New studies show that white snus affects the oral mucosa differently from traditional snus. At the same time, there is growing interest in how product development can reduce irritation – an issue that entrepreneur Bengt Wiberg has been championing for several years.
People who use white snus are less likely to develop changes to their mucous membranes than those who use traditional portion snus. This is shown by a new clinical study conducted by researchers at the Karolinska Institute. At the same time, the study shows that white snus causes different changes to the oral cavity than traditional snus.
Almost 300 participants
The study involved 272 people divided into three groups: users of tobacco-free nicotine pouches, users of traditional portion snus, and a control group who did not use any of the products. Smokers, as well as those using nicotine replacement therapy, were not allowed to take part in the study. The researchers examined the participants’ oral mucosa and dental health through clinical examinations.
The results showed that changes to the mucous membrane were common in both snus groups, but more common amongst users of traditional snus. 79 per cent of users of nicotine pouches had some form of local change, compared with 89 per cent amongst traditional snus users. Furthermore, the changes were generally less extensive among users of tobacco-free pouches.
Different types of change
The changes occurred almost exclusively where the pouch was placed under the lip. However, the researchers observed no clear differences between the three groups in terms of caries, dental status or other more general measures of oral health.
One important difference, however, was that users of tobacco-free nicotine pouches were more likely to show redness of the mucous membrane (erythema) and reported more oral discomfort. Among users of traditional portion snus, on the other hand, hyperkeratosis – a thickening of the mucous membrane, or ‘snus lesions’/‘snus-related changes’ as it is usually known – was more common.
The results do not necessarily mean that nicotine pouches cause either fewer or more severe harm than traditional snus. Rather, the study suggests that the products affect the oral mucosa in different ways. Redness and irritation are often signs of an ongoing inflammatory reaction, whilst hyperkeratosis is a tissue adaptation that develops over a longer period of time.
The researchers also investigated gingival retraction, that is, receding gums, but found no statistically significant differences between the snus groups.
”Less harmful than smoking”
At the same time, the researchers emphasise that the local changes to the mucous membranes observed in both snus users and users of nicotine pouches must be distinguished from the diseases that have long been linked to smoking.
“Cigarette smoking is clearly associated with an increased risk of, amongst other things, tooth loss, gum disease, tooth decay and oral cancer. However, epidemiological studies of Swedish portion snus have not been able to demonstrate any link to diseases such as tooth decay, tooth loss or cancer of the mouth and throat. The local changes to the mucous membranes that may occur are therefore a different type of effect from the serious diseases associated with smoking,” the researchers write.
”Should not be accepted”
For Bengt Wiberg, founder of Stingfree AB, the difference between smoking and using snus is important, not least because many people use oral nicotine as a tool to help them stay smoke-free. At the same time, he has been working for some time on issues relating to oral health in connection with the use of both snus and nicotine pouches from a harm-reduction perspective, within the snus category. And he believes that local irritations should not be dismissed simply because the products pose lower health risks than cigarettes.
“Irritation and changes to the mucous membranes should not be accepted as an inevitable cost for those switching from cigarettes to nicotine pouches. It is, after all, remarkable that so many people, particularly young people, are experiencing changes that could lead to problems in the future. If we can reduce local tissue irritation through better product design, we will also remove one of the last obstacles to genuine harm reduction,” says Bengt Wiberg to Vejpkollen.
According to Bengt Wiberg, the irritation is likely to be caused by a combination of factors. He refers, amongst other things, to research that has identified a high pH level, mechanical friction against the gums and certain flavourings as possible causes of local changes to the mucous membrane.
“A higher pH level means that nicotine is absorbed more effectively through the oral mucosa, but at the same time it can increase local irritation,” says Bengt Wiberg.
Supported by a previous study
The Karolinska Institute study also reinforces the findings of another, smaller study reported by Vejpkollen earlier this year. That study tested a new type of nicotine pouch with a protective barrier against the gums for five weeks. The test subjects were dentists who used snus, and the pouch itself is an invention launched by Bengt Wiberg after he himself had developed gum problems following years of using snus.
Participants in the study reported less irritation, fewer changes to the oral mucosa and reduced inflammation of the gums. The study was small and lacked a control group, but the results suggested that the design of the bag itself may play a significant role in how the oral mucosa is affected.
“For most people, what they see in the bathroom mirror every morning means more than abstract health statistics. For someone who gave up smoking several years ago, the long-term health benefits are already a thing of the past – so the visible irritation on the gums right here and now becomes a very real and urgent problem,” Bengt Wiberg tells Vejpkollen.
Calls for long-term studies
The researchers behind the Swedish study are now calling for larger, long-term studies to better understand how different types of nicotine pouches affect oral health over time. A study is also currently underway at the University of Gothenburg, investigating redness and irritation following reports from several users of acute changes under the lip after using nicotine pouches.
The study by the Karolinska Institute was funded by the Public Dental Service.
