A Clinical Pharmacist's Opposition to the Health Minister's Misguided Nicotine Pouch Regulations

My name is Todd Prochnau. I am a clinical pharmacist and Certified Tobacco Educator (CTE) with 14 years experience running a pharmacist-led smoking cessation clinic. I would like to share my perspectives and concerns with Health Minister Mark Holland’s recent announcement about nicotine pouches. I believe it imperative to look at available scientific evidence when considering how nicotine pouches should be regulated in Canada. There are a few key points I would like to highlight.

1. Smoking cigarettes (combustible tobacco) remains the most harmful way for a person to consume nicotine. Nicotine is addictive but does not cause cancer, cardiovascular disease or respiratory disease. The currently authorized nicotine pouches in Canada (i.e.. Zonnic) have a risk profile comparable to conventional forms of nicotine replacement therapy (NRT) such as the gum or lozenge. It is estimated that nicotine pouches have 0.1% the risk of cigarette smoking [1]. Further regulating nicotine pouches is counter-intuitive and will result in a significant barrier to tackling the disease burden of smoking-related illnesses.

2. Restricting nicotine pouches to behind the pharmacy counter (BTPC) is not the best solution to mitigating the risk of unintended youth access to NRT products. Pharmacists are not required to age-gate patients for BTPC products. Pharmacists complete a clinical assessment for each individual patient before selling a BTPC product to that patient. Pharmacists have a professional and ethical responsibility to act in the best interests of their patient (regardless of age) which may include selling a nicotine pouch to a minor as an alternative to that minor smoking or vaping (harm reduction). The only way to restrict sale of nicotine pouches to minors is to age-gate the sale in retail stores as has been well established for alcohol, cannabis and tobacco sales.

3. Adult patients prefer a variety of flavour options in nicotine products and research shows that without these options people who smoke are more likely to go back to smoking cigarettes [2] [3]. As mentioned previously, nicotine pouches have 0.1% the risk of cigarette smoking [1]. The intention to restrict nicotine pouches to mint only may result in adult patients switching back to smoking cigarettes.

4. The ministerial order to restrict Zonnic (4 mg nicotine pouch) to behind the pharmacy counter (BTPC) does not address the widespread availability of illicit (“black market”) nicotine pouches that are readily available online or in some retail settings. These illicit nicotine pouches are not subject to flavor restrictions, often contain greater than 4 mg of nicotine and are not age gated since they are being sold illicitly. It is likely that moving Zonnic to BTPC will increase the availability of illicit nicotine pouches which have not been vetted by Health Canada. Australia has a much more restrictive vaping regulation than Canada, where nicotine vapes (e-cigarettes) can only legally be purchased via prescription. It is estimated that 90% of Australian vapes are now accessed via the black market [4]. Australia is also seeing a significant upward trend in youth vaping compared to countries like Canada, England and New Zealand due to their restrictive policy [4]. This illustrates that restricting access to nicotine pouches will likely further push people to access illicit nicotine pouches without age gating or maximum nicotine levels.

5. Any regulatory changes that affect NRT products should impact all products equally unless there is strong evidence to support treating specific formats differently. All NRT (including nicotine pouches) are clinically classified and categorized the same per the National Association of Pharmacy Regulatory Authorities (NAPRA). People who smoke should continue to have broad access to all NRT products. It is important to note that currently NRT gum or lozenge is available via self-selection without involvement of a pharmacist. Youth can readily purchase NRT gum or lozenges, and this ministerial order does not address this longstanding issue.

Todd Prochnau BSc.Pharm, R.Ph, APA, CTE

Sources

1. Murkett R, Rugh M & Ding B. Nicotine products relative risk assessment: an updated systematic review and meta-analysis [version 2]. F1000Research, 2022. 9:1225.
2. Action on Smoking and Health. Use of vapes (e-cigarettes) among adults in Great Britain, in ASH Fact Sheet. 2024; UK.
3. Friedman A, Liber AC, Crippen A & Pesko M. E-Cigarette Flavor Restrictions’ Effect on Tobacco Product Sales. SSRN, 2023.
4. Quit Like Sweden. SmokeFree New Zealand. Quitting Strong: New Zealand’s Smoking Cessation Success Story. 2024.