Increase in poisonings from new tobacco and nicotine products

Poisonings due to nicotine pouches, snus, heated tobacco and aromatic beads have increased in France since 2020, according to a report from poison control centres carried out by ANSES. Adolescents and young children are the first to be affected, but adults are also affected. ANSES is advocating better supervision of these products.

In the countries Anglo-Saxons, the proliferation of new tobacco and nicotine products has been accompanied by an increase in cases of poisoning. A study by the US poison control centers, published on October 31, 2023, reported 6,581 cases of poisoning by e-liquids and electronic cigarettes for the year 2023 alone, a figure that has increased significantly over the 2010s.[1].

This trend is also expressed in France, as indicated by a toxicovigilance study report published by the National Agency for Food, Environmental and Occupational Health Safety (ANSES)[2]The rapid growth in the number of reports collected led the public agency to initiate a self-referral on this subject.

Reports increasing since 2020

The ANSES report is based on data from poison control centres. It details the reports listed for five categories of tobacco and nicotine products: heated tobacco, chewing tobacco, nicotine pouches[3], snus[4] and aromatic balls[5]. For the period between 1 January 2017 and 31 December 2022, 295 cases were recorded: 12 cases for heated tobacco, 98 for chewing tobacco, 47 for snus and nicotine pouches and 138 cases for aromatic beads. These cases have been increasing since 2020, particularly for snus, nicotine pouches and aromatic beads. The proportion occupied by aromatic beads is all the more worrying since these products have recently arrived on the market. Chewing tobacco is not new, but gives rise to a certain number of reports, the packaging not being secure.

Accidental ingestions primarily affect very young children. They involve in particular heated tobacco sticks, chewing tobacco (median age: 1 year) and aromatic beads (median age: 3 years). Adolescents are more likely to be victims of intentional consumption of snus or nicotine pouches (median age: 14 years). Less commonly, adults have encountered problems with snus, sometimes with nicotine pouches and most often with aromatic beads. For the latter, these were accidental ingestions by confusing them with confectionery or following incorrect insertion into the filter of a cigarette.[6].

The symptoms noted were of low (82.6%) to moderate (17.4 %) severity. They were mainly nicotine syndromes of variable severity, with one or more symptoms: nausea, palpitations, tachycardia, dizziness, tremors, vomiting (sometimes prolonged with risk of dehydration), hypotension, convulsions and hypotonia. Cases of low-severity ocular projection have also been reported for aromatic beads.

Regulatory deficiencies on nicotine pouches and flavor beads

Anses acknowledges that the number of cases reported is inevitably underestimated. It only reflects reports sent to poison control centres, with many other situations not being reported.

The public agency draws particular attention to the nicotine pouches, which are not subject to harmonized regulations between European countries, nor to specific supervision in France despite the fact that they are nicotine products, which are themselves regulated. The agency points out the promotion of these nicotine pouches on social networks and calls on the educational community to alert parents, children and adolescents about new tobacco and nicotine products. Anses recalls that a bill banning nicotine pouches was filed in June 2023.

Aromatic beads are subject to CLP regulations.[7] on irritant substances, whose labelling and packaging obligations are not respected. Anses calls for compliance at a minimum of this regulation for aromatic beads, which it considers to be products that circumvent the ban on flavored cigarettes.

Keywords: Anses, poisoning, poison control centers, heated tobacco, chewing tobacco, snus, nicotine pouches, nicotine pearls

M.F.

[1] E-cigarettes and liquid nicotine, America's Poison Center, accessed 1^er December 2023.

[2] Tobacco products, related products and flavourings. Analysis of cases recorded by poison control centres (from January 2017 to December 2022), ANSES, toxicovigilance study report, September 2023, 40 p.

[3] Nicotine pouches are used like snus but do not contain tobacco.

[4] Snus are tobacco pouches that are placed between the lip and gum. They are often confused with nicotine pouches. Banned in the European Union (except Sweden), they are the subject of illicit sales online in many European countries.

[5] Aromatic beads are sold separately from cigarettes. They are placed in the cigarette filter and release aromas when bitten. These aromatic beads appeared in Europe after the ban on menthol cigarettes, in May 2020. Not to be confused with nicotine pearls, which appeared in France in May 2023.

[6] Nicotine or tobacco pouches: a risk for young people, ANSES, published on November 30, 2023, consulted on 1^er December 2023.

[7] Classification, Labeling and Packaging – Regulation No 1272/2008 of the European Parliament on classification, labelling and packaging of chemical substances and mixtures.