The study examined the facilitators and challenges of so-called tobacco endgame policies in Europe. These policies refer to goals and measures aimed at reducing the use of tobacco products in the population to such a low level that it no longer places a significant burden on public health. Tobacco causes more than seven million premature deaths worldwide each year.

The EU’s Tobacco-Free Generation target was launched in the 2021 Cancer Plan and was recently reinforced in the Safe Hearts Plan. The aim is to reduce the use of tobacco products among the European population to below five per cent by 2040.

EU support is decisive for achieving the targets

According to the study, achieving the targets is particularly supported by broad political commitment, effective and long-term cooperation between different actors, and an active civil society that keeps the issue visible and brings public opinion to light.

In contrast, tobacco industry influence on decision-making, the visible marketing of new nicotine products, and the slowness of regulation make progress towards the targets more difficult.

The interviewees saw the EU’s role as central in reducing the use of tobacco and nicotine products. Common EU regulation and examples from other countries can accelerate national measures and encourage countries to set more ambitious targets for reducing the use of tobacco and nicotine products.

“The ongoing revision of EU tobacco legislation provides an important opportunity to strengthen Member States’ actions and accelerate progress towards the Tobacco-Free Generation target,” says Senior Specialist Hanna Ollila from the Finnish Institute for Health and Welfare.

Finland has been a forerunner

In some countries, the target has been extended to cover nicotine products as well. Finland has been a forerunner in this respect. In Finland, the objective of the Tobacco Act is to end the use of tobacco and nicotine products. In practice, the aim is to achieve a prevalence below five per cent by 2030.

“It is important for Finland to continue its active role and ensure that national regulation remains up to date, particularly with regard to new nicotine products. The rapid increase in the use of nicotine pouches among young people requires swift additional measures, such as raising the age limit,” Ollila states.

The study is based on interviews with 23 experts in eight European countries. The interviewees included officials, researchers and representatives of non-governmental organisations. It was carried out as part of the Joint Action on Tobacco Control 2 -project, within a work package led by THL.

The warning label currently required on alcohol containers in the United States has not changed since its adoption in 1988, despite new evidence linking alcohol to several diseases. The label states the risks of drinking during pregnancy and while driving or operating machinery and warns generally that drinking alcohol “may cause health problems.” The label often goes unnoticed and unremembered by consumers.

“We wanted to test whether new warnings could better inform consumers about alcohol’s harms and better encourage people to consider cutting back on their drinking,” says lead author Anna H. Grummon, Ph.D., M.S.P.H., assistant professor at the Stanford University School of Medicine. The study was conducted as part of a larger project co-led with Marissa G. Hall, Ph.D., associate professor at the University of North Carolina.

Designed to compare the effects of differently worded and designed warning labels, the study recruited a nationally representative sample of 1,036 adults of legal drinking age (21 and older) who reported drinking at least once a week.

Participants viewed 10 messages — one control, eight new warning labels, and the current U.S. warning label — in random order. They then rated each message on how well it encouraged them to drink less alcohol, reminded them of alcohol’s harms, and informed them of something new.

“Each participant rated multiple warnings covering a range of health harms — such as cancer, liver disease, hypertension, and dementia, among others — so we could make direct, apples-to-apples comparisons between them,” says Grummon.

All the new alcohol warnings in the study outperformed the current U.S. warning label, but those highlighting cancer risk were particularly effective. This finding is notable as policymakers in the United States and abroad debate whether to adopt a cancer warning on alcohol products.

“Ireland, for example, is set to require cancer warnings on alcohol containers in the coming years, and Alaska already requires a cancer warning to be posted in bars, restaurants, and liquor stores where alcohol is sold,” says Grummon. “Our findings suggest these policies could help people understand the risks of drinking and potentially reduce consumption.”

Study participants also rated the effectiveness of warning icons and label design. Triangles and octagons were perceived as more effective and attention-grabbing than other icons, such as a magnifying glass.

More research is underway. Grummon and Hall are currently running a randomized trial to test whether new alcohol warnings effectively lead people to drink less. The study will also measure whether the warnings improve knowledge of alcohol-related harms over time.

