Let's imagine the nicotine and tobacco market 10 years from now, in 2035

The innovators have not yet spoken their last word

Technological innovations have transformed the field of tobacco and nicotine, but we can speculate on the potential for further innovations in the years to come, and on their impact on behaviors, policy and society. E-cigarettes appeared over 20 years ago and heated tobacco products over 40 years ago (Premier, Eclipse), so these are not particularly recent technologies. Recent innovations include nicotine pouches (not exactly high-tech products), nicotine salts in e-liquids (but nicotine salt is a 19th-century technology), improvements to coils, heating blades and other hardware components of e-cigarettes and heated tobacco products, and endless variations of existing products (e.g. discartable puffs, a myriad of refillable devices). There are many competing manufacturers in the sector, and in principle competition should drive innovation. However, given the wide range of existing pharmaceutical products and dosage forms, we can only wonder why more new nicotine products haven't been brought to market.

So, what will the situation look like in 2035 ? The physicist Niels Bohr famously said that: "prediction is very difficult, especially about the future", but let’s give it a try.

New and old molecules:

We can speculate that synthetic nicotine (that is, not extracted from tobacco) will represent a growing share of the nicotine market, because it can be marketed as a “cleaner” or “tobacco-free” form of nicotine, and because it can bypass tobacco regulations (at least until authorities regulate it too).

We can hope that cytisine will be more widely used. Cytisine is extracted from plants (e.g. Cytisus Laburnum), it is a natural insecticide, like nicotine, and it has pharmacological properties that resemble those of nicotine and of the smoking cessation drug varenicline. Cytisine has been used as a smoking cessation drug since the 1960s in Eastern Europe, and recent studies show that it is safe, effective and cost effective for this purpose. We can speculate that cytisine will gain approval in more countries and will be offered as an affordable smoking cessation treatment everywhere.

Varenicline is an effective smoking cessation drug that was recalled by the manufacturer in 2021, but a generic version is now available in the UK. We can hope that generic varenicline will be made available in more countries in the coming years.

Let us predict that other molecules that are pharmacologically close to nicotine, cytisine and varenicline will be discovered and will be used as nicotine substitutes, either as smoking cessation / nicotine cessation drugs or for hedonic use, or to circumvent regulatory oversight. For example, some e-cigarette refill liquids contain 6-methylnicotine (6-MN), with the misleading “nicotine-free” claim, but there is little scientific evidence for its efficacy and safety, and 6-MN may be more toxic than nicotine. The emergence of these new molecules will require a constant adaptation of regulatory frameworks.

We can also speculate that some manufacturers of nicotine and tobacco products, having gained expertise in the field of nicotine delivery via various devices and galenic formulations, will diversify their production and produce inhalers, oral pouches, buccal films or any other device to administer not only nicotine but also medications, wellness products, cannabinoids or illicit drugs.

E-cigarettes and other inhalable products:

The e-cigarette market will continue to evolve, because it has a strong user base and because this is a highly competitive market with many manufacturers who are responsive to users’ preferences. Innovations may include more precise dosage control, biometric systems for personalized dosage or feedback, e-liquids with active substances other than nicotine, and cleaner aerosol with fewer harmful components. One limit to the development of new inhalable products is the irritant and aversive nature of nicotine, but nicotine salts are less aversive, and perhaps some new molecules that attenuate nicotine withdrawal symptoms will be less aversive than nicotine. We can imagine nebulizers or other technologies that aerosolize nicotine or other molecules without burning or heating them, or dry powder inhalers for pulmonary delivery, or improved nasal inhalers with either a liquid/aerosol or a powder.

Heated tobacco:

If current trends continue, heated tobacco products will continue to attract smokers and replace combustibles, because of changing social norms and perception of reduced risk. In Japan for example, the number of cigarettes sold decreased by half over the past 10 years, largely replaced by heated tobacco products. Currently, heated tobacco products are used almost exclusively by former and current smokers. But this group shrinks over time, as adult smokers quit, switch to non-combustible products or die. The future of heated tobacco will depend on their ability to attract young people, a bleak perspective. If cigarettes eventually become a marginal product or disappear from some markets or in some subgroups, heated tobacco products will then become the most toxic of all tobacco products (because pyrolysis occurs even if there is no combustion), and heated tobacco could then replace cigarettes as the most vilified and controversial tobacco product.

