Editor’s Note: Dr. Alex Eaton is a resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center. He is interested in medical education and health disparities research, specifically pediatric pain management in the setting of historic practices of race-based medicine. Alex is planning to pursue a fellowship specializing in pediatric critical care. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
A concerning new chapter in adolescent health has emerged with the rise of synthetic nicotine analogues—chemical compounds that mimic nicotine but sidestep current tobacco regulations. A new article and accompanying video abstract by Louisiana Sanchez, PhD, and colleagues at University of Southern California, the University of Michigan, and the University of Nebraska, being early released this week in Pediatrics, reveals that these products are already making significant inroads among young people, raising urgent questions for pediatricians, parents, and policymakers (10.1542/peds.2024-070484).
Unlike traditional nicotine products, synthetic nicotine analogues such as 6-methyl-nicotine (marketed as "Metatine" in products like Spree Bar) exploit a critical regulatory gap. These substances are exempt from the FDA's premarket tobacco product application requirements, allowing manufacturers to bring them to market without demonstrating safety or assessing their impact on public health—particularly among vulnerable youth populations.
The implications are troubling. Animal studies suggest that 6-methyl-nicotine may be more toxic than regular nicotine, particularly for the brain. They are also almost certainly more addictive than traditional nicotine products.
This study of 1,760 adolescents and young adults (AYAs) aged 14-25 years conducted in mid-2024 revealed alarming penetration rates for these new products. Within less than a year of market entry, 20.1% of participants were already aware of nicotine analogue vaping products, and 8.4% reported having used them.
Perhaps most concerning, these products aren't just reaching youth already engaged in tobacco use. Nearly 15% of AYAs who had never used any tobacco products were aware of these nicotine analogue products, suggesting that marketing efforts are successfully and impressively expanding beyond traditional tobacco user demographics.
The study also found that current tobacco users were at dramatically higher risk of being aware of these products and 6-38 times more likely to have ever used these products. This pattern of poly-substance use raises additional concerns about combined exposure effects that remain largely unstudied.
For clinicians caring for AYAs, these findings underscore the need for expanded substance use screening. Just asking about tobacco or cigarette use may no longer be adequate. Clinicians should consider asking specifically about synthetic nicotine products and be aware that even tobacco-naive youth may have encountered these substances.
The lack of age verification requirements for many of these products—with some companies relying only on basic honor systems—means that underage access remains largely uncontrolled. Marketing claims describing these products as "toxic-free" or posing "no additional risk" may mislead young people into perceiving them as safer alternatives to traditional tobacco products.
While federal regulatory action would provide the most comprehensive solution, several states are beginning to act independently. California recently enacted legislation subjecting nicotine analogues to the same regulatory standards as other tobacco products, providing a potential model for other jurisdictions.
As the landscape of nicotine products continues to evolve in unexpected directions, pediatric clinicians must remain vigilant about emerging threats to adolescent health. The rapid adoption of synthetic nicotine analogues among youth serves as a stark reminder that regulatory frameworks must evolve as quickly as the industries they seek to govern—particularly when the health of our most vulnerable populations hangs in the balance.
