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The Dose Transcript for March 28, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Earlier in March, Canada's health minister said he would restrict the marketing and sale of nicotine pouches to young people. And Health Canada released a public advisory warning Canadians about misusing nicotine pouches. We know that young Canadians who have never smoked represent a growing market for nicotine products, and these are not innocuous. They can also pose a threat to youth. So this week, we're asking, what do I need to know about recreational nicotine products? Hi, Nicholas. Welcome to The Dose.

NICHOLAS CHADI: Hi, Brian.

BRIAN GOLDMAN: How often are you having conversations these days about nicotine products with young people you treat and their families?

NICHOLAS CHADI: Very often, actually. So my practice is both in general adolescent medicine and also in more specialized substance use clinics. So in that context, I see young people who interact with different substances, including nicotine. So a lot of young people, teens will ask me, you know, what are these new products? What are these pouches that are coming out? What am I seeing on the internet? What are my friends telling me about when it comes to synthetic nicotine products? Which is what we're referring to when we're thinking about new forms of recreational, quote unquote, nicotine.

BRIAN GOLDMAN: Is it parents or is it young people themselves who are asking questions?

NICHOLAS CHADI: It's both, I would say. Parents ask me, are these products harmful? What do we know about them? Young people ask me, how do they compare to e-cigarettes or cigarettes? What should I know about these products? And so definitely, a lot of conversation around what these products are.

BRIAN GOLDMAN: You're the right person to be speaking about on this important conversation. Before we begin, can you give us a hi, my name is? Tell us what you do and where you do it.

NICHOLAS CHADI: Hi, I'm Nicholas Chadi. I'm a pediatrician specialized in adolescent and addiction medicine, as well as a researcher at Sainte-Justine University Hospital Centre in Montreal. I'm also the tobacco and nicotine spokesperson for the Canadian Pediatric Society.

BRIAN GOLDMAN: As I was poking around and reading about this topic, you know, talking about nicotine pouches and other products, I saw from time to time the term recreational nicotine. I'm not sure that this has any clinical cachet, but what does it mean to you? What do we mean by recreational nicotine?

NICHOLAS CHADI: I've heard this term also, Brian. And likewise, I'm not sure this is a term that's approved or anything. But when I hear this, what I hear is there are new and emerging synthetic nicotine products. Many of them come in different flavours that are becoming more and more popular, especially among young people. We're talking about nicotine patches, gums, lozenges, gummies, even toothpicks that are being sold online or sometimes are being sold in different convenience stores, corner stores, gas stations, depending on where you live.

BRIAN GOLDMAN: Is it just nicotine or synthetic nicotine? I gather when it's with pouches, there may be flavours involved as well. Same thing with vaping.

NICHOLAS CHADI: So there's always going to be different chemicals and additives. If it's a pouch, if it's an e-cigarette, it's never just nicotine in flavours. There's always different solvents or different liquids or solids holding everything together. And the question is what are actually those other products and what are some harms that could affect human health? And a lot of those questions are still unanswered.

BRIAN GOLDMAN: How are these products that we're talking about right now regulated differently from nicotine replacement therapies?

NICHOLAS CHADI: Very differently. So recently, Health Canada approved one very specific type of recreational nicotine product. The nicotine pouch is sold by a tobacco company as a health product. And that means that there is some oversight on the product, but certainly not much regulation when it comes to advertisement and sale. And so nicotine replacement therapy is very tightly regulated. It's been tested. It's been shown to have some effectiveness in helping adults quit smoking and some emerging evidence for younger people. And that's really not the case for other nicotine products that are emerging. They haven't been tested the same way, and they can be sold. And advertisement can be targeted towards younger people, which is really not the case with tobacco products or nicotine replacement therapy.

BRIAN GOLDMAN: What are the names of the products that are available in Canada?

NICHOLAS CHADI: So the one that we hear about is Zonnic. And so there are lots of other names and other products that aren't in legal sale but are searchable online. VELO is a term that you would hear from other countries. And so they come in different shapes and flavours, but they should be legally sold as we speak.

