Nicotine and smoking behaviors have diversified rapidly over the past decade. Alongside declining cigarette use, a broad array of alternative nicotine products has gained widespread adoption, particularly in the United States and Europe and primarily among adolescents and young adults. These include electronic cigarettes, oral nicotine pouches, heated tobacco products, smokeless tobacco,  and non-nicotine vaping products. At the same time, evolving cannabis legislation has contributed to increased use of inhaled cannabis, often in combination with nicotine (“dual use”).

The growing diversity of nicotine products, variability in device technology, delivery, frequency of use, and patterns of dual or poly-use complicate risk classification and challenge traditional underwriting frameworks.

Alternative nicotine products were initially introduced with the aim of reducing harm or supporting smoking cessation, yet they have not been approved for this purpose. Their health impacts appear to vary by user profile: for current smokers who fully transition away from combustible tobacco, these products may reduce exposure to combustion-related toxicants, while uptake among never-smokers (particularly younger users) introduces new risks associated with nicotine dependence and potential downstream health effects.

The implications extend beyond underwriting into pricing, experience monitoring, and long-term mortality and morbidity assumptions. If emerging products sustain nicotine addiction, continue marketing to the younger ages, or contribute to chronic cardiovascular or respiratory effects, they may impact progress in reducing smoking-related disease and claims. Insurers therefore face a critical question: how should alternative nicotine and smoking products be classified today, in the absence of long-term outcome data, while remaining aligned with emerging medical evidence?

Insurance definitions of smoking tend to be simple and, in most markets, classify individuals as smokers if they have used a nicotine-containing product within a defined time window (often 12 months), regardless of product type, intensity, or route of exposure. Verification commonly relies on cotinine testing, which confirms recent nicotine exposure but provides limited insight into cumulative exposure, combustion, or product-specific risk.

This binary approach was effective when cigarette smoking dominated nicotine use. It is increasingly misaligned with current behaviors. Non-combustible nicotine products (e.g., nicotine pouches) may test positive for cotinine yet carry different health risks from combustible tobacco. Conversely, some vaping products may test negative for cotinine while still posing relevant respiratory or cardiovascular risks.

Moreover, cotinine cannot reliably distinguish between light and heavy use, detect duration of exposure, or identify whether nicotine originates from tobacco combustion, heated tobacco, synthetic nicotine, or nicotine replacement therapy. As a result, underwriting decisions continue to rely heavily on self-reported disclosures, which are often inaccurate in the context of newer perceived "low risk” products.

This creates a growing gap between exposure, true health risk, and insurance classification, a gap that is likely to widen as product innovation and uptake continue.