On January 7, 2025, the American Heart Association (AHA) released a comprehensive policy statement examining the cardiovascular health implications of smokeless oral nicotine products. Published in Circulation, the statement evaluates emerging products such as tobacco-free nicotine pouches, lozenges, gums, tablets, and gummies, many of which contain synthetic nicotine.
This is the AHA’s first detailed update on non-combustible oral nicotine since its previous guidance on smokeless tobacco, reflecting the rapid evolution of the nicotine market and the growing popularity of these alternative products.
Key Findings and Scientific Assessment
The AHA statement presents the following core conclusions based on a review of current evidence:
- Addiction Potential
All smokeless oral nicotine products—whether tobacco-derived or synthetic—are considered addictive. Nicotine exposure through these products can reinforce dependence, particularly among youth and nicotine-naïve individuals. - Cardiovascular Biomarkers and Risk
Use of smokeless oral nicotine products is associated with changes in certain cardiovascular biomarkers, including blood pressure elevation and increased platelet activity. However, the evidence on long-term cardiovascular disease outcomes remains limited and inconsistent across product types. - Risk for Individuals with Pre-existing Cardiovascular Conditions
Among people with ischemic heart disease or cerebrovascular disease, use of some smokeless products (notably those containing tobacco) has been linked to increased all-cause and cardiovascular mortality. Data on tobacco-free and synthetic nicotine products remain insufficient. - Cancer and Oral Health Considerations
While the carcinogenic risk varies by product composition, the absence of combustion reduces exposure to many harmful toxins. That said, concerns persist regarding the potential for oral mucosal irritation and carcinogenesis, particularly with tobacco-containing products.
Policy and Clinical Implications
The AHA recommends that:
- Prevention of Initiation remains a top priority. Public health strategies must focus on preventing nicotine use among youth and non-smokers.
- Cessation Support using FDA-approved pharmacologic and behavioral therapies should be prioritized for individuals who use nicotine in any form.
- Regulation of Emerging Products should be expanded to include oral nicotine alternatives—particularly those containing synthetic nicotine, which currently occupy a regulatory gray area in many jurisdictions.
- Transparency and Research Requirements should be enforced for product manufacturers, including disclosure of ingredients and toxicological profiles.
A Need for Further Research
The policy statement highlights significant gaps in current scientific knowledge:
- Longitudinal studies are needed to assess the cardiovascular outcomes associated with long-term use of nicotine pouches and other non-combustible oral products.
- Chemical analyses must be conducted across a wider range of commercial products to identify potential carcinogens or cardiovascular toxins.
- Research should focus on high-risk populations, including individuals with underlying heart disease, to better stratify health risks.
GINN Perspective
This policy statement represents a meaningful step toward an evidence-based approach to evaluating smokeless nicotine products in the context of cardiovascular health. While the risks of combustible tobacco are well established and considerably higher, the statement underscores that non-combustible alternatives are not without health implications.
At the Global Institute for Novel Nicotine (GINN), we support efforts to distinguish between product categories based on relative risk and encourage regulators to apply proportionate, science-driven policies. We also reaffirm our commitment to advancing independent, transparent research that informs responsible product development, regulation, and consumer education.
Citation:
Dennison Himmelfarb, C. R., Benowitz, N. L., Blank, M. D., et al. (2025). Impact of Smokeless Oral Nicotine Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment. Circulation, 151(1), e1–e21.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001293
