INTRODUCTION

One of the primary contributors to a diverse range of human health issues is smoking, which encompasses a spectrum of illnesses ranging from life-threatening cardiovascular diseases to debilitating lung cancers and chronic obstructive pulmonary disease¹. The detrimental consequences of smoking extend beyond these circumstances, affecting nearly every organ in the human body². Cigarette smoking remains the primary method of nicotine consumption in a wide range of demographics and regions³. Nicotine, a chemical compound that is naturally present in tobacco leaves, is the primary cause of the addictive nature of cigarette smoking. Nicotine is eventually released into cigarette smoke during the combustion process. The addictive appeal of smoking is significantly enhanced by the natural prevalence of nicotine in the tobacco plant, which captivates users with its potent psychoactive effects⁴. The effects of nicotine are rapidly disseminated throughout the duration of the frame as it rapidly and effectively permeates the bloodstream upon inhalation during a smoking session⁵. Nicotine binds to neuronal nicotinic receptors, which may help regulate mood and promote relaxation⁶, while the pharmacokinetic profile of nicotine shows a sudden rise in plasma nicotine levels followed by a decrease in those levels⁷.

Recently, a brand-new category of nicotine products, known as nicotine pouches (NPs), has come into existence. NPs have a physical resemblance to Swedish snus, but they do not contain any tobacco leaf, but they do contain nicotine salts. Oral nicotine pouches, also known as ONPs, are a growing variety of smokeless nicotine products that are currently in the process of becoming more popular⁸. Nicotine pouches typically comprise small, white pouches that measure approximately 25 mm in length. To facilitate the gradual release of nicotine without the need for combustion, these pouches are intended to be placed stealthily between the gums and the lips in order to maintain their discretion⁹. The contents of these pouches contain a wide variety of components that have been meticulously chosen. In addition to nicotine, which is the primary active component, nicotine pouches may also contain a variety of flavors, ranging from mint and citrus to more individual fruit blends, to cater to a wide range of user interests and preferences¹⁰. Furthermore, alkaline salts are frequently incorporated into the components to adjust the pH level of the contents of the pouch. This adjustment helps to maximize the amount of nicotine that is absorbed and improves the overall effectiveness of the product¹⁰. This may increase attractiveness and lead to an increase in nicotine consumption, particularly among populations that were previously unfamiliar with nicotine, such as young people and teenagers¹¹.

In 2023, nicotine pouches were introduced in Saudi Arabia and as a result there has been a sense of both interest and challenge regarding the potential effects that they may have on users¹². According to our hypothesis, consumers of nicotine pouches might experience gum irritation and gastroesophageal reflux disorders. To verify our hypothesis, we investigate the effects that nicotine pouches have on the health of users in Saudi Arabia.

METHODS

RESULTS

Table 1 showed that married individuals were significantly more likely to have used nicotine products (76.2% vs 32.4%, p<0.001), suggesting a strong relationship between being married and nicotine use. Males were much more likely to have used nicotine products (63.1% vs 7.3%, p<0.001), highlighting a notable gender difference in nicotine use. There was a borderline significant association between nationality and nicotine use (p<0.051). Non-Saudis appeared to have used nicotine products more often (57.1% vs 36.0%, p<0.001). There was a clear age-related pattern in the usage of nicotine products, with younger age groups (15–23 years) being less likely to use these products (31.4%) compared to older age groups, particularly those aged 30–35 years (90.9%).

Table 2 shows that 108 participants (75.5% vs 24.5%, p<0.001) reported being aware of nicotine pouches before the study, while 79 participants (73.1% vs 26.9%, p<0.001) reported having used nicotine pouches. The most common number of nicotine pouches used per day was <5 units (46.8%), followed by 5–10 units (30.4%), and fewer participants reported using >10 units (p<0.001). The most commonly reported dosage was 6–10 mg (55.7%), with smaller percentages using 1–3 mg or 3–6 mg (both 10.1%, p<0.001). The most commonly used brand was DRZT (88.6%), while fewer participants reported using VELO or other brands (p<0.001).

While symptoms such as mouth or gum irritation and nausea were more frequently reported, no notable pattern of symptom distribution was evident.

DISCUSSION

The study aimed to describe the awareness and use of nicotine pouches, both in general and according to tobacco product usage, as well as to characterize the symptoms associated with nicotine pouch use and other behaviors among individuals who use nicotine pouches. This study indicates that men, particularly married individuals, frequently use a dosage of 6–10 mg per day. Additionally, the most common symptoms reported by nicotine pouch users varied, with mouth or gum irritation and nausea being the most prevalent.