BRIAN GOLDMAN: So Zonnic is available in Canada. Are you saying that young people are just hearing about other products, or are they actually able to obtain them? I'm trying to get a sense of whether the regulatory system is tight enough, the import system is tight enough that they can stop these products from getting across the border. Or is it possible that people may travel to the United States and obtain the product while they're there?

NICHOLAS CHADI: So anecdotally, some young people that I see in my practice as a pediatrician have told me that they have used nicotine pouches or gummies or other types of nicotine containing candies. My sense is that they get them from friends that are maybe ordering them online or getting them from across the border. There's actually very little research on how many people in Canada are using these products. There's starting to be some research in the US saying that more and more young people are actually buying and using these products. It's something that's quickly changing and rapidly emerging. So we'll certainly have to keep an eye on those trends.

BRIAN GOLDMAN: Any idea what doses of nicotine we're talking about that young people might be consuming?

NICHOLAS CHADI: Certainly. So the Zonnic product that we were talking about earlier contains two to four milligrams of nicotine per dose. That's very similar to what you would find in a nicotine replacement gum or lozenge, for example. We could sort of make an equivalence between what you would find in a nicotine e-cigarette pod or a pack of cigarette. So if you use about 10 of those pouches or gums, you would get something similar to the equivalent of a pack of cigarettes. So it can go up pretty quickly.

BRIAN GOLDMAN: And how would the average person who doesn't smoke, who doesn't consume or vape nicotine on a regular basis, how would they react to that?

NICHOLAS CHADI: So being a nicotine naive, if we can use this term, person, you would get a stimulating effect. So nicotine is a substance that quickly reaches the brain. It also has an effect on the body. So it awakens your brain for a period of 30 to 60 minutes. You're more alert. You can get a sense of well-being for a short period of time. It also makes your heart beat faster, your blood pressure rise. And so those are the effects that a person would sense when they first use a product like that.

BRIAN GOLDMAN: So it would be comparable or similar to the first time a teen might smoke, except you wouldn't get it in the effects of inhaling tobacco smoke.

NICHOLAS CHADI: Yeah, I would say that.

BRIAN GOLDMAN: What do we know about the market for recreational nicotine for teens?

NICHOLAS CHADI: So we can look at the past. We know that e-cigarettes came very quickly, around the years 2013, 14, 15. And there are some parallels that we can draw there. And so e-cigarettes were not regulated at all when they were first introduced to the market. And a lot of advertising campaigns showed young people who looked healthy and were using products that contained nicotine, that came in all sorts of different flavours. The products were small, slick, easy to find, easy to access. And so we saw that from almost no young people using these products, almost half of adolescents had tried them in the past year in the span of only a few years. And so the potential market for new and emerging forms of nicotine that are also coming in different flavours that can be targeted towards youth and advertised strongly by companies is quite large. We're talking about a million or millions of young people who could be using those many who are not currently using forms of nicotine. They could be young people who use cigarettes or e-cigarettes, but they could also be young people who use neither of those.

BRIAN GOLDMAN: Do we know at this point, or are we just guessing that these products, nicotine pouches, for instance, are being aimed or marketed specifically at teens who have never smoked?

NICHOLAS CHADI: Well, I don't know if you've seen any of the ads that are there in the media space for Zonnic. What I see is is people who look young, who look healthy. And I could see that these ads look very, very similar to what I saw a few years ago with many of the e-cigarette companies. So certainly, the companies may not say that they're targeting young people directly, but that's really what we're seeing.

BRIAN GOLDMAN: And it's interesting you’ve asked me have I seen ads? Where am I going to find these ads? Are they going to be on Instagram? Are they going to be on TikTok, media that I don't necessarily visit as often perhaps as I should if I'm interested in the subject? Because I am.

NICHOLAS CHADI: It's interesting you ask. I mean, I saw them in online newspapers that have an adult readership. I've also seen them online. And interestingly, these products have an ability to sort of self-promote. So as soon as young people who are either influencers or simply teenagers posting content on the internet, they could be talking about those products, and without even planning it, being contributors to the advertisement of these products. So I would say you could see ads for those products that are kind of formal ads made by the company, but also informal ways of promoting them that would be virtually anywhere in the virtual or online space.