Oral and ingestable products:

The current growth of the nicotine pouches market is spectacular, and this trend is expected to continue, driven by health concerns, discretion, ease of use and the availability of a wide variety of products. We can expect a further diversification of pouches (flavors, nicotine strength, functional additives) and distribution channels. We can speculate that other new oral nicotine products will appear, with improved nicotine bioavailability, faster or slower nicotine release, and coatings or additives that reduce mouth irritation (e.g. Stingfree snus). Oral products with added ingredients to improve mood or relieve craving and other withdrawal symptoms could also appear. Mucoadhesive buccal films may also appear, they can have several layers for rapid or delayed substance release, or layers containing other active ingredients (e.g. to improve mood or to treat withdrawal symptoms). Many other oral products (nicotine wafers, gums, gummies, dissolvable tablets etc.) have been tested, some have been discontinued and others are currently available, and more such products may appear.

Whether there is a market for drinkable or edible nicotine products is doubtful, because much of the ingested nicotine is destroyed by the liver, and because drinking nicotine is dangerous. However, beverages with very high nicotine content were used during ritual ceremonies for centuries in pre-Columbian times. Here too, surprises can happen.

Traditional nicotine replacement therapy:

Traditional nicotine replacement therapy (NRT: gums, patches, tablets, sprays and inhalers) will still be relevant in 2035, but it will face a growing competition coming from products that are very similar in their principles and function (e.g. nicotine pouches vs. nicotine gums), but are much cheaper because they are not submitted to the same regulatory hurdles and manufacturing requirements. The frontier between medications and recreational products will be blurred even further, and the debate on whether nicotine products should be regulated as medications or as recreational products will intensify. To remain competitive, some manufacturers may develop new NRT products that deliver nicotine faster, or in larger amounts, or with better flavors, or via innovative devices.

The transdermal nicotine patch is an old technology (it was invented in the 1980s) that has not evolved much in the decades since. Microneedle patches may deliver nicotine more efficiently than current transdermal patches, with quicker release of nicotine, or controlled sustained release, or they could be used to deliver substances other than nicotine concomitantly, for smoking cessation, withdrawal relief, mood management or hedonic use.

Biosensors and online services:

Medication and wearable biosensors can be integrated (e.g. heart rate, stress levels, environmental cues and various user reactions, including withdrawal symptoms), and we can imagine that these technologies will also be used with nicotine delivery systems, for example for instant delivery when cravings are detected, or for personalized delivery patterns throughout the day. These combined drug-device systems can be integrated into tele-support and coaching, or customized by AI to deliver an optimal dose of nicotine. These electronic devices generate data, and companies can be expected to use this data to develop targeted marketing strategies. Manufacturers will also increasingly rely on data collected from users by more traditional means (smartphones, websites) for marketing purposes. This creates new challenges for privacy protection and regulators. The developers will also release more efficient and more effective smoking cessation applications on mobile phones and websites.

Other indications:

We can imagine that nicotine will be marketed not just for smoking cessation, withdrawal relief or hedonic use, but also for other indications, such as mood enhancement, cognitive enhancement (e.g. for concentration), as a stimulant, or to treat diseases, but nicotine treatment does not appear to be effective for ulcerative colitis, Parkinson and Alzheimer’s, even though it may have positive cognitive effects in people with cognitive impairment.

Nicotine has always been used as a mood enhancer and, in this debate, we should always bear in mind that the nicotine market (including new products) is largely a market for the vulnerable: the mentally ill, illicit drug users, the poor and less educated, the marginalized, etc. In my opinion, this point is not stressed enough.

Dual use:

With the continuous emergence of new products, dual/multiple use will become more common (i.e. the simultaneous use of two or several nicotine or tobacco products). Research will be necessary to assess whether dual / multiple use for each possible product combination and user category is beneficial (e.g. as a temporary preliminary stage before stopping smoking) or harmful (e.g. if it increases the user’s level of dependence). It will be a challenge to advise smokers on the most effective product combination to quit smoking, to inform consumers of the consequences of dual/multiple use, to scientifically assess the public health impact of dual/multiple use, and to regulate these products.

Consolidation:

There are currently many small manufacturers of nicotine products, and we can expect this market to consolidate, with mergers and acquisitions. This could stifle innovation, as innovation often comes from small companies competing against each other. We may fear that their massive investments and greater expertise will leave Big Tobacco as the main player after the elimination of companies less able to survive in a highly competitive and regulated environment, and that Big Tobacco will push its non-combustible products and continue to undermine traditional tobacco control efforts, as they always have, but this time with fewer and weaker private sector players to oppose them or compete with them.

