Nicotine pouches can increase plasma cotinine levels more than cigarettes

Cotinine is a chemical compound formed when the body breaks down nicotine. Because it indicates how much nicotine a person has absorbed, it is used to measure nicotine exposure and can also be used as a marker of physical nicotine dependence.

The findings come from a Finnish study using two population-based surveys from 2017 and 2022–2023. Researchers measured plasma cotinine levels in adults who used different tobacco and nicotine products, including cigarettes, electronic cigarettes (e-cigarettes), snus and nicotine pouches.

Highest cotinine levels for snus and nicotine pouches  

Cotinine levels were elevated among all participants who used tobacco and nicotine products daily.

People who used snus had higher cotinine levels than those who smoked cigarettes. In addition, 35- and 45-year-old individuals who used nicotine pouches also showed higher cotinine levels than those who smoked cigarettes.

Predominantly, no difference was observed in cotinine levels between people who used cigarettes and e-cigarettes, as well as between individuals who used e-cigarettes and nicotine pouches.

Those who used multiple tobacco and nicotine products had higher cotinine levels than individuals who only smoked cigarettes or only used e-cigarettes.

The use of any nicotine product increases cotinine levels

The results show that using any tobacco or nicotine product is clearly associated with elevated cotinine levels in the blood, indicating physical dependence.

It is important to note that the data were collected before higher-strength nicotine pouches became legally available in Finland. Today, nicotine content is capped at 16.6 mg/g under the Tobacco Act. The differences in cotinine levels between those who use nicotine pouches versus other products could be even more pronounced today.

Further legislative measures and support for quitting are needed

The objective of the Finnish Tobacco Act is to end the use of tobacco and nicotine products. However, achieving this goal will require additional action. Possible measures include reducing nicotine content in products and limiting their attractiveness, especially to young people. In this, prohibiting flavours in all nicotine products should be enacted. In addition to regulating ingredients, setting an age limit of 20 years would be crucial.

At the European level, EU’s plan to tackle cardiovascular diseases (Safe Hearts Plan) includes the flagship initiative to modernise tobacco control legislation at the EU level. Thus, the forthcoming revision of the Tobacco Products Directive should include stronger measures to curb the use of new and emerging tobacco and nicotine products especially by adolescents.

Alongside regulative measures, the cessation of all nicotine products should be promoted in healthcare. The healthcare professional’s role is to identify individuals’ tobacco and nicotine product use, encourage them to quit, and support them in quitting.

The article is written by Otto Ruokolainen, senior specialist, Finnish Institute for Health and Welfare (THL)