Health outcomes associated with the use of e-cigarettes, heated tobacco products, and nicotine pouches

Tobacco consumption is the single most preventable cause of illness and death in the European Union, accounting for almost 520 000 deaths in 2021. The emergence of new tobacco and nicotine-related products, including electronic cigarettes (e-cigarettes), heated tobacco products, and nicotine pouches, has raised concerns about their potential health effects and role in smoking initiation and cessation. This report synthesises the evidence and interpretations from authoritative public health organisations, national health authorities, and official risk assessment bodies, on the associations between these emerging products and health outcomes, smoking initiation, and smoking cessation.
Given the limited time these products have been on the market, the current evidence is largely restricted to short- and medium- term health outcomes, while there is lack of long-term evidence, for which the assessed reports highlight the need for further research to enable accurate risk estimation. E-cigarettes are not harmless and are associated with adverse short- and medium-term health outcomes, including cardiovascular and respiratory outcomes. There are also concerns surrounding the inhalation of nicotine, together with metals and other substances with unclear toxicity. Heated tobacco products, though there is less evidence available, have been associated with similar health risks as e-cigarettes. In turn, nicotine pouches lack sufficient evidence regarding their health effects due to limited time on the market. Finally, the role of these products in smoking initiation and cessation is still unclear, with some studies suggesting that e-cigarettes may act as a "gateway" to smoking, particularly among youth. Our analysis also suggests that e-cigarettes may be linked to smoking initiation. Evidence on this potential "gateway" effect is currently lacking for heated tobacco products and nicotine pouches, and the role of these products in smoking cessation remains unclear.
This report concludes that several of the examined sources recommend a precautionary approach towards these emerging products due to the concerning associations with short- and medium-health outcomes and the lack of long-term evidence. Furthermore, long-term follow-up is necessary to accurately estimate their health risks. Effective tobacco control policies and public health strategies are crucial for reducing the burden of tobacco-related diseases in the European Union, and the insights from this report can inform and support such efforts. [Author's abstract]