Joseph Hart 27 September 2023


How often have you seen a health body talk about smoking alternative products and then hand-wave them away because we don’t have enough long-term research to say they are safe? I’ve personally lost count.

The frustrating thing about these arguments is that novel products will never come with 20 years of clinical research behind them. Instead, health experts will sit on their hands and let people smoke combustible cigarettes instead of recommending alternative harm-reduction products. Deaths and smoking-related illnesses pile up because many medical professionals are afraid to stick their necks out.

Now, I want to be clear. I am sympathetic. I know scientific and medical people; many are cautious about nailing their colours to the mast unless they have absolute certainty. I respect that while also seeing the inadvertent harm these ideals can cause. 

However, an exciting new research paper, Applications of biomarkers of exposure and biological effects in users of new generation tobacco and nicotine products: Tentative proposals (Scherer, 2023), could be here to change all of that by offering an alternative to long-term studies.

What does the paper say?

The authors lay out the problem. There are 1 billion global cigarette smokers and 8 million associated deaths annually. Most alternative smoking products are less than 10 to 20 years old. As the paper states, “Therefore, particularly for some smoking-related diseases, epidemiological studies to test harm reduction potential are only now becoming feasible.”

Epidemiology is the study of how and why diseases occur in different groups of people. It’s a great way to determine how food, products, or other lifestyle factors contribute to health outcomes. However, it takes decades to establish effects with confidence. But this is where biomarkers might come in useful.

For the sake of clarity, a biomarker is a “defined characteristic that is measured as an indicator of normal biological processes, pathogenic processes or responses to an exposure or intervention.” Or, to put it more simply, biomarkers are measurable substances in our bodies that give information about our exposure to certain compounds and potential physiological effects. 

One significant advantage of biomarkers is that they’re easy to obtain because they are present in urine, saliva, and blood.

As the paper suggests, two types of biomarkers can be used in nicotine product research. They are:

• Biomarkers of exposure (BOE)

• Biomarkers of biological effect (BOBE)

How biomarkers can help with the research of smoking-alternative products

The most obvious and exciting benefit of using biomarkers is that they can help speed up research into the health effects of smoking alternative products. Researchers can use them alongside epidemiological studies or even in place of these long-term scientific investigations.

While they have been used in the US to help authorise a few heated tobacco products (HTP) and electronic cigarettes, they have yet to be used for nicotine pouch applications. Overall, the main impact of these studies has been to clear the way for these products to state in their marketing materials that they are less harmful to public health than combustible cigarettes. The public needs the right information to make healthier choices, so these trials are very welcome.

How biomarkers can affect insurance policies

Currently, insurance companies typically lump users of smoking-alternative products and cigarettes in categories when determining premiums. Obviously, this is outrageous. The relative risk of snus or nicotine pouches is dramatically different from smoking. It’s like being penalised for being a skydiver just because you take a few flights each year.

Biomarkers could help insurance companies properly assess the policy risk by giving a better idea of the true impact of their customers’ nicotine-delivery methods. 

Another point of note is that 91% of insurers let customers self-declare their use of nicotine products. If nicotine pouches and cigarettes are treated the same, i.e., with high annual policy prices, then pouchers are incentivised to fudge the truth. However, should they get ill, these omissions could impact the legitimacy of their policy. Biomarkers could provide a single source of truth that benefits all parties.

Final thoughts

The wheels of justice move slowly, but nothing matches the grinding pace of an epidemiological study. Biomarkers could offer a way to evaluate the risk of novel smoking-alternative products and help scientists and policymakers better understand the relative risk of harm-reduction products like nicotine pouches over shorter time frames. Ultimately, this could save lives.