“We know from tobacco control that well-designed warnings can inform consumers and encourage healthier choices,” says Grummon. “Given that alcohol-related deaths are increasing, we hope policymakers will consider whether updating alcohol warnings should be part of a broader strategy to address alcohol-related harms.”
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Grummon, A. H., Lee, C. J. Y., Campos, A. D., Lazard, A. J., Brewer, N. T., Whitesell, C., Ruggles, P. R., Greenfield, T. K., & Hall, M. G. (2026). New alcohol warnings outperform the current U.S. warning in a national survey experiment. Journal of Studies on Alcohol and Drugs, 87(3), 433-443. https://doi.org/10.15288/jsad.25-00226

By W.B. Kagan

image: “Government warning” alcohol label

View more Credit: Journal of Studies on Alcohol and Drugs

Their study, published in JAMA Network Open, was the first to assess trends in young children’s nicotine exposures across all types of products.

Researchers at the New Jersey Poison Control Center, based at Rutgers New Jersey Medical School, used the National Poison Data System to analyze more than 92,000 reported nicotine exposures in children ages 5 and younger between 2016 and 2023 to understand how the rise of newer products – specifically disposable e-cigarettes and nicotine pouches – has changed the risks for young children.

They found that while tobacco exposures from conventional products such as cigarettes decreased by 43%, electronic cigarette-related incidents have increased 243% over the past eight years and often involved children who inhaled the vapors directly from the devices. They also found children exposed to e-cigarettes were more likely to require a visit to a health care facility compared with those exposed to cigarettes.

“This significant spike in children breathing in these substances tells us the risk has changed: It’s no longer just about a toddler swallowing something they found on the floor,” said Perry Rosen, lead author who conducted the research at the New Jersey Poison Control Center before becoming a medical student at New York Institute of Technology College of Osteopathic Medicine. “Many recent cases involve children actively using e-cigarette devices after gaining access to them.”

Young children naturally mimic the behaviors they see around them. “When children see caregivers or older family members vaping, they may copy that behavior—bringing the device to their mouth and inhaling—without any understanding they are exposing themselves to a harmful substance,” said Diane Calello, executive and medical director of the New Jersey Poison Control Center. Unlike cigarettes, these devices are often ready to use, brightly colored, require little effort to activate, and appear more like toys than a harmful product.

Even moderate ongoing exposure among users of vaping products—which can include adolescents—has been associated with lasting health effects on developing lungs, including increased  risk of bronchitis and worsening asthma, although such effects have not yet been reported in young children.

Despite federal laws passed in 2019 and 2020 to raise the minimum purchase age and restrict certain flavors, the upward trend in childhood poisonings has continued.

In New Jersey, liquid nicotine can only be sold in child‑resistant containers under the New Jersey Liquid Nicotine Child-Resistant Container Act (N.J.S.A. 2A:170‑51.9), which adopts federal safety standards requiring packaging that young children cannot easily open. This state law aligns with the federal Child Nicotine Poisoning Prevention Act of 2015, which mandates child‑resistant “special packaging” for all liquid nicotine products nationwide. However, while these may prevent a child from swallowing the liquid, children may still be lured by an enticing device and mimic the behavior they see – inhaling the nicotine.

She emphasized that existing protections focus largely on liquid nicotine ingestion, not behavioral exposure. “Child-resistant packaging may prevent a toddler from swallowing liquid nicotine, but it does nothing to stop a child from copying what they see an adult do,” Rosen said. That’s why we need safety standards that address the device itself, not just the container.”

“Current laws which focus on child-resistant packaging for nicotine liquids, are no longer enough,” Calello said. “This study underscores the need for safety regulations at the device level. For example, manufacturers should be required to include flow restrictors or designs that make it more difficult for a child to activate a device.”

This ‘overview’ of systematic reviews summarises existing evidence from several systematic reviews and makes the findings more accessible.  The overview pooled the evidence from fourteen systematic reviews of smoking cessation interventions from 2014 to 2023.

Findings from higher-quality reviews consistently showed greater smoking cessation with nicotine-containing e‑cigarettes than other interventions. Lower-quality reviews produced more variable and imprecise estimates. When restricted to higher-quality evidence, results consistently favoured nicotine e‑cigarettes over nicotine replacement therapy, non-nicotine e-cigarettes, and other comparators.

