In this instalment of our Harm Reduction Heroes series, Snusforumet talks to Konstantinos Farsalinos, the Greek cardiologist and nicotine researcher whose sweeping new review of nicotine pouches concludes they are likely the safest tool yet developed for smokers who can’t or won’t quit – and who pulls no punches about the ideological forces he believes are distorting the science. 

When Konstantinos Farsalinos sat down to write his latest paper, he had a template already waiting: a review he had published a decade earlier on e-cigarettes that asked almost exactly the same question.  

The approach was the same. Only the product has changed. 

The Greece-based cardiologist, affiliated as an external research associate with the University of West Attica and the University of Patras, has spent more than a decade producing peer-reviewed research on reduced-risk nicotine products – over 110 studies in total.  

His long experience gives him a deep familiarity with the evidence base, as well as a persistent frustration with what he sees as a field too often captured by ideology. 

People who are ideologically opposed to nicotine will never stop making arguments against it.

“People who are ideologically opposed to nicotine will never stop making arguments against it,” he explains. 

“I think it is important to bring back common sense and an evidence-based approach to public health discussions. Because the debate in the EU today is completely irrational.” 

His most recent attempt to bring back common sense is through publishing a comprehensive narrative review of nicotine pouches in Internal and Emergency Medicine. 

With dozens of references spanning chemical composition, toxicology, biomarkers of exposure, pharmacokinetics, and population-level usage patterns, the February 2026 paper, Farsalinos believes, is the most comprehensive synthesis of available evidence to date on nicotine pouches. 

“Of course, it’s going to be outdated in three or four years,” he says with a laugh. 

“But for the time being, it covers basically all the available literature.” 

A one-stop shop for the science 

The logic behind such a sweeping review is partly scientific, partly strategic, but still a valid and valuable public health strategy.  

Fragmented research creates opportunities for cherry-picking – for advocates on either side to seize the studies that fit their position and discard the rest.  

A single document covering all dimensions of the debate makes that harder and is something that can be handed to a politician or regulator with confidence that they will find what they need. 

The review’s central finding is stark: nicotine pouches sit at the very bottom of the tobacco product risk continuum.  

“Nicotine pouches could represent a promising harm reduction tool with a risk profile likely adjacent to pharmaceutical nicotine replacement therapies,” Farsalinos concludes in the paper’s abstract. 

Because they contain no tobacco leaf and use pharmaceutical-grade nicotine instead, they eliminate the agricultural impurities, heavy metals, and tobacco-specific nitrosamines that remain present even in carefully manufactured Swedish snus, which is subject to standards dictated by the country’s food safety legislation.  

Chemical analyses consistently show harmful constituents are either undetectable or present at negligible levels. Biomarker studies in humans show that people who switch from cigarettes to pouches experience reductions in toxicant exposure comparable to quitting smoking entirely. 

For the longer-term picture, Farsalinos applies the “bridging” principle: in the absence of decades of epidemiological data specific to pouches, the extensive evidence on Swedish snus – which has not been linked to lung cancer, significant cardiovascular disease, or elevated risk for most cancers – provides a reasonable worst-case proxy.  

Pouches, being chemically cleaner, can only be safer. 

‘We are 99.9 percent sure’ 

Which raises an obvious question: if the evidence is this clear, why does the paper still hedge? 

Farsalinos is candid about the gap between what the evidence shows and what can survive peer review in a politicised field.  

“In reality, things are much more certain from a common sense perspective than what’s presented in the manuscript,” he says.  

Getting a paper published often requires accepting language that implies more uncertainty than the evidence warrants – the alternative being that the study never reaches the scientific domain.  

The value having a citable piece of scientific literature that carries weight in regulatory debates outweighs the need to include language indicating almost 100 percent certainty. 

There’s no way that a pouch is going to be more harmful than snus.

“There’s no way that a pouch is going to be more harmful than snus,” he says.  

“We are 99.9 percent sure about it simply because of common sense. But you can’t express certainty without direct epidemiological evidence.” 

