker]
Well, I think there's so many things that are wrong with those comparisons. Because ultimately, what you really want to know is what a person's exposed to. How much nicotine do they have in their body? What is the impact of the nicotine exposure? But when you think about the fact that you're going to take a pouch, and compare it to a cigarette, and the only thing you're going to compare is the nicotine? You're not even going to talk about the HPHCs? I mean, that's obviously meant to drive fear. And then you don't even think about the use. How many pouches do you use in a day? How long do you use each of those pouches for? Because this makes a pouch very different than a cigarette. A cigarette, can you imagine trying to smoke a cigarette for an hour? But you could leave a pouch in your mouth for an hour. It's going to have a slower uptake of nicotine, so therefore it's going to be in your body for a longer period of time. When do you have your next pouch? How does that compare to when a person would have their next cigarette? How intensely are they smoking that cigarette, and how much nicotine are they exposing their body to? These are the things that really drive it. The behaviors around it, how a person uses it, that drives the nicotine exposure. And this kind of just... oversimplifies it, filters it down, and creates, I think, the message that they want people to get, which is the message you got from it, which is nicotine pouches are scary because you get way more nicotine without even measuring how much nicotine a person gets. And we know this is not really what they think because if you looked at nicotine from a nicotine replacement therapy, a drug designed to get people off of cigarettes, We know that nicotine patches actually expose people to higher levels of nicotine throughout a day because it's constant throughout the day. And when you smoke, you get a peak and then it goes away. You get a peak and it goes away. And over the course of the day, you probably get less nicotine than you do from the patch. Yet the vast majority of smokers don't get the nicotine in the way that they want it from the patch that 85% on average go back to smoking. So we know that it's not just the nicotine, that we have to consider how the products are used, how they deliver the nicotine, and everything else in the ritual built around smoking.
05:47 - 06:19
[Carrie Wade]
Right. And I just want to pick up on something you said about fear mongering. I think wouldn't it be something if instead of making comparisons about nicotine content to nicotine exposure from a pouch to a cigarette, wouldn't it be something if instead you were talking about the comparisons of toxicants and the harmful and potentially harmful constituents that lead to smoking related disease i just want to throw that out there but i know we're coming to the end of time so is there anything that you think should be key in our minds when we're thinking about this
06:20 - 06:57
[Gizelle Baker]
I think what everybody has to do is not get caught up in the headlines because I think this is only the first of many headlines that are going to be thrown out there to kind of discourage and dissuade people from switching to less harmful alternatives. If we really want to achieve public health, we need to step below the headlines and really look at what the message is. We need to understand that less is better than more when it comes to the toxicants and to the exposure. And we need to accept that Although nicotine is addictive, delivering nicotine in a way that people will actually give up cigarettes is actually good for public health.
06:57 - 07:03
[Carrie Wade]
Well, with that, thank you. We'll see if this new format works. And thank you for joining me.
07:08 - 07:12
[Karin Jacobson]
Gizelle, I pass the word to you for additional comments and remarks.
07:15 - 08:43
[Gizelle Baker]
Well, I mean, I just think that it's really easy to oversimplify things and to come up with a comparison to make a point. We can all do it. As scientists, we can all find a fact about a study which we can use to totally discredit a very valid study. No study will ever be perfect. ideals are really these things that cannot be taken apart and looked at and understood. And I think if we really want to drive public health and we want to be able to advance the science in the direction we have to go, it's really about understanding what the science is telling us And I think part of the problem is that you don't have the two sides of the debate ever together having a debate. You have a lot of discussions where you have one side having a discussion and going through the nuances of the science on that side and the other side having a different discussion looking at the nuances of the science on that side. And I truly believe that both sides will be not 100% correct, that the best science will come out of the compromises and the understanding of both sides of the argument to get it right. But for me, the problem is that the people who are smoking, the people who are consuming nicotine are the ones who are being misled by this type of rhetoric and this lack of a true open scientific debate.
08:45 - 08:55
[Karin Jacobson]
Thank you, Gizelle. Do we have any questions from the audience? Yes, in the back.
08:55 - 09:53
[Inna Maslenchuk]
Thank you very much, Gizelle, for your presentation. I'm not asking the provocative question at this time. Yeah, from your presentation I got that the using of pouches, it's a more steady nicotine level, right? and in cigarettes, it's more picky. And did you observe or do you have any studies with a correlation between this nicotine steadiness and between the nicotine addiction? Why I'm asking about this, because for the government of Ukraine and governments around the world, they are more concerned about the nicotine addiction due to the presence of pouches in the market. And so, yeah, did you get some information or did you learn something regarding this? This correlation between steadiness and between the addiction.