Young people, gateway:

Young people tend to adopt innovations more quickly than older people do, and the proportion of nicotine users (all products combined) among young people may well increase (as it does in England). Thus, a major concern is and will remain use of these products by young people, in particular young non-smokers. It remains to be seen whether these new products simply replace cigarettes, or whether they are also a gateway to smoking. The gateway theory is a causal theory, but in the absence of experimentation (i.e. randomized trials) it will remain exceedingly difficult to prove whether the association between new product use (e.g. vaping) and smoking is causal. For example, the fact that an increasing proportion of young smokers first started using nicotine via e-cigarettes does not prove that youth vaping causes youth smoking, as antecedence (i.e. the cause must precede the effect) is a necessary but not a sufficient element to prove causality. I explain this in more detail in my article published in the journal Addiction and entitled Gateway effects and electronic cigarettes.

If combustible cigarettes become a marginal product (e.g. only 1% of young women in Norway smoke), it will be interesting to see whether these new products can sustain the existence of a nicotine market in a smoke-free society (i.e. in a situation where no users started to use nicotine with cigarettes or became addicted through cigarettes). We should think thoroughly about whether a smoke-free nicotine market is socially acceptable, as it is not unlikely that such a market will become reality, and this would have profound consequences.

Ageing:

The burden of smoking-related disease is borne largely by people over 60, and the aging of the baby-boom generation means that there will be an increase in cases of older people with smoking-related diseases, with rising healthcare costs and increasingly complex home care (e.g. for people with multiple chronic conditions, including COPD). Specific smoking cessation interventions may need to be developed for this population, and the tobacco and nicotine industries will probably develop specific marketing strategies and for this population.

Cessation support:

Smoking cessation support and treatment will remain as important as ever, and we can only hope that this field will be sufficiently innovative to meet the challenges posed by the constant arrival of new technologies. Integrating these new products into existing treatments will face ethical, ideological and technical challenges, as well as investments in basic and continuing training for healthcare professionals.

We hope that treatments will be better reimbursed in the future. On way to do it is to include smoking cessation treatments in health care packages, e.g. for patients with cardiovascular diseases or cancer.

One intervention which is not used enough is financial incentives: they are effective and their effect is maintained several months after the last reward has been distributed. Why not give prevention money directly to smokers (often from lower social classes) instead of giving it to communications agencies who almost always have competing interests (and whose collaborators and investors are rather middle- or upper-class). For my own prevention projects, I've always had difficulty finding communications agencies that had never worked with the tobacco or alcohol industries and that were committed never to work with them.

Numerous ongoing studies are evaluating the effectiveness of vaping cessation interventions. This may be useful, but one wonders whether efforts to wean people off vaping are diverting resources from efforts to wean people off smoking, and whether this could be counterproductive given limited resources and the much lower risk of vaping compared with smoking.

Consequences of the replacement of cigarettes:

Smoking prevalence is declining globally across all age groups, as stricter tobacco control policies are implemented, social norms change, and cigarettes are ostracized and replaced by non-combustible products (e.g. snus, heated tobacco). Consequently, the survival of the tobacco and nicotine industry will depend on its ability to attract young people to offset the decline in the number of adult smokers. Once there are no more cigarettes (or very few), these products can no longer be presented as smoking cessation aids or reduced-risk substitutes for cigarettes. This will make these products increasingly controversial.

As these new products gain a greater share of the nicotine market at the expense of combustible products, we can assume that nicotine will become less associated with the illnesses caused by burning tobacco. Since the main obstacle to nicotine use (i.e. the health risks) will be largely eliminated, the number of nicotine users could increase. For example, among young people in the UK, the total number of smokers + e-cigarette users is currently increasing. However, this is not the case in every country, e.g. in the US, both smoking prevalence and vaping prevalence declined in young people in recent years. In Switzerland, the prevalence of e-cigarette and heated tobacco use increased in recent years, while the use of combustible cigarettes decreased, but the total number of users of these 3 products decreased.