The overview also created an ‘Evidence and Gap Map’ (EGM) to identify gaps in the current evidence that urgently need to be filled.  There are currently no high-quality systematic reviews directly comparing nicotine e-cigarettes with cytisine, bupropion, or nicotine pouches.  Also, direct evidence comparing nicotine e-cigarettes with varenicline is extremely limited, with only a single small trial at high risk of bias.

The EGM also showed that current evidence of serious adverse events associated with e-cigarettes is inconclusive, and that most of the studies collected data from high-income countries.  Future primary research on e-cigarettes for smoking cessation should continue to collect data on serious adverse events and expand its data collection to include low-and middle-income countries.

Lead author DrAngela Difeng Wu, Senior Researcher and Lecturer at the Nuffield Department of Primary Care Health Sciences, University of Oxford, says “We hope this overview and Evidence and Gap Map can lay to rest some claims that evidence is ‘mixed’ regarding the impacts of nicotine e-cigarettes on smoking abstinence.  In fact, the evidence is clear and consistent across all of the meta-analyses we consulted:  e-cigarettes are effective at helping people stop smoking.”

To speak with lead author Dr Angela Difeng Wu, please contact her at the Nuffield Department of Primary Care Health Sciences, University of Oxford by email (angela.wu@phc.ox.ac.uk).

Full citation for article: Wu AD, Conde M, Butler AR, Knight E, Lindson N, Livingstone-Banks J, Hajek P, McRobbie H, Begh R, Theodoulou A, Notley C, Turner T, Zhitnik E, and Hartmann-Boyce J. Electronic Cigarettes for Smoking Cessation: An Overview of Systematic Reviews and Evidence and Gap Map.  Addiction. 2026. DOI: 10.1111/add.70388.

“These findings are clinically valuable for they show us that this injectable extended-release buprenorphine formulation is safe to use in pregnancy and results in better opioid abstinence outcomes compared to sublingual buprenorphine,” said Nora D. Volkow, M.D., director of NIH’s National Institute on Drug Abuse (NIDA). “This is especially relevant in the context of the ongoing opioid overdose crisis and public health emergency.”

Illicit opioid use and untreated OUD can have dire consequences during pregnancy, including risk of fatal overdose for the mother and the development of neonatal opioid withdrawal syndrome (NOWS) and other adverse consequences for the baby. Treating OUD in pregnancy with sublingual buprenorphine is effective, but it has disadvantages, including risk of misuse, potentially poor adherence, and daily fluctuating blood levels known as peak-trough effects that may inadequately mitigate opioid-related cravings and withdrawal, leading to continued opioid use. The researchers in this study wanted to see if using a weekly formulation of subcutaneous (under-the-skin), extended-release buprenorphine injections during pregnancy—with the option of a monthly formulation for postpartum participants who were not breastfeeding—might promote as good or better opioid abstinence rates and NOWS outcomes.

In the multicenter trial, 140 pregnant adults were randomized to receive either injectable extended-release or sublingual buprenorphine (with or without naloxone). The trial, supported by the NIDA Clinical Trials Network as part of the NIH Helping to End Addiction Long-term ® Initiative (NIH HEAL Initiative^®), was the first randomized trial testing extended-release buprenorphine for OUD in pregnancy and postpartum.

The researchers found that rates of illicit opioid abstinence during pregnancy, as measured by urine drug screens, were significantly higher for those receiving weekly extended-release buprenorphine and were non-inferior postpartum compared to participants receiving sublingual buprenorphine.  While the percentage of participants experiencing non-serious maternal adverse events did not differ between the types of treatments, they were more commonly rated as medication-related in the extended-release group during pregnancy. Serious maternal adverse events were less common in the extended-release group throughout the trial. NOWS outcomes did not differ between the treatment groups.

“We knew that injectable extended-release buprenorphine leads to superior rates of illicit opioid abstinence in non-pregnant adults, but there had been no completed randomized clinical trial testing its use during pregnancy,” said principal investigator and lead author John Winhusen, Ph.D., professor of Psychiatry and Behavioral Neuroscience at the University of Cincinnati College of Medicine. “It is exciting to share the results of this trial, which have immediate clinical application: this longer-acting medication can safely and more effectively support treatment and recovery in pregnant patients.”

