Which oral nicotine products carry the greatest risk to oral health?
In this GFN Science Lab presentation, Helen Cowie examines how the shift from smoking to smokeless and oral nicotine products changes the way tobacco harm reduction should be assessed.
The discussion explores the current evidence on oral health risks across different product categories, including combustible cigarettes, traditional oral tobacco, snus and nicotine pouches. While cigarettes and several traditional oral tobacco products have well-established oral health harms, the presentation highlights evidence suggesting a substantially lower risk profile for oral nicotine pouches compared with smoking.
Transcription:
00:10 - 00:18
[Sud Patwardhan]
Next presentation is by Helen Cowie from British American Tobacco. If we can have the video there, and then we can have questions about it afterwards.
00:22 - 07:08
[Video]
Hi, Helen. Lovely to see you today. I have a few questions about oral health and nicotine products. My first question is around tobacco harm reduction, which has historically focused on smoking-related diseases, such as heart disease and lung cancer. Why bring oral health in this conversation now? That's a great question. Oral health matters because how we measure tobacco harm reduction has to evolve as the site of exposure evolves. With the shift from combustion to smokeless products, especially oral nicotine pouches, the oral cavity really becomes the primary site of administration and that's a meaningful change because it reshapes the health questions that we need to investigate and actually how we approach risk assessment going forward. The challenge we face today pretty much is a confused public narrative. Media coverage often blends youth concerns, isolated reports of oral irritation and precautionary calls for regulation without clearly distinguishing between product types or exposure levels or strength of evidence. And as a result, short-term localised effects can be misrepresented as long-term harm while really the reduced risk profile of oral nicotine products compared with cigarettes gets lost. And it's because of this confusion that I'm suggesting that clearer science and proportionate evidence-based policy is urgently needed. If we view this from both a scientific and a policy perspective, including oral health completes that harm reduction picture. It aligns risk assessment with real-world use as well as strengthening the credibility of evidence-led risk-based regulation. Where do smokeless products sit on the risk continuum? So when you place them on the risk continuum, the current weight of evidence and the expert consensus suggests that oral nicotine products sit towards the lower end, closer to licensed medicinal nicotine replacement therapies. And these are substantially different from smoking. But that doesn't mean that they're risk-free or non-addictive. But what it does mean is that the type and magnitude of risk are fundamentally different from combustible tobacco. And it's because of this that they need to be evaluated using appropriate endpoints, including oral health. Historically, the continuum was built around inhalation-driven diseases, and that made complete sense when smoking was the dominant behaviour. But nicotine use is changing. More people are moving away from smoking and towards smokeless products, with today hundreds of millions of people using them worldwide, including tens of millions using oral nicotine pouches. And when exposure itself changes, the science has to keep pace. And that means shifting our focus to the mouth and having a better understanding of what this means for oral health, particularly when compared to smoking. When you look across different oral products compared to smoking, what does the current body of evidence actually tell us about oral health risks? Well, if you take a high-level view of the oral health science and meta-analysis literature, a clear risk gradient emerges. Combustible cigarettes and many traditional oral tobacco products are associated with well-established oral health harms from gingivitis and periodontitis to oral lesions. And in contrast, the current weight of evidence on oral nicotine pouched products indicates a substantially lower risk profile than cigarettes. They're not risk-free, and localised irritation or inflammation at the site of application is still being studied, but the nature and the scale of that risk appear to be meaningfully reduced. Crucially, I'd suggest that while some evidence gaps remain for newer categories like nicotine pouches, we shouldn't ignore them and that these should be treated as priorities for emerging high quality scientific evidence, particularly at the clinical and the population level. So when we recognise those evidence gaps, how should industry be responding in a practical scientific way? Well, at BAT, we've taken a very deliberate approach, building a science program around the gaps in evidence rather than trying to force oral products into frameworks designed for smoking. And a key part of our work on oral health is focused on adverse outcome pathways. We're moving beyond chemistry to biology, and we're utilizing techniques like 3D human gingival models to map the response at the tissue level. Essentially, we're mapping the biology step by step from exposure in the mouth through any early cellular changes to right through to potential clinical outcomes. And this helps us understand not just how disease might develop, but where it's unlikely to, which is a really important distinction when assessing risk. Alongside this, we're investigating the capabilities needed to validate those pathways. We're linking laboratory science with human data to test whether biological predictions actually translate into real-world outcomes. And that naturally shapes how we're thinking about the future of clinical research. we're moving towards oral health-focused studies that are using decentralised designs and mobile health tools to capture richer, more relevant real-world data, rather than just relying solely on clinical snapshots. Thank you, Helen. One last question. So if you had to distill your thoughts from today down to one or two sentences, why is oral health such an important focus area for tobacco harm reduction? because harm reduction strategies only work if they evolve to keep pace with how products are being used. As nicotine use shifts towards oral nicotine pouch products, the mouth becomes the primary site of administration. Bringing oral health science into the evidence base strengthens both the risk assessment and the broader public health case for harm reduction potential of these products compared with smoking. That covers all my questions. Thank you so much, Helen, for walking me through everything today.
