If implemented - which may take at least another three years - it would mean that all cigarettes and cigars sold in the United States must contain about 95% less nicotine than they currently do. (Photo by Pixabay)
Cigarettes are the only legal consumer product that, when used regularly, can lead to premature death in half of its long-term users.
In response to this long-term health threat, in late June 2022, the Biden-Harris administration announced a plan to advance new standards for cigarettes and other combustible tobacco products to make their nicotine content minimal or non-addictive.
The New Zealand government has recently announced a similar nicotine reduction strategy, which is being described as a key component of the country's new smoke-free plan.
Before Biden-Harris's proposal, earlier in his presidency in 2017, Trump developed a plan aimed at reducing the amount of nicotine allowed in cigarettes. From 2013 to April 2022, Mitch Zeller, the director of the Center for Tobacco Products at the US Food and Drug Administration, stated in 2019 that "this rule may have the greatest impact in the history of public health on public health.
What does this proposal mean in practice? If implemented - which may take at least another three years - it would require a reduction of approximately 95% in the nicotine content of all cigarettes and cigars sold in the United States. As nicotine is the addictive substance in tobacco, this would mean these tobacco products would be almost non-addictive. No longer would young people become addicted to cigarettes, and current smokers would find it much easier to quit.
As a public health science professor who has researched smoking cessation for over 30 years, I am impressed by any intervention that increases the quit rates of smokers without a cessation plan. In our recent randomized clinical trial involving very low nicotine cigarettes, my research team at Penn State University and colleagues at Harvard University found that those assigned to use the cigarettes had over four times the likelihood of quitting compared to those using regular nicotine cigarettes.
Research indicates that the potential public health benefits of successfully implementing a nicotine reduction standard for cigarettes could be significant.
According to a study conducted by the US Food and Drug Administration in 2018, lowering the nicotine standard for cigarettes is predicted to significantly reduce smoking rates by 2060, dropping from the current rate of approximately 13% to below 2%. This could prevent 16 million people from becoming regular smokers and prevent over 2.8 million deaths caused by tobacco.
In addition to heart disease, stroke, and cancer, smoking can also lead to infertility, erectile dysfunction, cataracts, premature aging, hair loss, and tooth loss.
It is not just a "light" or "low-tar" cigarette.
The proposed standards will not simply result in something akin to "light" cigarettes. Light cigarettes have been sold for decades with nicotine levels similar to regular cigarettes, around 10-15 milligrams per cigarette. To comply with the new standards, cigarettes may need to contain less than 0.5 milligrams of nicotine.
Light" or "low tar" cigarettes have small holes in the filter, allowing air to flow into the filter to dilute the smoke. When machine-smoked, light cigarettes provide lower levels of tar and nicotine per puff. However, when held by humans, the holes are often blocked by fingers, making it easy for smokers to inhale more difficult to draw in the same amount of nicotine and tar.
Some skeptics of proposed nicotine reduction have raised a concern that smokers may actually smoke low-nicotine cigarettes more intensely, like "light" cigarettes. However, dozens of studies have indicated that for extremely low-nicotine cigarettes, smokers do not increase their smoking intake.
On the contrary, smokers quickly realized that cigarettes with very low nicotine content were not very satisfying, and gradually reduced their smoking quantity. In randomized trials, those who used cigarettes with extremely low nicotine content were also more likely to quit smoking.
The function of electronic cigarettes.
When the Trump administration first proposed reducing nicotine in cigarettes, Zeller and former FDA director Scott Gottlieb recognized that one of the main challenges to the success of the plan was the possibility that the regulation could lead to a black market for high nicotine cigarettes.
Zeller and Gottlieb understand that a key way to prevent this situation is to allow non-combustible nicotine products, such as e-cigarettes, to remain on the market. E-cigarettes provide satisfying levels of nicotine to smokers while significantly reducing the amount of toxic substances users are exposed to compared to traditional cigarettes. Therefore, the harm from e-cigarettes may be much smaller.
A recent study conducted by our team and colleagues at Virginia Tech found that non-planning smokers who use e-cigarettes with nicotine resembling cigarettes have a higher rate of completely quitting smoking compared to those who use e-cigarettes without nicotine or do not use them at all.
Family and friends' support, along with nicotine patches, are some of the strategies this smoker is using to quit smoking.
Controversy surrounds electronic cigarettes
The potential for e-cigarettes to replace traditional smoking is being cited as the reason why the US Food and Drug Administration announced a ban on all sales of Juul, the biggest electronic cigarette brand of the past five years, just two days after the Biden-Harris administration announced a significant reduction in the allowed nicotine content in cigarettes. Juul is appealing the decision and the FDA has suspended the ban until further review, which is expected to take several months.
Juul is not the only e-cigarette facing a ban threat. Out of the millions of e-cigarette applications submitted to the FDA by the September 2020 deadline, over 99% have been rejected.
Against the backdrop of the FDA's efforts to reduce nicotine in cigarettes, the agency's ban on electronic cigarettes seems perplexing and counterintuitive, as the availability of e-cigarettes is crucial to the feasibility of this plan. Many researchers, myself included, believe that a range of legal and regulated high-nicotine e-cigarette products on the market are critical to reducing consumer demand for illegal high-nicotine tobacco products.
Health authorities in other parts of the world, including the United Kingdom and New Zealand, have recognized the significant role that e-cigarettes can play in reducing smoking. New Zealand's nicotine reduction plan explicitly includes providing e-cigarettes as an alternative nicotine product.
According to research, electronic cigarettes are much less harmful than traditional cigarettes and have been shown to assist smokers in quitting the harmful habit. Therefore, it is appropriate to keep a variety of e-cigarette brands available on the market until the plan to reduce nicotine in traditional cigarettes is successfully implemented.
As we quietly passed World Lung Cancer Day like any other day, I believe we now have a plan that can reduce the number of deaths caused by this terrible disease more than anything else. This plan has been proposed by both Republican and Democratic governments and has the support of the best science available today. In my view, implementing nicotine standards for combustible tobacco represents our best chance at finally ending cigarette addiction.
Jonathan Foulds is a professor of public health sciences and psychiatry at Pennsylvania State University.
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