CUD is characterized by continued use of cannabis despite ‘clinically significant impairment’ such as ignoring important social, occupational, or recreational activities and persistent use despite physical or psychological problems associated with cannabis.  Cannabis use is also associated with psychosis, sleep disorders, withdrawal, and mood and anxiety disorders.

Varenicline is an effective medication for quitting tobacco.  This trial, conducted at the Medical University of South Carolina and published in Addiction, tested whether varenicline could help with CUD. Results showed it helped men reduce cannabis use, but not women. (Varenicline works equally well for both sexes as a stop-smoking aid.)

The trial included 174 participants with CUD who used cannabis at least three days per week.  Participants were randomized to varenicline (working up to a dose of 1 mg twice daily) or placebo for 12 weeks.  Participants also received a weekly brief medical management session to encourage their adherence to both the medication and the treatment plan.

The men in the study who received varenicline used cannabis fewer times per week than the men on placebo.  Specifically, the varenicline group averaged 7.9 cannabis sessions per week during the study and 5.7 sessions in the week following the study, compared with more than 12 weekly sessions for the placebo group.  The male varenicline group also used cannabis an average of 3.8 days per week, compared with 4.7 days per week for the male placebo group.

The women in the study who received varenicline did not differ in their cannabis use from the women on placebo.  The varenicline group averaged just over 10 sessions per week, compared with the placebo group’s 9.2 weekly sessions (which dropped to 8.2 in the week following the study).  The female varenicline group used cannabis an average of 4.9 days per week, compared with 3.6 days for the female placebo group.

The female varenicline group showed higher withdrawal and craving scores and higher anxiety than any of the other groups.  Perhaps connected with that, women receiving varenicline reported lower medication adherence than women receiving placebo.

Lead author Professor Aimee McRae-Clark says “Cannabis use disorder is rising quickly in the United States. Current pharmacological treatment options are very limited, and so our ability to help people reduce their cannabis use is also limited. Our study found that varenicline, a drug that helps people to reduce or stop smoking, may be effective at reducing cannabis use as well, but only for men.  Our next step is to further explore varenicline for cannabis use disorder, using a larger sample size of women, to better understand this sex difference in the treatment outcome.  In the meantime, we are encouraged that varenicline shows potential promise in treating this fast-growing problem.”

This Open Access paper is available on the Wiley Online Library from the embargo date (https://onlinelibrary.wiley.com/doi/10.1111/add.70296) or you may request an early copy from Jean O’Reilly, Editorial Manager, Addiction, jean@addictionjournal.org.

Full citation for article: McRae-Clark AL, Gray KM, Baker NL, Sherman BJ, Tolliver B, Burt J, Steplight A, Chapman E, and Wagner A.  Varenicline for cannabis use disorder: A randomized controlled trial.  Addiction. 2026. DOI: 10.1111/add.70296

Primary funding:  This work was supported by the National Institutes of Health (UH3DA043231).

Declaration of interests: Dr. McRae-Clark has served as a consultant for Indivior Pharmaceuticals and has received research support from Pleo Pharma. Dr. Gray has served as a consultant for Indivior Pharmaceuticals and received research support from Aelis Pharma. The other authors report no interests to be disclosed.

Addiction is a monthly international scientific journal publishing peer-reviewed research reports on alcohol, substances, tobacco, gambling, editorials, and other debate pieces. Owned by the Society for the Study of Addiction, it has been in continuous publication since 1884.

The study examined data from a large trial, funded by the National Institute for Health and Care Research (NIHR) and Cancer Research UK (CRUK), which followed 886 adult smokers over one year. Participants were offered e-cigarettes or nicotine replacement products as part of a stop-smoking attempt.

Published in Nicotine & Tobacco Research, the research looked closely at how people used e-cigarettes during this period and whether different patterns of use were linked to long-term success.

Smokers who were still smoking after they started their quit attempt but also used an e-cigarette were more likely to stop smoking at four weeks and at one year than people who continued to smoke without vaping. Importantly, dual users who did not manage to stop smoking altogether were far more likely to substantially reduce their smoking rate and their objectively measured intake of chemicals in cigarette smoke, than unsuccessful quitters who did not vape.