BRIAN GOLDMAN: Remind us how addictive nicotine products are.

NICHOLAS CHADI: Very. So we do know nicotine quite well from cigarettes. And it's synthetic nicotine here, meaning that it's created in a lab. It doesn't come from the tobacco plant, but it acts in the same way on the same receptors in the body and brain. And nicotine is one of the most addictive substances out there. Many experts have compared the addictive properties of nicotine to those of cocaine. And so after using only a few times, the brain recognizes the pattern and wants to use more. So you can become addicted to nicotine after only a few days or weeks of use if you're a young person, specifically because your brain is a little bit more vulnerable to the effects of different substances. And we know that nicotine is more addictive than other common substances like alcohol and cannabis. So certainly quite addictive.

BRIAN GOLDMAN: What other effects, health effects are you concerned about?

NICHOLAS CHADI: So we can think first about the effects of nicotine. And as a pediatrician, I do worry about the effects of nicotine on a young developing brain. We know from different studies, many of them were conducted in animal models, but also emerging evidence from studies looking at young people developing over time, that nicotine actually affects how the brain develops. It could affect on a long term how some capacities, for example, to memorize and learn and do complex things, can grow and actually get to their maximal capacity over time. But also, we know that nicotine can impact things like emotional regulation, can have also an impact on sleep. And more and more studies are showing that young people who use nicotine also may be more likely to have mental health issues, but also to be addicted to other substances. So certainly, the healthiest thing for a young person would be not to be exposed to nicotine while the brain is still forming. The other thing we could consider is that these emerging products that aren't really very well regulated at all can contain a number of different chemicals. And so depending on how they are absorbed or used, if it's an oral product that you place in your mouth, there could be chemicals that would be an interest for gum health or for your teeth. If it's something that you swallow, there could be, you know, harms for the digestive tract or other parts of your body. And certainly, we'd need to study those. We’d need to know exactly what are the chemicals in products that are found and the additives and the flavours in the product itself. And that requires time and requires research. This is starting to be done with e-cigarette products. I would say we're a bit late in the process. We're starting to know a lot about the harms from tobacco products, but we really know very little about these emerging synthetic nicotine products.

BRIAN GOLDMAN: That reminds me to ask you, what do we know right now about the use of nicotine in e-cigarettes by young people who've never smoked before?

NICHOLAS CHADI: So we know that the majority of young people who use e-cigarettes are young people who have not smoked cigarettes before.

BRIAN GOLDMAN: Wow.

NICHOLAS CHADI: So the claim from a lot of companies that those are mainly products to reduce harms or to help people quit smoking actually is not very true for young people, and let alone the fact that there is no clear evidence that they would even help young people quit smoking. Still, you know, considerably controversial for adults. So really, young people using e-cigarettes with nicotine are not long term smokers. It's mostly sort of a new population of young people who are trying, who are experimenting something, who are attracted by flavours. Even though flavours are banned in different provinces in different ways, they're still very accessible in e-cigarettes. So you can see a lot of parallels here and some risks with emerging products that wouldn't be regulated at all, like nicotine pouches or other forms of recreational nicotine.

BRIAN GOLDMAN: And are we starting to see through studies, some of the risks that you're most concerned about?

NICHOLAS CHADI: So we certainly are seeing a number of studies talking about risks related to e-cigarettes and the different chemicals that they contain. Some of my colleagues are finding a pre-disease state in the lungs of young people who've used e-cigarettes for as little as a few months. So things like increased cough and mucus and decreased exercise tolerance. And if they have lung disease like asthma, it definitely makes things worse. So that's something we certainly know is coming with e-cigarettes. The research is catching up, I would say, with tobacco research. It's really too early to say for these new and emerging synthetic nicotine products. And also, because they're not approved or they're not designed to be nicotine replacement therapy, they would have to be studied differently. The path to study medications before they become approved is is very clear. And so because these are not considered medications, well, then research needs to be done also in a different way.

BRIAN GOLDMAN: You know, I'm getting the impression that the genie is already out of the bottle or is preparing to make a scape. What actions do you want the federal and provincial governments to take regarding the recreational nicotine products that we've been talking about? Products like pouches.

