Is it safe for a patient with a kidney transplant to use nicotine pouches?

Nicotine Pouches and Kidney Transplant

Nicotine pouches should be avoided in kidney transplant recipients, as any form of tobacco or nicotine product use is harmful and associated with worse patient survival, graft survival, cardiovascular disease, and malignancy. 1

Evidence Against Any Tobacco/Nicotine Use

The KDIGO guidelines explicitly state that "any tobacco use is harmful" in kidney transplant recipients (KTRs), not just cigarette smoking. 1 While nicotine pouches may seem like a safer alternative, they still deliver nicotine systemically and fall under the category of tobacco products that should be avoided.

Key harms documented in kidney transplant recipients who use tobacco/nicotine products include:

• Reduced patient survival - tobacco use is an independent risk factor for death 1
• Reduced graft survival - smoking increases risk of graft failure with relative risk ranging from 1.06 to 2.3 2
• Increased cardiovascular disease - including ischemic heart disease, cerebrovascular disease, peripheral vascular disease, and congestive heart failure 1
• Increased malignancy risk - post-transplant cancers are more common in tobacco users 1
• Worse kidney function - former smokers show worse eGFR trajectories over time compared to never smokers 3

Clinical Approach

Screen and counsel all kidney transplant recipients about tobacco/nicotine use at every visit:

• Screen during initial transplant hospitalization 1, 4
• Screen at least annually thereafter 1, 4
• Document all forms of tobacco/nicotine use including pouches, not just cigarettes 1

Offer treatment to all patients using any nicotine products: 1, 4

• Provide counseling and develop a quit plan 4
• Arrange pharmacotherapy for nicotine cessation 4
• Use nicotine replacement therapy (NRT) as a bridge to complete cessation, not as a substitute for continued nicotine use 1, 4

Important Distinction: Nicotine Replacement Therapy vs. Nicotine Pouches

There is a critical difference between using nicotine pouches recreationally versus using FDA-approved nicotine replacement therapy for smoking cessation:

• Nicotine replacement products (gum, patches, lozenges) are safe and effective when used as part of a structured smoking cessation program in kidney transplant recipients 1, 4
• These products can be used in combination for maximum effectiveness 1, 4
• No drug interactions exist between nicotine replacement therapies and immunosuppressive agents 1, 4
• The benefits of smoking cessation far outweigh any theoretical risks from temporary NRT use 4

However, nicotine pouches used as an ongoing nicotine delivery system (not for cessation) perpetuate nicotine addiction and do not eliminate the cardiovascular and other risks associated with chronic nicotine exposure. 1

Long-Term Effects

Even former smoking has lasting negative effects on transplant outcomes. Studies show that patients with a history of smoking before transplantation have increased hazard of graft loss (adjusted HR 1.60) and death-censored graft loss (adjusted HR 2.29) compared to never smokers. 3 This suggests that any nicotine exposure, even if discontinued, may have persistent detrimental effects on the transplanted kidney.

Bottom Line

The goal should be complete nicotine abstinence, not substitution with nicotine pouches. If the patient is currently using nicotine pouches as a substitute for cigarettes, transition them to FDA-approved nicotine replacement therapy as part of a structured cessation program with the explicit goal of complete nicotine discontinuation. 1, 4