Recently, a new type of nicotine product, known as oral nicotine pouches, has emerged. These pouches are smokeless and tobacco-free but contain nicotine salts⁸. They consist of small pouches approximately 25 mm in length that are placed between the gums and lips, allowing nicotine to be absorbed into the bloodstream. This offers a method of nicotine delivery that does not involve inhaling smoke¹³. The findings of this study reveal that the sociodemographic characteristics of nicotine users are mostly males, married, aged ≥23 years. This is consistent with the 2019 Global Adult Tobacco Survey (GATS) conducted by MOH in Saudi Arabia¹³ and several other studies involving nicotine products and their prevalence in Saudi Arabia^14-16. A significant difference between our study and another⁸, which uses data from the 2013 SHIS, is in the prevalence of tobacco products based on marital status, while our findings revealed a higher prevalence of nicotine products in married participants similar to more recent studies^16,17, the other study reported unmarried participants to be significantly more likely to use nicotine products. Of note, regarding our study and those previously mentioned, only one study¹⁷ is nationally representative.

As for the usage of nicotine pouches, excluding participants with no previous use of nicotine products or any awareness of nicotine pouches, 73.1% of participants aware of nicotine pouches have ever used them. Comparatively, the finding of Sparrock et al.¹⁸ investigating awareness and use of nicotine pouches among a 2021 nationally representative sample of US adult current commercial tobacco users, found that 39.2% of those aware of nicotine pouches have ever used NPs. Another study¹⁹, conducted in 2019 among UK current and former smokers and vapers, shows only 27.8% of participants that are aware of NPs, have ever used them.

The daily use of nicotine pouches among consumers suggests a potential dependence, consistent with findings from studies on electronic cigarettes conducted by Soule et al.²⁰ which also showed a dependence similar to that of traditional cigarettes. Also, some consumers might be using nicotine pouches to quit smoking by substituting cigarettes with them. Similar findings were observed in research done by Benmarhnia et al.²¹ on electronic cigarettes used for smoking cessation, where daily users began to use ENDS (Electronic Nicotine Delivery Systems) to quit smoking. Furthermore, consumers might replace cigarettes with nicotine pouches due to the perception that they are less harmful. Prior research by Plurphanswat et al.²² indicated that consumers switched from tobacco products to ZYN pouches because they perceived them to be less harmful.

Consumers showed a tendency to prefer higher dosages with fewer units, suggesting they may seek a particular level of satisfaction. On the other hand, some opted for frequent usage of low to normal dosages, implying they may not have been satisfying an addiction but were still consuming comparable nicotine levels to traditional tobacco products. Research by Stanfill et al.⁹ has found that nicotine and pH levels in some nicotine pouches are similar to those in conventional tobacco products. Moreover, frequent consumption of large amounts of nicotine pouches could be indicative of developing a negative behavior, like binge eating, where individuals consume large quantities while feeling powerless to stop, accompanied by discomfort and shame. A study conducted by Anzengruber et al.²³ on eating disorders involving 1524 women found an increased risk of smoking among those who engaged in binge eating behaviors.

The data also show some interesting patterns regarding symptoms. As nicotine pouches are used in NRT, it is expected for them to be less harmful than cigarettes^24,25. While almost a third (34.2%) reported no issues, others experienced mouth or gum irritation (42%) and nausea (42%). This is to be expected, as both nausea and mouth irritations are common effects of nicotine use in general⁵. Interestingly, one study done by Mallock-Ohnesorg et al.²⁶ in which the oral mucosa was inspected 10 minutes after the removal of nicotine pouches, moderate mouth irritation was reported by participants, local adverse effects were seen even with nicotine-free pouches, while mouth irritation during smoking was low. This indicates that it may be possible for mouth irritation to be due to other ingredients in the pouches²⁶. Similarly, 35.4% of users reported gastroesophageal reflux (GERD) and 25.3% experienced high heart rate. While these could be coincidental, both symptoms are known to be correlated or induced by tobacco products^27,28.

CONCLUSIONS

This study on the effect of nicotine pouches on users in Saudi Arabia revealed that some users reported symptoms like mouth or gum irritation and nausea more frequently. Further research is needed to explore in depth the factors associated with use and the appearance of adverse effects in the Saudi population.