09:53 - 11:35
[Gizelle Baker]
Well, I think we don't have any studies that go to the level of addiction, but I do know that even when you look at people who are smoking on a daily basis, not every one of those people are addicted to nicotine. I think there was a study by Donnie that showed that about 60% of daily smokers are addicted and about 40% of smokers. are addicted to, I would say, smoking, if you ask me, which includes the addiction to nicotine component. But I think, again, we're trying to get down to the substance of nicotine, and the substance of nicotine, the addictiveness of nicotine, we know when it's delivered through a patch, is at a much lower level of addictive potential than a cigarette, because a cigarette involves a very fast delivery of the nicotine, those peaks change the way the dopamine is released in your brain. You can see that in animal models of studies looking at real-time What are the impacts of that? So a constant nicotine dose actually delivers lower amounts or releases lower amounts of dopamine in your brain than a constant peak and trough type picture. So there's lots of components around that, and the addiction piece is going to come at that intersection of the substance and the reinforcing effects of the substance, which will be dependent on the way it's delivered and the amount that's delivered, and then the reinforcing behaviors that go with it. So you cannot break this all the way back down to just that simple question on that. And with pouches, it's going to then come to the behaviors that get layered on the use of the nicotine through the pouch.
11:36 - 11:42
[Karin Jacobson]
Thank you. Thank you. And I see we have another question.
11:44 - 11:59
[Attendee]
You spoke about the comparison between cigarettes and nicotine pouches. Can you give us an idea of the daily exposure of nicotine from those products? Because that's probably a better comparison.
12:00 - 12:18
[Gizelle Baker]
We did an analysis, and obviously its range is looking at the average number of products that are used per day and then using a PK delivery and exposure from a single use of each. And we came to the fact that the ranges from a pouch overlap with the ranges of a cigarette.
12:18 - 12:28
[Attendee]
Have you done repeated dosage? Because you said nicotine pouches about 8 to 10 pouches per day?
12:28 - 13:14
[Gizelle Baker]
Yes. So what we did for that comparison is we took the number of pouches that are used in a day, we took the number of cigarettes used in a day, and we looked at the single use. And what we concluded from the fact that the ranges, when you looked at them, would be comparable, is we said that the next step would be to actually do it and look at a person's use throughout the day and look at it overall, because what you don't include in that is the excretion. And we know for a fact that with a pouch being used longer than a cigarette, that within your PK curve and that you've got the excretion piece already starting to come in, so the peak is not... equal to the highest amount or the total amount of nicotine consumed. It's the overall exposure. So these things are going to be important and some of the things that will come.
13:16 - 13:21
[Attendee]
So you're assuming that the usage time would be the same throughout the day?
13:22 - 14:17
[Gizelle Baker]
Exactly. So what we took was the average use time of the pouch in the U.S. because we used the product use pattern data in the U.S. We took the average number of pouches used, the average use time, and then we used that to help us compare the nicotine absorption. And again, this doesn't account for the fact that people may use it longer in the morning and shorter in the afternoon and over time vary their actual nicotine absorption. And that's where that whole behavioral piece comes into play, which is it's not these simple calculations that can give us all of the information. Each one of those calculations helps us understand another aspect of it. But even between people, the way that they use it could be very different. The same number of pouches, the same amount of time, and their outcomes could still look very different. So it will take some approximation if you want to understand what's happening at a population level.
14:17 - 14:17
[George Cassels-Smith]
Thank you.
14:19 - 14:22
[Karin Jacobson]
Thank you. And I see we have another question in the back.
14:26 - 14:44
[Alexander Nussbaum]
Alexander from Philip Morris, Germany. You presented something that is very rare, a medical association improving a statement over time. So I'm really curious if we know why they did it, were they called out publicly, or did they come to the realization on their own?
14:46 - 15:30
[Gizelle Baker]
I have to say they didn't tell me. But there was a lot of media on it and a lot of conversations happening in the U.S. around that. Which ones they listened to, which ones they didn't, I'm not aware of. But yes, there was a lot of attention that came when they raised the... But you have to remember, from July until February, it stayed at three packs. So it did stay there for a long time. I think somewhere in the January, February range is when you started to see it hit the media in many different formats and social media. And very short order thereafter, it became one to three. And then about two months later, it became one to one and a half. So with the continued discussion, it did go down.
15:30 - 15:34
[Karin Jacobson]
Thank you. Yes, and we have a question in the front.
15:36 - 16:15
[George Cassels-Smith]
Yeah, I think a lot of these conversations are in regards to your daily intake of nicotine. But, uh, as Mr. Russell pointed out in the eighties, one smokes for the nicotine and dies from the tar and nicotine has been poorly understood. And it now seems that it has addictive qualities, but it's not the carcinogen that we thought it was. So why in this conversation in regards to the HPHCs or harmful or potentially harmful constituents associated with a daily intake of whatever nicotine level you have?
16:17 - 16:58
[Gizelle Baker]
I mean, I think that was the point we were making is the more important thing in this discussion with where we are today with the highest proportion of nicotine consumption still happening through cigarettes with high levels of toxic exposure, that the most important and critical question today or issue should be getting people off of cigarettes. not focusing only on addiction, because I don't think you're going to address the public harm by fighting addiction. You're going to address public harm by actually supporting smokers to move away, and this is where the discussion should actually be, if harm reduction or even public health is the true purpose of the conversation.