Sugars in Tobacco Products: Toxicity Research and Implications for Tobacco Product Regulation.

Sugars are naturally present in tobacco plants and are introduced as additives during the manufacturing of various tobacco- and nicotine-containing products. Product palatability and appeal are the primary reasons for manufacturers' attention to the sugar content in tobacco and nicotine products. However, because of the complex chemistry of sugars and their thermal decomposition, these versatile constituents are also contributing to the toxicity profile of tobacco and nicotine products. Using published empirical data, this non-systematic review summarizes the state of knowledge on the toxicologically relevant chemical transformations of sugars and artificial sweeteners in tobacco and nicotine products, including waterpipe tobacco, combustible and electronic cigarettes, heated tobacco products, and smokeless tobacco, and available research on the associated health effects of sugar-derived toxicants. Implications of sugar and sweetener content for abuse liability of various tobacco products are also discussed. Based on the findings of this review, research gaps are identified and policy recommendations are made for regulating sugars and artificial sweeteners in tobacco and nicotine products, including adding sugars and artificial sweeteners to the list of harmful and potentially harmful constituents (HPHCs).