Dr Francesca Pesola, Senior Lecturer in Statistics at Queen Mary and lead author of the study said: ‘The sooner smokers quit the better, but for those who find it difficult to stop smoking abruptly, vaping can help with doing it gradually over time’.

Dr. Peter Hajek, Professor of Clinical Psychology, Director of the Health and Lifestyle Research Unit at Queen Mary and co-lead author of the study said: ‘Smokers (and clinicians) sometimes believe that if smokers do not manage to stop smoking soon after starting vaping, they should stop using e-cigarettes to avoid ‘dual use’. These results show that dual use promotes genuine harm reduction and that it can be a useful step to stopping smoking altogether.’

The study generated three other important findings.

People who used e-cigarettes experienced lower urges to smoke than those using nicotine replacement therapy. This can explain why vaping helps smokers quit and why dual users find it easier to smoke less and eventually stop.

Most e-cigarette users started on high nicotine strengths and moved to lower strengths over time. By one year, around one in 10 people using e-cigarettes had shifted to nicotine-free e-liquids. Smokers may benefit from knowing that vaping can provide an avenue to gradually wean themselves off nicotine.

Tobacco flavoured e-liquid was unpopular and seems to have been less helpful than other flavours. All participants were initially given tobacco-flavoured e-liquid, but most quickly switched to other flavours such as fruit; and those who stuck with tobacco flavour were less likely to remain smoke-free at one year.

Approximately 11.9 per cent of adults in the UK smoke and quitting smoking remains one of the most effective steps a person can take to improve their health.

Nicotine pouches, which entered the UK market in 2019, are small tobacco-free sachets placed between the lip and gum to deliver nicotine. They are currently unregulated in the UK and can be legally sold to under-18s, although the UK Government’s Tobacco and Vapes Bill proposes new age restrictions on their sale.

Researchers from the Scottish Centre for Social Research (ScotCen), conducted the first qualitative study in the UK to explore how 14–16-year-olds understand and use nicotine pouches. The study involved 16 focus groups with 77 pupils and interviews with 13 school staff across four Scottish schools.

Key findings:

• High awareness and experimentation: Most pupils knew about nicotine pouches, often referring to them as ‘snus’ or ‘upper deckies’. Experimental use was common, and more established use was also reported, particularly among older male pupils.

• Discreet use in schools: Many young people said they liked that pouches can be used discreetly, including during school hours or on public transport, unlike vapes or cigarettes.

• Adverse health effects: Pupils reported negative effects from using pouches, from gum pain and burning sensations in the mouth and throat, to sickness, sweating and fainting.

• Perceived as safer than vaping: Despite these effects, some young people believed pouches were “better for you” than vaping or smoking, because they avoided lung damage. One male pupil told researchers: “I’d rather have worse gums than worse lungs.”

• Staff unaware of use: School staff members had good knowledge and awareness of vaping among pupils in schools, and were taking measures to address this. In contrast, they had limited knowledge of nicotine pouches and were largely unaware that pupils were using them.

Andy MacGregor, Director of Policy Research at the Scottish Centre for Social Research, said: “Our study shows that awareness and experimentation with nicotine pouches among young people is already widespread and that these products are being used under the radar in schools. Because pouches can be bought by under-18s and used discreetly, they pose a unique challenge for teachers, parents and policymakers. Stronger regulation and better public health messaging are urgently needed.”

Allison Ford, Associate Professor at the Institute for Social Marketing and Health at the University of Stirling and Principal Investigator of the New Nicotine Products (NNPs) in Scotland (NIPS) Study, said: “This important paper highlights the accessibility of nicotine pouches to young people in Scotland and young people’s awareness of nicotine pouch marketing and promotion.

“The wider NIPS study is examining the retail availability, marketing and display of NNPs in Scotland. Its findings will help the Scottish Government decide if new rules are needed on how vapes and nicotine pouches are displayed and marketed in shops, to protect young people from using these products.”

Jamie Pearce, Professor of Health Geography at the University of Edinburgh, said: “Nicotine pouches are becoming more widely used among young people in Scotland which may lead to long-term and harmful effects for health. There is an urgent need to take steps to reduce the marketing, availability and sale of nicotine pouches to young people.”

