First study in Latvia on the harmful effects of alternative nicotine products
In her doctoral thesis, Sintija Miļuna-Meldere explores the impact of smokeless tobacco, nicotine pouches, and electronic cigarettes on oral health. The aim of the study was to evaluate the effects of these products on the oral microbiota, inflammatory biomarkers in saliva, and overall oral health.
Tobacco addiction has a significant impact on human health, complicating the prevention, diagnosis, and treatment of oral diseases. Latvia has one of the highest smoking rates in the EU – according to the Centre for Disease Prevention and Control (CDPC), 36% of men and 23% of women aged 15–74 smoke cigarettes. Alternative nicotine products are becoming increasingly popular as substitutes for conventional cigarettes, attracting even those who have never smoked before. Their impact on oral and general health remains poorly understood, as these products have only recently entered the market.
‘At present, this is the only study in Latvia examining changes in oral health among users of smokeless tobacco, nicotine pouches, and e-cigarettes. The findings confirmed my hypothesis that alternative nicotine products induce changes in the oral mucosa and microbiota and increase inflammatory biomarkers in saliva,’ explains Sintija Miļuna-Meldere, author of the thesis.
Objectives of the thesis:
- To investigate and evaluate the use behaviour of smokeless tobacco (ST), nicotine pouches (NP), and electronic cigarettes (EC) among 18–35-year-olds.
- To conduct visual and histological examination of the oral mucosa in users of ST, NP, EC and in a control group.
- To assess the oral microbiota in ST, NP, EC users and compare it with that of the control group.
- To determine the levels of inflammatory biomarkers in the saliva of ST, NP, EC users and compare them with those in the control group.
Alternative nicotine products used in Latvia
Smokeless tobacco (ST) is prohibited in Latvia, but it is still used. It is brought into the country illegally and sold on demand. ST is available in the form of pouches or chewing tobacco and must be refrigerated. It is typically placed under the lip or behind the cheek. In addition to tobacco, ST contains nitrosamines – known carcinogens believed to be primary agents in the development of lung and oral cancers. It also contains hazardous substances such as arsenic, cadmium, benzopyrenes, nicotine, and formaldehyde, as well as a variety of flavourings to enhance user appeal.
Nicotine pouches (NPs) contain powdered nicotine and other ingredients. The nicotine content varies depending on the manufacturer and brand. NPs are legally available in Latvia and other EU countries. Although manufacturers recommend usage for up to 30 minutes, respondents reported using them for up to 90 minutes, often using multiple pouches at once. Some even use them during physical activity or sleep, increasing the risk of aspiration and dental caries. The long-term health effects of such excessive use remain unknown.
Image: Nicotine pouches
Electronic cigarettes (ECs) deliver vapour rather than smoke. They contain nicotine-infused liquid, chemical compounds, and flavourings. Disposable e-cigarettes (commonly known as vapes) have become particularly popular among young people and children. According to the CDPC, 51% of Latvian adolescents aged 13–15 have tried disposable e-cigarettes. These products pose risks to the developing nervous system and are associated with an increased likelihood of future substance use. Their popularity continues to rise, even among those who have never previously used tobacco products.
Key findings
ST and NP products are used more commonly by men, typically in higher doses and for longer than recommended, often during sport or at night. ECs are more frequently used by women, including those with no history of tobacco or nicotine use.
In ST and NP users who used at least 5–10 pouches daily for over 5 years, mild dysplasia or precancerous lesions were observed at the site of application. These included keratosis, mucosal thickening, cell necrosis, connective tissue oedema, and chronic inflammatory infiltration. No mucosal changes were found in EC users.
Quantitative and qualitative changes in oral microbiota were observed in the saliva and gum pockets of ST, NP, and EC users. These included increased presence of periodontal pathogens, a known risk factor for periodontitis. Interleukin-6 (IL-6) levels in saliva were significantly higher in ST users and correlated with mucosal changes. Inflammatory biomarkers were also elevated in this group.
Next steps
Given the recent emergence of nicotine products and their popularity among young people and adolescents, it is important to inform dentists, general practitioners, sports coaches, educators and parents of children about the harmful effects of these products on oral and general health. The CPDC should raise public awareness of the dangers of tobacco and nicotine products.
Dentists are among the first healthcare professionals able to detect early changes in oral mucosa and educate patients on the harmful effects of nicotine product use. To support this role, an outpatient monitoring form is needed for documenting nicotine product use and tracking mucosal changes. Saliva testing should be incorporated into routine dental visits, as it is a non-invasive method for evaluating both periodontal pathogens and inflammatory biomarkers.
Further research is required into the long-term effects of these products—especially in children and young people—as well as the consequences of using multiple nicotine products simultaneously. Monitoring oral mucosal recovery after cessation is also a key area for future study.
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