An iconic move
Signed into law in 2009, the Family Smoking Prevention and Tobacco Control Act (“The Act”) gave the Food and Drug Administration (FDA) the power to regulate tobacco products.1 Almost nine years later, on March 15, 2018, the Food and Drug Administration (FDA) released a statement asking for public comments in helping set the standard nicotine amount to “minimally or non-addictive levels.”2 Nicotine is the addictive component of cigarettes that reinforces and sustains cigarette smoking, but it is actually the tar in cigarettes that eventually causes the harmful health conditions.3 Reducing the nicotine could potentially end cigarette smoking in the United States by decreasing the number of people addicted to it.
So, how did we get to this point of victory over Big Tobacco?
A historical overview
Cigarette use gained momentum around the 1940s as men headed to war and women began to work. Cigarette companies used to provide cigarettes in the military rations. Smoking was a trend that spread like wildfire. By the 1950s, close to 47 percent of Americans were smoking despite the emergence of multiple studies indicating a potential link between smoking and lung cancer. Around this time, the Federal Trade Commission released the statement that smoking advertisements claiming that cigarettes provide health benefits are deceptive. In fact, at the time, nearly 50 percent of physicians were smoking cigarettes, and some were even prescribing cigarettes to aid in digestion. Frantically, the cigarette companies responded to the possible regulation measures by creating cigarette filters, which they claimed would reduce nicotine and tar inhalation. With an estimated 4,336 cigarettes per capita per year (equivalent to every person smoking more than one pack every two days), smoking reached its peak in the 1960s and filtered cigarettes made up nearly two-thirds of all cigarette sales.3,4,5,6
Public opinion shifted, and the decline in smoking started with the pivotal Surgeon General’s (SG) Report in 1964, which explicitly stated that excessive smoking causes lung cancer. A year later, the Federal Cigarette Labeling and Advertising Act was passed, requiring the SG warning on all cigarette packs. Four years later, Congress banned cigarette companies from advertising with the passage of the Public Health Cigarette Smoking Act. In the 1980s, nicotine gum to help smokers wean off of tobacco products received FDA approval as it was later proven that nicotine was an addictive drug. The next 38 years would be marked with state bans on smoking in public areas, bans on smoking in airlines, multiple lawsuits against tobacco companies for harming the public, public stigmatization of smokers, a battle to gain control over the regulation of these products, and declining numbers of smokers in the United States. 5,6,7,8
The potential effects of a nicotine reduction strategy
With an estimated 37.8 million adults still smoking in the United States, the FDA is trying to understand what will happen if they reduce the nicotine content and by how much they should do so.9 Let’s explore some potential consequences and responses to those concerns:
Consequence 1: Smokers may increase the number of cigarettes they smoke every day or smoke cigarettes more vigorously to offset the decrease in nicotine per cigarette.
Response: This concern stems from the results of studies showing that when smokers are given “light cigarettes,” or cigarettes that reduce nicotine delivery and tar but do not reduce actual nicotine content, they increase their cigarette usage to compensate. A 2012 study, however, tested the effects of reducing the actual nicotine content in cigarettes and had two main findings: 1) reducing nicotine content in cigarettes leads to a decline in nicotine in the blood and urine as well as a decrease in cigarette smoking and 2) there is a “nicotine-reinforcement threshold” beyond which smokers tend to relapse after 6-8 weeks. According to study results, the control group (the group that had the regular cigarettes with 10-15 mg of nicotine) had no change in usage; the group that had the 0.3 mg of nicotine reduced nicotine intake but switched back to regular cigarettes at the end of the study; and the group with the 0.5 mg of nicotine successfully reduced nicotine usage and sustained low levels around the follow-up time.10,11 Essentially, this study showed that the chances of smokers increasing their cigarette use when faced with reduced nicotine content is relatively low.
Consequence 2: Smokers may switch to electronic cigarettes (e-cigarettes) or other products that have higher nicotine content.
Response: Yes, this is quite likely. In fact, a 2017 study showed that people who were given low nicotine content cigarettes supplemented their nicotine cravings with non-combustible tobacco products such as e-cigarettes.12 While there is much debate over the safety of e-cigarettes, several researchers have said that e-cigarettes should be used as harm-reduction because they do not contain as much tar and other harmful substances as cigarettes do.13 Thus, having smokers switch from cigarettes to e-cigarettes may be a harm reduction strategy. That being said, more transparency is required so that people understand what is in the vapor that they are inhaling through e-cigarettes. Moreover, there is a chance that smokers may switch to dip and chewing tobacco which can deliver more nicotine depending on the amount of product used and the amount of time the product stays in the mouth.14 To reduce the chances of people switching to these products, there must be concurrent policies in place to heavily tax such products to dissuade people from buying them.
Consequence 3: Smokers may switch to alcohol, marijuana, or other drugs to stimulate the reward and pleasure centers of the brain.
Response: A 2016 study shows that compensatory alcohol use is unlikely to happen and that in turn, alcohol use may decline with a decline in smoking as a result of using low nicotine cigarettes.15
- Consequence 4: Smokers may experience heavy withdrawal and severe mental health problems.
Response: Multiple studies have shown that people experienced very few to no withdrawal symptoms regardless of whether they reduced nicotine content immediately or tapered it off. These studies did not see any significant mental health effects from the reduction.10,16
Consequence 5: The demand for cigarettes with higher nicotine content may lead to a black market.
Response: Black markets are illegal underground economies that arise when the demand for a good outweighs the availability of that good, usually due to government regulation. While there is a high possibility of a black market arising (high nicotine cigarettes being sold illegally for high prices), there is a much greater chance that the nicotine-regulation will work if it occurs throughout the entire country. For instance, if every gas station or smoke shop sells low-nicotine content, the sheer number of people smoking low nicotine cigarettes should outweigh the number of potential black markets that could arise. It is also important to recognize that smokers tend to be minorities of lower socioeconomic status.17 Thus, for many current smokers, high cost could discourage use of black markets as well.
Supplementing a nicotine reduction policy
To benefit from the effects of a nicotine-reduction policy, the FDA will have to create additional policies to help the public with the transition. As mentioned previously, taxes on alternative nicotine delivery systems will be vital in dissuading people from compensating for the lower nicotine content. Moreover, the government should understand that individual variations exist in their sensitivity to certain doses and resulting effects. So far, studies have had relatively large sample sizes but they can never capture the full range of impact on individuals. Thus, the government will have to ensure that smokers have access to mental health facilities, smoking cessation programs, and other interventions at affordable cost.
Save the youth
Finally, while the FDA commissioner’s primary intention to prevent the youth from getting addicted to smoking is commendable, this effort may not stop them from getting addicted. The young people of today start on e-cigarettes and other nicotine delivery systems (such as JUULs). Because these products are designed to look like regular school supplies and do not create the pungent smell that cigarettes do, they are attracting students at alarming rates.18 The infamous cigarette companies that the FDA spent years taking down are producing many of these new products.
Thus, as we focus on tackling the beast in front of us, another rises from behind.
Author bio and photograph:
Priya Vedula is a health policy analyst at the Institute for Health Policy and Leadership. Her work involves examining health policies and regulations with a focus on oral health, mental/behavioral health, and hunger. She received her Master of Public Health degree from Columbia University.