• The Scottish Centre for Social Research (ScotCen) is an integral part of the National Centre for Social Research (NatCen). Based in Edinburgh, they have decades of experience of listening to the public and making sure their voice is heard.

• This research was conducted by ScotCen as part of the New Nicotine Products in Scotland (NIPS) study.

• The study involved 16 focus groups with 77 pupils aged 14–16 and 13 interviews with school staff across four Scottish schools. Fieldwork took place between 3 and 26 March 2025.

In the early 2000s, use of prescription opioids to treat acute and chronic noncancer pain increased substantially in Canada, and with it came a rise in opioid-related harms. The availability of more opioid products, coupled with aggressive marketing of these drugs, contributed to these early increases in Canada and in other countries.

Many initiatives have been introduced with the goal of reducing these harms throughout the country, including policy changes, a focus on continuing medical education for evidence-based prescribing, and a national Canadian guideline for opioid prescribing published in 2017.

With these changes, a need has emerged for national information on prescription opioid use in Canada and how this varies in different parts of the population. Researchers aimed to help fill this gap with a study of opioid prescribing in 6 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, and Quebec) between 2018 and 2022. The number of people newly starting opioids declined 8% during the study period, and the total number of people accessing opioids declined 11%. In 2022, across Canada, approximately 1.8 million people started an opioid to manage pain for the first time. However, the rate of opioid prescribing varied among provinces, ranging from 55 new opioid starts per 1000 people in Ontario to 63 per 1000 people in Alberta.

“[T]he interprovincial variations in our findings may indicate differences in the implementation of prescribing guidelines, underscoring the need for coordinated national strategies and ongoing evaluation of their effects on patient outcomes,” writes Dr. Tara Gomes, a researcher in the Ontario Drug Policy Research Network at St. Michael’s Hospital, Unity Health Toronto, with coauthors.

Annual rates of new prescriptions were higher for females, older adults, and people living in lower-income neighbourhoods and rural regions. Codeine was most usually prescribed in most provinces, with the exception of Quebec, where people were more commonly dispensed morphine and hydromorphone. Oxycodone dispensing decreased over time, although in Ontario over one-quarter of opioids prescribed were still for oxycodone in 2022.

The authors caution that although lower rates of opioid prescribing may reflect doctors’ efforts to ensure safe and appropriate prescribing, a balance is needed to ensure that people are not left without pain relief or cut off from medications without appropriate supports and coordination of care.

“Importantly, although these recommendations intended to promote safer opioid prescribing, improper implementation can lead to rapid dose tapering, abrupt opioid discontinuation, and reluctance to initiate patients on opioids when clinically indicated. In some cases, these changes have led to patients seeking access to opioids from the unregulated drug supply, which are inherently more harmful,” write the authors.

The researchers suggest that clinicians engage in conversations with patients to ensure shared decision-making, and assess pain levels and ability to function.

“The truth is … that opioids are less effective and less safe than many care to admit,” writes Dr. David Juurlink, an internist and researcher at Sunnybrook Research Institute and the University of Toronto, Toronto, Ontario, in a related commentary https://www.cmaj.ca/lookup/doi/10.1503/cmaj.251666 praising the continued decline in opioid prescribing.

Opioids can be effective when carefully prescribed, particularly for short periods. But, with long-term use, their effectiveness can wane and they can harm patients in ways that are hard to appreciate.

“Most clinicians have seen how well opioids can work when first given,” writes Dr. Juurlink. “But they are at their pharmacologic best in the initial days of treatment. Continue them for weeks, months, or years and the calculus becomes progressively less favourable.”

Juurlink urges thoughtful prescribing, which “begins with recognizing that all patients in pain fall into 1 of 3 mutually exclusive groups: those not yet on opioids, those taking opioids chronically (sometimes called ‘legacy patients’), and those with established addiction. The latter 2 groups overlap and are easily harmed by rapid dose reduction, but they can also be harmed by dose escalation. For such patients, when pain intensifies, nonopioid strategies are preferred. The first group, by contrast, has the most to gain from thoughtful opioid stewardship.”