NICHOLAS CHADI: There is a sense of urgency among my colleagues and a lot of professionals and researchers I speak with and also a lot of parents I speak with. We have the opportunity to not repeat the mistakes that were done previously, for example, with e-cigarettes. So before introducing any new product on the market for legal sale, it needs to be studied. There needs to be some evidence that it's actually not harmful or less harmful, or that there would be some form of benefit for people using it. And in the meantime, I think there should be very close and tight regulation and making sure that these products are not in the hands of young people. That said, policies and regulations are one thing, but also, there's a big need for education and awareness. So some young people will still find ways to find products that are not in legal sale, will get them from online sources or across the border. So there needs to be a very large and societal conversation about these products. Tobacco companies have been very sneaky in the past decades in finding ways to reach young people with their products. And this isn't so new. So again, new products, same target population. I think it needs to be team work for people working together at the government level, also in schools with young people or trusted adults who interact with young people who can actually have a level conversation about what these products are and what the risks may be.

BRIAN GOLDMAN: And finally, what should parents do?

NICHOLAS CHADI: They should get informed and talk about it. So there actually isn't very much information about these products yet. But just listening to podcasts like this and asking themselves the question, is it something that I would want my son, my daughter, my child to be using is a good first step. And having a non-judgmental conversation with their young ones to try to understand what young people know and hear about these products, and try to sort of raise awareness that if the companies selling tobacco products are also selling these products, well, there's this chance that they'd be not be hoping for healthy results. And so even if a product like Zonnic may be labelled as a health product, having an educated discussion as a family about what it means and how to be careful about what the risks may be.

BRIAN GOLDMAN: Well, you think we should have more conversations about this, and hopefully, this podcast will edify our subscribers. Dr. Nicholas Chadi, thank you so much for speaking with us on The Dose.

NICHOLAS CHADI: Thank you for having me, Brian.

BRIAN GOLDMAN: Dr. Nicholas Chadi is a pediatrician and researcher specializing in adolescent and addiction medicine. He's also the nicotine and tobacco spokesperson for the Canadian Pediatric Society. Here's your dose of smart advice. Recreational nicotine refers generally to the non-medical use and marketing of nicotine products. Nicotine pouches are small bags that contain either synthetic nicotine or nicotine extracted from tobacco plants, as well as other ingredients like candy-like flavours. Other nicotine products include tobacco free chewing products, gums, lozenges, pellets, candies and toothpicks. In the US, a pouch with the brand name Zyn made by Philip Morris has become quite popular. Zyn is not available in Canada, but would be available to young people who visit the US. Another pouch named Zonnic, sold by Imperial Tobacco Canada, has been available here since late 2023. These products have not been regulated as closely as smoking cessation or nicotine replacement therapies like patches, inhalers and gums. In 2023, Health Canada approved Zonnic as a licensed natural health product for nicotine replacement therapy, which means there are no restrictions on who can purchase it. Teens have been able to buy Zonnic legally. I note that B.C. and Quebec have changed the regulations, so you can only buy it at the pharmacy from behind the counter. Each Zonnic pouch contains two to four milligrams of nicotine, which is roughly equivalent to three or four tobacco cigarettes. Experts are concerned that youth who have never smoked can obtain these products easily. Used for recreational purposes, nicotine has no therapeutic benefit. It produces a slight Short-Lived sense of well-being or high. As the body develops tolerance, users may consume a greater amount to achieve the high. Nicotine is highly addictive, and just five milligrams a day is enough to start the process. Teen non-smokers who use nicotine are more likely to use nicotine and smoke cigarettes later in life. Nicotine can also increase heart rate and blood pressure. It can also increase symptoms of depression and anxiety, and oral nicotine products can lead to gum disease. The impact of nicotine on the developing brain and other potential long term health effects aren't fully known, so caution is the best advice. Ask your teen what they know about nicotine pouches and other products, and if your teen has seen them used or heard peers talk about using them. Make sure they know the potential risks. Being curious instead of accusing can help keep the lines of communication open. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant and Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do I need to know about nicotine recreational products? - Transcript

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