New Study Shows that Americans Support Reducing Nicotine Levels in Cigarettes

A study published online ahead of print in the American Journal of Public Health reports the results of a survey of public opinions regarding cigarette regulation. The primary finding was that the overwhelming majority of the public supports regulations that would mandate substantial reductions in the amount of nicotine in cigarettes, reductions that the authors claim would bring nicotine to a "non-addictive level."

According to the press release accompanying the article: "A vast majority of U.S. adults support reducing nicotine in cigarettes to below nonaddictive levels if it means fewer children and adults will become addicted to cigarettes, according to a new study led by Harvard School of Public Health (HSPH) researchers. The study was published online February 16, 2012 in the American Journal of Public Health. ... Lead author Gregory N. Connolly, director of the HSPH’s Center for Global Tobacco Control, and Hillel Alpert, research scientist and senior author, and colleagues conducted a nationally representative public opinion survey of 511 nonsmokers and 510 smokers adults aged 18 and older, excluding Hawaii and Alaska, from May 18, 2011 through June 5, 2011. ... Among the findings:

• More than 3 in 4 persons (77%), including 81% of nonsmokers and 74% of smokers, supported the reduction of nicotine in cigarettes to levels below the threshold of addiction if it could cause fewer children to become addicted to cigarettes.
• Nearly 2 in 3 (65%) persons supported reducing nicotine in cigarettes to nonaddictive levels, including 73% of nonsmokers and 58% of smokers."

The article concludes: "The FDA should consider protecting children by removing all but nonaddictive cigarettes from the marketplace."

The Rest of the Story

There's just one problem with this story. What is the "non-addictive level" of nicotine? What is the threshold level of nicotine in cigarettes, below which cigarettes are not addictive?

Unfortunately, we simply do not have the science base to support the contention that there is a specific threshold level of nicotine, above which cigarette smoking is addictive and below which cigarette smoking is not addictive.

It may be, for example, that there is no specific threshold for the addictive nature of cigarette smoking. Remember that smoking is not just a pharmacologic addiction, but a behavioral and social addiction as well. It is possible that even in the absence of nicotine, cigarette smoking could still be addictive.

In fact, there is evidence to support this contention. A large number of electronic cigarette smokers are maintaining themselves on zero nicotine cartridges. Yet they continue to rely upon the use of electronic cigarettes. In other words, they are still addicted to "vaping," yet they are not inhaling any nicotine. The behavioral aspects of the cigarette smoking process cannot be ignored.

Moreover, it may be that even minute quantities of nicotine are enough to occupy sufficient nicotine receptors in the brain to cause some level of addiction. The idea of non-addictive levels of an addictive substance is not something that has been previously recognized in addiction science. For example, has any scientist proposed that there is a level of heroin below which it is not addictive? Are there non-addictive levels of cocaine? Are there non-addictive levels of benzodiazepines?

An even bigger problem is that by reducing the levels of nicotine in cigarettes, the FDA might actually be increasing cigarette-related disease. How so? Since smokers need to maintain a consistent dose of nicotine, a substantial reduction in dose would result in significant amounts of compensation, meaning that smokers would inhale more deeply and smoke more of the low-nicotine cigarettes mandated by the FDA. This would result in a major increase in tar exposure (that is, exposure to carcinogens and lung and heart toxins), resulting in increased rates of heart disease, lung disease, and cancer.

The rest of the story is that the issue is not as simple as this research would have us - and the public - believe. Congress was very careful in crafting the Tobacco Act to ensure that no major actions would be taken by the FDA that would substantially threaten cigarette sales. One of these actions was to prohibit the FDA from eliminating nicotine from cigarettes. The agency cannot require the companies to reduce nicotine below practicable levels, and there is no scientific certainty that the lowest practicable level of nicotine is a non-addictive one.

Reducing nicotine in cigarettes could be a great public health victory, or it could be a complete disaster. We simply don't know at this point. But one thing is for sure. The issue is not as simple as anti-smoking groups have made it out to be.