In the first Cochrane review on the topic, the evidence suggests that switching to oral nicotine pouches from smoking reduces exposure to harmful substances, “which is what we would expect to find,” says senior author Jamie Hartmann-Boyce, assistant professor of health policy and management at the School of Public Health and Health Sciences and an editor for Cochrane, the global health research nonprofit based in the United Kingdom.

Because the Cochrane team only found four small studies that were appropriate for their review, the evidence is not yet clear on whether oral nicotine pouches can help people quit smoking or vaping. But the foundation now exists for Hartmann-Boyce and team to continue their investigation. Their ongoing Cochrane reviews have revealed the best evidence-based ways to quit both vaping and smoking.

“Other nicotine products, like patches, gums, and nicotine vapes, are definitely beneficial for helping people quit smoking,” says Hartmann-Boyce, a leader in tobacco health policy and management in the U.S. “We knew that we weren’t going to have that many studies of pouches in this review when we published the first time, but we also know there are loads in the pipeline, and we hope to regularly update this as those new studies come out. We’ve given ourselves a platform to collect that data and integrate it quicker than we would have been able to before.”

About the size of a tea bag, oral nicotine pouches contain nicotine powder and flavorings, but no tobacco leaf. The pouches are marketed as a smokeless alternative to tobacco products and occasionally as a way to reduce or quit smoking.

Unlike nicotine gum, patches, lozenges, nasal sprays and inhalers, the nicotine pouches are not FDA-approved smoking cessation aids. But earlier this year, the FDA approved the marketing of 20 Zyn nicotine pouches in the U.S., concluding that the evidence showed it offered “greater benefits to population health than risks.”

It was the first oral nicotine pouch to be so approved in the U.S., a significant FDA decision, Hartmann-Boyce notes. “An inherent argument behind the decision for these new products to enter the market is that they have the potential to move people away from smoking,” she says.

“From an academic perspective, one of the most interesting things about oral nicotine pouches is that for a long time, we have been promoting nicotine replacement therapies, like patches and gums, to help people quit smoking. The World Health Organization lists them as an essential medicine. They are a critical tool within public health, and it’s currently difficult to come up with a compelling, detailed description of why we think the risks of oral nicotine pouches—if well-regulated—would be meaningfully different than nicotine replacement therapy to an individual user.”

The pouches are placed between the lip and gum, which allows nicotine to be absorbed through the mouth. They appear similar to snus, a Swedish oral pouch filled with ground-up tobacco leaves and flavorings. The user doesn’t need to spit when using either oral nicotine pouches or snus.

“So in the same way vaping is different from smoking, because it doesn’t involve tobacco leaf, oral nicotine pouches are different from snus,” Hartmann-Boyce says. “Snus isn’t going to increase your risk of lung cancer, but it is going to increase your risk of mouth cancer, throat cancer and tongue cancer because of the tobacco leaf and chemicals in it.”

She adds that rates of smoking and smoking-related disease and death have gone down significantly in the countries that allow snus. “So, there’s certainly a harm-reduction element in thinking about non-combusted tobacco and nicotine products.”

Hartmann-Boyce notes that for people who don’t use any nicotine products, it’s best not to start. Nicotine is highly addictive, and the risks of new products are not yet well understood, particularly in people who don’t have a history of smoking.

“But it is rational, if you are someone who is addicted to smoking, to switch to using an alternative nicotine product if you can’t quit completely,” she says.

This effect is called psychological cessation fatigue, and its influence on ex-smokers is not affected by how long you’ve been an ex-smoker or whether you vape to reduce cravings.  Even after years of not smoking, after withdrawal symptoms and conditioned responses are no longer strong, and even with regular hits of nicotine from vaping, the cumulative mental and emotional cost of sustaining not smoking can become so high that it overwhelms your coping skills and motivation to stay quit.

This study followed almost 2,000 adult ex-smokers in Australia, Canada, England, and the United States.  Most participants had quit smoking years before the study began.  At the start of the study, each participant expressed 1) how tired he or she was with trying to stay quit, 2) how strong the urge to smoke was in the past 24 hours, and 3) how confident he or she was in remaining an ex-smoker.