07:11 - 07:25
[Sud Patwardhan]
Thanks to Helen and also the gentleman there, Dr. Tommaso, for asking you those questions. And any questions from the audience, please? Name, affiliation, and then the question, please.
07:25 - 08:57
[Mohamed Bin Khayel]
Good afternoon, all of you. My name is Dr. Mohamed Bin Khayel. I am from Libya. I'm the head of the Libyan Thoracic Society. I'm a thoracic surgeon. Thoracic is a medical terminology of a chest and lung surgery. In my position, I am encountering many patients with the smoking-related diseases like emphysema, cardiovascular diseases, and lung cancer, et cetera. And nicotine smoking has been proved 100% that it has been related to those diseases. And it is really interesting to see that shifting to the other products like the HTP and the vaping, it reduces the harm on the cardiovascular and the respiratory system. And of course, as a doctor, I cannot ask the patients to switch to another thing. I'm asking my patients to cease smoking, not to switch. But I'm interested to, if there's any evidence or to prove for a long health study that these products, the HTPs, reduces the harm reduction on the cardiovascular and the respiratory system, I'd be very happy to ask my patients to to switch to those products. So my question is, are you going to make, because I saw only two years studying like this, are you going to, are there any plans to make a long health programs or studies on the harm reduction effects on those systems? Thank you very much.
08:57 - 09:28
[Sud Patwardhan]
Thank you, doctor. Appreciate somebody coming from Libya here and asking important questions. I think it's always good to have folks from beyond the usual countries that come and talk about tobacco harm reduction. This question is perhaps more generic, and I don't know if it's actually targeted at the first speaker as well. We can deal with this now, or we can park it and take it at the end. Would you be happy to hang around till the end of the session? It's not hardly 45 minutes from now. So shall we park that question? Because I would like everyone to be able to answer that. And it's not oral health specific, if I may. Please.
09:28 - 10:08
[Libby Clarke]
Hi, Libby Clark from Imperial Brands. I wanted to ask you about how important do you think it is that you're generating data specifically on the oral nicotine pouches, specifically when we've got so much epidemiology from snus in Sweden and the Nordics? Do you think having that specific data really facilitates the conversation with regulators and helps to kind of shift some of the mindset? Because I think there's a lot there that we can use to read across and obviously kind of substantial investment and effort to kind of regenerate huge, huge data sets on a product that's so similar. Yeah.
10:08 - 11:39
[Helen Cowie]
That's a great question. And you're right, there is an awful lot of data on snus to show that it has a very low association with oral health disease. And you see it in one of my slides there. But where we're lacking on the long term data is on the oral nicotine pouches. And this is is really an acknowledgement to the fact that from everything that we see, from the toxicology, from clinical outcomes, from population-level data, we're seeing that there is no evidence to show that it would be any different to snus. And if anything, the study databases is certainly growing. But we do acknowledge that it's still in its infancy. It's still growing. And therefore, I guess part of my reason for highlighting this today really is that call to action in terms of, as BAT, we are starting to invest quite heavily in this area because we recognize that we need the evidence, we need the data, and we need high quality evidence and research to be published. And certainly we are very active in that area. But I do think that if we want policymakers and regulators really to understand the evidence, they're going to want category-specific evidence. And I think just bridging across to the SNUS data, while it's very strong, it's not category-specific, hence why we're kind of talking about this as a topic today.
