ASH Scotland, the independent arm of Action on Smoking and Health, has released a guide to help midwives advise their patients about nicotine use during pregnancy. Sadly, it does more to confuse than educate.
Schrodinger’s nicotine
If you read a lot of public health information about nicotine, you’ll notice that nicotine often exists in a kind of superposition among health officials. Depending on the level of quackery we are dealing with, nicotine can be a lethal cancer-causing compound, something that destroys developing minds, or, in the case of ASH Scotland’s guidance, something that is safe to use during pregnancy.
Yes, that’s right, ASH has said of nicotine, “like any medicine, there may be minor side-effects to some NRT products.” Now, you might ask, is this the same compound that has been getting a public kicking from governments, NGOs, and public health officials? Yes, yes, it is. But there is a catch.
You see, as ASH Scotland explains, “Medicinal NRT products are far safer than tobacco or commercial nicotine products (e.g. vapes, nicotine pouches, etc.).”
Let’s address that claim.
Is medicinal NRT far safer than commercial nicotine products?
Obviously, we won’t address whether tobacco or medicinal NRT is the safest. It’s pretty clear that combustible cigarettes are lethal, and especially inadvisable during pregnancy. What I’d like to address is the claim that medicinal NRT is “far safer” than nicotine pouches.
Public health and regulatory bodies (such as the US CDC and some obstetric bodies) advise that pregnant women should not use nicotine pouches at all, primarily because any nicotine exposure in pregnancy can impair fetal growth and is associated with higher risks of adverse outcomes. Additionally, these groups also advise against consumption because pouches have not been evaluated as cessation medicines.
Despite claims that “any nicotine exposure at all” can lead to complications during pregnancy, ASH Scotland insists that medicinal NRT comes with minor side effects. So, which is it?
What does the evidence say?
ASH Scotland seems very certain that medicinal NRT is “far safer” than commercially available nicotine. However, as a starting point, medicinal NRT, such as patches, gum, lozenges, sprays, inhalators, etc, is the same chemical compound nicotine base, no matter whether it is extracted from tobacco or made synthetically.
However, there are three areas where they suggest that medical and commercial nicotine differ. Let’s look at those and evaluate whether that adds up to being “far safer”.
Chemical form and purity
Some research tries to split the difference between medical NRT and commercial nicotine by suggesting it’s all a matter of purity. In other words, NRT products must meet pharmacopeial standards, typically around 99% purity with very tight limits on specified impurities.
However, many nicotine pouches also use pharma-grade nicotine. However, some tests have shown that roughly half of the tested products do have low traces of TSNAs. While many of the studies anonymise the brands, this is an area where transparency could do a lot to help the consumer make the right choices for themselves.
Dose and delivery
Medical NRT products use low doses. This fact partially explains why products are less effective in stopping smoking trials than vapes and pouches.
I’m not sure this constitutes one product being far safer than another. It assumes that medical NRT products are taken as directed. Low-strength pouches, used in a reasonable way, could surely achieve the same effect. On the flip side, if the nicotine levels are not satisfying, the consumer is at a greater risk of returning to cigarettes.
Regulation
Finally, medical NRT is clearly regulated in the UK by the Medicines and Healthcare products Regulatory Agency (MHRA). Nicotine pouches are generally sold as consumer products, so they don’t have the same robust checks and balances. However, with the right oversight and regulations, this problem is more than solvable.
Final thoughts
ASH Scotland’s Midwives guide steps beyond the evidence to make a value judgement that can’t really be backed up. In theory, its weaker products should carry less risk, but not enough to be deemed “far safer” by any sane interpretation of the phrase.
The fact is, the evidence is not quite there. Of course, until more research is done, I’d urge anyone who is pregnant to exercise caution.