Two years later, 9.2% of the ex-smokers had begun smoking again.  The odds of relapse among ex-smokers with high fatigue were 1.64 times higher than those with low fatigue.  In other words, the ex-smokers who were most tired of trying to sustain not smoking had a 64% higher likelihood of relapse than ex-smokers who expressed no cessation fatigue.

High urge to smoke and low confidence with remaining an ex-smoker also predicted smoking relapse, but the predictive strength of cessation fatigue was both stronger and at least partly independent of these other two measures.

Lead author Dr Hua Yong, of Deakin University in Australia, says “Smoking is notoriously hard to quit.  About 95% of unassisted attempts to quit ultimately end in relapse, and even when evidence-based treatments like nicotine patches are used, relapse rates are still high.  Our research suggests that ‘tiredness with efforts to remain not smoking’ can be a useful screening tool to catch ex-smokers who are at higher risk of relapse and give them support when they need it.  We could incorporate assessment of cessation fatigue in routine health checks and be ready to provide relapse prevention interventions where needed. Ex-smokers might also be advised to seek more help when they begin to experience fatigue.”

In a new analysis, researchers explored the possible consequences of that reduction in costs through the eyes of those who make up the drug supply chain. The authors summarize potential long-term implications for the structure, conduct, and performance of the illegal opioid supply industry, as well as potential consequences for drug law enforcement organizations.

The analysis was conducted by researchers at Carnegie Mellon University, the University at Albany, the University of Arizona, and the University of Maryland. It is published in Global Crime.

The United States has had a substantial illegal opioid market for more than 50 years. Starting around 2000, a rise in prescriptions for opioids for pain management led to an additional market in diverted prescription opioids. And around 2015, illegally manufactured fentanyl entered the market, which spurred continued increases in fatal drug overdoses.

“Although there has been much research on these changes, few studies have considered the motivations for the rise in fentanyl from the perspective of the illegal drug traffickers,” says Jonathan P. Caulkins, professor of operations research and public policy at Carnegie Mellon’s Heinz College, the lead author.

The analysis begins by asking how fentanyl, a cheap, synthetic opioid, might affect supply and demand in a market previously dominated by heroin, a plant-based, semi-synthetic product that in North America is more expensive, less potent, and less lethal than fentanyl.

Fentanyl is much cheaper to produce than heroin, generating a supply shock in the market for illegal opioids that may have implications beyond the standard prediction that prices will drop and consumption will increase. In their analysis, the authors describe the shock of cheap production, showing why this might lead to proportionately smaller reductions in the retail price than in the import price of illegal opioids. Then they consider the implications for illegal opioid suppliers and supply, relying on knowledge about the idiosyncrasies of illegal drug markets.

The authors then assess effects on the demand side of the market; given the demand elasticities for illegal opioids, price reductions lead to only modest declines in expenditures and thus also in drug-related income-generating crime. They also consider possible implications for the ability of law enforcement to affect the market, addressing why high-level seizures of fentanyl become even less relevant than when heroin was the principal illegal opioid. Among the authors’ conclusions:

• The implications of fentanyl’s lower cost will be larger in Mexico’s high-level markets than in U.S. retail markets because the cost of the drug represents a smaller part of the cost of supply in U.S. retail markets. Hence, the market shift toward fentanyl may have less pronounced effects on crime, violence, and criminal incomes in the United States than on economic outcomes in Mexico.
• That asymmetric impact has implications for high-level interdiction and drug enforcement: Seizures at higher market levels are less valuable to law enforcement precisely because drugs are less costly for traffickers to replace.
• In Mexico, the shift to synthetic fentanyl represents a major loss of income for farmers who grew poppies.
• The health implications in the United States are enormous, with significantly increased rates of overdose.
• The spread of fentanyl has also led to changes in domestic markets beyond a drop in price, including more frequent adulteration of illegal opioids with other dangerous substances and the spread of counterfeit pills containing fentanyl. In addition, fentanyl has made the prospect of using illegal drugs scarier for drug consumers.

“In our analysis, we walk through potential implications for both the supply side and the demand side of the market,” notes Shawn D. Bushway, professor of public administration at University at Albany, who coauthored the article. “We believe our work is the first explicit economic analysis of potential effects of fentanyl on the illegal market for opioids.”