The published paper is therefore a compromise – not between what the evidence shows, but between “common sense” and what can survive the political pressures and technical scientific details embedded in the peer review process. 

“It’s not a report I wrote and released on my website,” he says.  

“It’s something that underwent peer review. That makes the argument very, very strong.” 

The ‘wait 30 years’ fallacy 

Another frequent argument for restricting nicotine pouches is that they are simply too new: a lack of long-term epidemiological data warrants implementing restrictions out of caution.  

Farsalinos has little patience for this argument. 

“The argument will never fall away,” he says.  

When e-cigarettes were new, he recalls, critics said to wait ten years. Ten years passed; the goalposts moved to twenty years. He tells of a toxicologist in Japan who told him that if, in thirty years, reduced-risk products were proven less harmful than cigarettes, we would “think about it.” Not act, but think about it. 

“If we had this mentality in medicine, we’d still be stuck in the nineteenth century,” he says.  

“There is not a single medication that requires twenty or thirty years of clinical evidence before being prescribed. In medicine, we always make recommendations based on current evidence.” 

Farsalinos remains confounded that the countries most committed to precautionary logic about pouches continue to permit the unrestricted sale of deadly cigarettes.  

“It’s a complete irony,” he says in exasperation. 

“The countries that ban pouches at the same time allow the legal sales of cigarettes, which is by far the most lethal nicotine-containing product.” 

Youth, flavours, and the prohibition fallacy 

No debate about reduced-risk nicotine products escapes the youth argument: that flavours attract young people, and these products therefore pose a gateway risk justifying restriction.  

Farsalinos does not dismiss concern about youth use – the review calls for strict age restrictions and continuous monitoring. But he challenges the claim that flavours are the primary driver, and that prohibition is an effective remedy. 

Data from the US CDC’s National Youth Tobacco Survey shows that when adolescents were asked why they used e-cigarettes and could cite as many reasons as they liked, flavours ranked seventh – cited by just eleven percent.  

“How can these people suggest that it’s because of flavours that kids are using these products?” he asks. 

Denmark banned flavoured e-cigarettes in 2022; within two years, youth vaping in the 15–29 age group had increased by seventy percent, and the vast majority of vapers were using fruit flavours, which were supposed to have been banned two years before.  

“The argument is debunked by the data,” he says.  

According to Farsalinos, curbing youth uptake is a matter of better enforcement, not full-blown prohibition. 

“It’s a matter of enforcement,” he says. 

“When enforcement doesn’t work, that doesn’t mean prohibition is the solution. Prohibition only makes things worse. It never achieves the desired effect. It’s nonsense.” 

The industry-capture argument 

For those who dismiss tobacco harm reduction as an industry narrative, Farsalinos points to a telling comparison.  

Pharmaceutical research is almost entirely funded and controlled by the companies that sell the drugs – yet regulators accept this model without much dissent. The tobacco and nicotine industry, by contrast, funds only a small fraction of independent research on harm-reduced nicotine products.  

Most is produced by academic institutions with no industry involvement; in the case of Swedish snus, the foundational epidemiological work came largely from Karolinska Institutet. 

“There is no need to ‘trust the industry’,” he says.  

“It’s not a requirement to accept evidence supporting tobacco harm reduction. We have independent data – a lot of data – and the ability to produce independent data.” 

A return to common sense 

The review concludes that nicotine pouches represent a viable exit from combustible tobacco that are substantially less hazardous to consumers’ health.  

Realising that potential requires smart regulation: ensuring product availability for adult smokers, enforcing age restrictions, capping high-nicotine products, and monitoring usage. None of that requires prohibition. All of it requires taking the evidence seriously. 

“I just want to bring common sense back into the debate,” says Farsalinos. 

“The purpose of the work is for the whole community – not only scientists, but also regulators, politicians, consumers – to understand what’s happening. This is what public health is all about.” 

Whether they choose to look is another matter.