Smoking rates remain high in the UAE and Middle East but new smoke-free nicotine alternatives entering the market could be critical to efforts to help people kick the habit.
The UAE has approved the sale of synthetic nicotine pouches - subject to sellers meeting safety standards set out by the government - which are taken orally and held under the gum for about 40 minutes to gradually release a nicotine dose.
They provide a less harmful alternative to cigarette smoking and vaping, as nothing is burnt or inhaled. Nicotine, however, is highly addictive. About 12 per cent of people in the UAE smoke and 20 per cent in the Middle East, figures from the World Health Organisation show.
Exact numbers of people using e-cigarettes are unclear, but the UAE vaping market is expected to be worth $78 million this year, according to market analysts Statista. The fast-growing industry has also sucked in young people, with university research suggesting almost a quarter of UAE students have vaped. Doctors said a proven, less harmful alternative could help more people quit smoking, known to cause multiple cancers, cardiovascular disease and respiratory disease.
“We have a massive gap in the market here and lots of patients come to me looking for support and help with giving up smoking,” said Dr Rachel Kaminski, a pulmonologist at Saudi German Hospital in Dubai.
“From my background in the UK's National Health Service, nicotine replacement products had massive benefits. If you can deal with the actual nicotine addiction and give smokers something else, you take away some of the other risks that smoking has, such as other carcinogens and passive smoking effects on children.”
Top priority
Tobacco and e-cigarette control is a top priority for the UAE, with a key public health strategy implementing a smoke-free environment and increased public awareness of the health risks. International health agencies and the US Food and Drug Administration have also warned that associated risks of using e-cigarettes and vapes are unsupported for smoking cessation.
Two million people in the Gulf were undiagnosed with chronic obstructive pulmonary disease, a lung disease connected with smoking, according to Dr Rachel Kaminski, who works with the Emirates Thoracic Society in advising on smoking cessation.
“There are some risks with nicotine pouches,” said Dr Kaminski. “It's addictive, and people can find themselves dependent rather than quitting nicotine at all.
“Some people have side effects, particularly those with pre-existing health conditions. Nicotine itself, we know can have some effects on the cardiovascular system, such as elevating blood pressure.
“As they have not been around for long, we need more long-term research to fully understand the health implications. We do know if adolescents start using these products they can have potential consequences, particularly in brain development.
“Their usage should be monitored, legislated and only prescribed appropriately. If we're going to do it, we should do it properly and do it right.”
Quitting aids
The potential of nicotine pouches has been proven elsewhere, particularly in Europe. Among Swedish men, rates of lung, lip and oral cancer, as well as oesophageal and stomach cancers, have reduced considerably since 1980.
In 2022, for the first time, female users of snus and nicotine pouches outnumbered those who smoked, about 7.5 per cent of Swedish women. Dr Karl Fagerstrom, an academic researcher from Uppsala University in Sweden and addiction expert, developed the Fagerstrom Test for Cigarette Dependence.
He has made significant contributions to the development of nicotine replacement therapies, such as nicotine gum, patches, sprays, and inhalers and contributed to almost 60 publications on medicine and smoking cessation. Dr Fagerstrom opened his first smokers' clinic in 1975, and recognised similar traits in smokers as drug addicts.
“I realised we need to treat smoking as drug dependence,” Dr Fagerstrom told The National. “As a doctor, it is like blood pressure - you want to know the measure of how severe it is, so by formulating this scale I could assess the degree of dependence.”
The test’s questionnaire determines a smoker’s level of dependence, with a score of 1-2 considered low and 9-10 high. A course of smoking cessation tools can then be prescribed accordingly.
When about 5 per cent of patients were unable to give up smoking, Dr Fagerstrom looked at alternatives for nicotine delivery. He said nicotine was responsible for about 60 per cent of cigarette addiction, while the behavioural aspect, such as hand-to-mouth routine, contributes about 40 per cent to an addiction.
“There is a misconception that nicotine is the cause of cancer and vascular disease,” he said. “The more behaviour involved and the more sensory effects [such as inhalation or injection] the stronger the dependence.
“With cigarettes, you have a very strong behavioural dependence and a strong nicotine dependence. From when you inhale until you have the nicotine in the head is 10 to 15 seconds faster than an intravenous injection. Cigarettes produce the most dependence, followed by heat-not-burn products, then vaping and finally snus.”
Falling smoking rates
Snus pouches and similar tobacco-free nicotine pouches have been hailed as significant contributors to Sweden having some of the lowest smoking rates in Europe. As a result, cancer rates and lung conditions caused by smoking are also considerably below the European average.
Some pouch users have experienced changes to gum structure and oral health after long-term use, and nicotine itself is highly addictive.
Sweden has slashed smoking rates and transitioned towards harm-reduction public health policies on tobacco. However, the country is one of the few nations with more female smokers (6.8 per cent), than male (5.9 per cent), due largely to the popularity of snus with men.
In 2018, there were about 40 cases of lung cancer per 100,000 people in Sweden, compared with 113 in Hungary and an EU average rate of 71 per 100,000 people.
About 37 nations now regulate and sell nicotine pouches, which first entered the US market around 10 years ago. More countries are introducing regulations, including the UAE.
A major manufacturer is Philip Morris International, the cigarette manufacturer that purchased Swedish Match, Sweden's largest producer of synthetic nicotine pouches, Zyn.
Zyn contains no tobacco leaf, but does contain pharma-grade synthetic nicotine and food-grade ingredients. Of the 43 compounds screened within Zyn nicotine pouches, 36 are classified as harmful.
These compounds are also found in nicotine replacement therapy gum.
“We have replaced the smoking, cigarette smoking with alternative nicotine products, pouches, and that has really had a dramatic impact on the public health here in Sweden,” said Patrik Hildingsson, director of oral category communication at PMI.
“Cigarette smoking is harmful to health, there is no doubt about that. To reduce the harm, you need to quit, but many people just don't, they stay with their cigarettes. “For these people, we need to give them alternatives to get out of the combustions, the smoke process and the chemicals that comes with burning a crop.”