11:40 - 11:40
[Libby Clarke]
Thank you.
11:43 - 12:27
[Sud Patwardhan]
Any other question in the audience for now? I have a comment and a question, if I may, please. Oral health is the window to the body and body's health. And so I'm quite pleased to see that the company and perhaps most companies are looking at that to generate the data, relevant data. I also like your phrase of from chemistry to biology. Now, it's all good to hear all these things. A huge tobacco-related disease burden is in low- and middle-income countries, or LMICs, as you would call them. It's a leading question, mind you. Do you think there is any opportunity for this to make a difference there? And if so, has the company got plans to do it? Will you conduct research in those countries, and so on?
12:28 - 15:08
[Helen Cowie]
Absolutely. The oral health burden across the world is massive. I was reading a document the other day that was a WHO document and it talked about three and a half billion people worldwide suffer some form of oral health disease. So bearing in mind there's only, I don't know, something like 8 billion people in the world, that's kind of a good somewhere, but my maths is awful, but 40 to 50% of the world that are suffering from some form of oral health disease. And a large proportion of those are in lower middle income countries. So, you know, again, the WHO have published as part of their relatively recent global strategy and action plan on oral health, a number of strategies and recommendations for global policymakers, healthcare professionals, et cetera, to follow to try and address those three and a half billion people. And across those recommendations and the strategies, avoiding tobacco and introducing policies around tobacco and tobacco-related products, of course, is one of those because we know that there is quite a significant and a heavy burden of tobacco on oral health. But within that document, there is absolutely no mention of smokeless products. So despite the fact that there is evidence being generated and the SNUS evidence is very strong, but it's not acknowledged by a lot of the big bodies like WHO. So I think kind of building on that and building on the recognition that within a lot of the LMICs, the low and middle income countries, traditional use of chewing tobacco and products like naswar, nasvay, gutka are very common and there is a lot of very strong evidence to show that they can have quite a substantial, very negative impact on oral health on gingivitis, on periodontitis, and kind of as well as just tooth discoloration and things that actually generating the evidence that shows that not only moving away from combustible cigarettes, but actually moving away from some of these more local fermented tobacco products could actually have a really positive impact on LMIC health.
15:09 - 15:42
[Sud Patwardhan]
Thank you so much. That's very comprehensive. Also, I've been attending GFNs for now, what, 14 years since the beginning. And it's interesting to hear words like gingivitis and periodontitis being mentioned here, which is a sign of how the folks attending and an evolving bunch of people attending are sort of also bringing the science in and also the LMIC context is not forgotten. So I appreciate you answering that. We hope to see some data if you're generating any data next year. Indeed, we'll be here. Any questions in the audience again? But name and affiliation, please, and then question.
15:42 - 16:17
[Filip Nawaro]
Filip Nawaro from, I work in NGOs in Warsaw here. And my question was the snus, the data in connection with cancer. As I read it, there was no association with a little star that there is not enough data about it. I found it a bit strange. Did I read it well? That there is not enough research made on connection of snus and cancer. Is it true?
16:18 - 16:27
[Sud Patwardhan]
So can I just make sure I understand the question, that there is no data that connects snus and cancer, or there is data that shows that there is no connection between snus and cancer?
16:27 - 16:56
[Filip Nawaro]
I read on this presentation that there is no association between cancer and snus, and there was little star, asterisk, that there is not enough research made on this topic. And it became a bit strange to me. That's why I'm asking about this thing. And if you at least know any correlations between, if there are any correlations, if not hard data.
16:57 - 17:33
[Helen Cowie]
The data there specifically was around oral health because that was the topic of the presentation. So where we're saying there is limited data or low association with snus and cancer, it's specifically in relation to oral health rather than all body cancers completely. Yeah, but there is a recognition that there is a very low association with it, but the evidence base, although the evidence base is consistent, the evidence base is relatively small in that area.