Cigarettes will not disappear, but given the range and quality of new products, cigarettes will increasingly be considered an obsolete and inferior product. As a result, we can speculate that smoking will persist only in specific subgroups of “hardcore smokers” who cannot quit or do not want to quit, such as those with the strongest levels of nicotine dependence, people with mental health problems (who currently buy 40% of all the cigarettes sold in the USA), or people using illicit drugs. Smoking may also persist for cultural reasons, or because cigarettes are more effective at delivering nicotine, or are cheaper. The fact that low-risk, non-combustible products are likely to end up dominating the nicotine and tobacco market will have far-reaching consequences for the way nicotine is viewed, and for prevention, regulation and policy. If smoking-related mortality and the related healthcare costs fall dramatically because there are few smokers left, tobacco and nicotine may become less of a priority, and the objectives of public health policy may shift from reducing mortality and morbidity to reducing the number of nicotine users. But while the legitimacy of a policy that succeeds in reducing mortality is indisputable, a policy aimed at reducing nicotine consumption will be less legitimate and more controversial if such consumption has only a minimal impact on health.

To compensate for falling smoking rates, the industry will also be looking for new markets. With the emergence of a middle class with sufficient purchasing power in many Asian, African and Latin American countries, the marketing of nicotine and tobacco can be expected to intensify in these regions.

Communication and controversy:

With the expected increase in the number and types of nicotine products, as well as the number of indications for nicotine use and the possible addition of other active substances to products, it will become increasingly difficult to accurately communicate the risks of each product, galenic formulation and device. Tobacco harm reduction will remain as controversial as ever, for reasons I explained in another post. Honest, balanced and well-informed communication will need to be designed for each audience (the general public, opinion leaders, policy-makers, healthcare professionals, manufacturers and vendors) on the addictive potential, toxicity, gateway potential, efficacy for smoking cessation and the potential of each product to replace cigarettes. This will only be possible if a concerted effort involving all stakeholders is put in place, and if this effort leads to compromise.

Policy and regulation:

Regulating these new products in a proportional and effective manner will be increasingly challenging because of the increasing complexity of this market, the changing status of nicotine in society, and the difficulty of reaching a consensus on policy goals (reducing mortality vs. reducing nicotine use, protecting young people vs. offering lower-risk alternatives to smokers). Participation of all those involved will be crucial (“nothing about us without us”) to reach acceptable and effective solutions to these new and old problems.

We can speculate that many countries will continue to ban some products, or some flavors, or set limits to nicotine concentrations (e.g. 20 mg/mL), but that in response to these bans, manufacturers, vendors and users will continue to find workarounds, including DIY, black market, or the separate sale of flavors or nicotine boosters. We can also fear that companies will continue to use innovative marketing strategies, including on social media, to reach young consumers and to circumvent advertising bans. They will modernize their marketing efforts using the latest technologies and social networks, as they have always done, and this may increase their ability to target specific audiences, in particular the young people on whom their future depends.

We hope that taxation and regulations will consider the continuum of risk and be proportional to the harmfulness of each product. Hopefully, regulations will also consider the environmental impact of products, the recycling of used products (e.g. batteries) or the use of biodegradable materials.

Even though there is some harmonization of regulations of tobacco control measures through the Framework Convention on Tobacco Control (FCTC, an international treaty under WHO), laws are national and differences between countries will create both challenges for international companies and incentives for illicit trade. Let us hope that the FCTC leadership and WHO will change their attitude and will become more open to tobacco harm reduction.

Research:

Tobacco harm reduction is controversial, and much of the research on e-cigarettes is biased. It will remain as important as ever to have sound scientific research, independent of manufacturers, vendors and private donors with a political agenda (e.g. Bloomberg) to document the risks of these new products, their effectiveness for smoking cessation, their prevalence of use in various population subgroups, particularly vulnerable groups such as people with poor mental health, and their effects on health disparities. It will be equally important to assess the effects of laws, regulations and public health interventions, to ensure that they are effective and do not have unintended consequences, in particular that they do not inadvertently increase smoking, that they are not socially regressive and do not have a disproportionate impact on vulnerable groups.

Conclusion:

Technological innovation is one of the main drivers of change in this area, as in all other aspects of modern life, but it is not the only one. Traditional approaches (taxation, ad bans, smokefree policies, addiction treatment, education and health warnings, i.e. the mpower package of actions within the WHO’s FCTC) will continue to be important to decrease smoking-related mortality and morbidity. These traditional approaches work, as shown for example by the facts that very few young people in the USA, or very few young women in Norway now smoke. Let’s hope that people in charge will be wise, knowledgeable and responsive enough to adapt the public health response to technological innovations in a timely manner, always bearing in mind the need to respect both users and non-users.

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I value your opinion and feedback, so please let me know if you see any errors or omissions in this article.