Could making cigarettes less addictive help people stop smoking?

One way to stop someone wanting something is to make it less appealing.

And that’s been the inspiration behind many of the current strategies and research to help people to quit smoking. But reducing the appeal of something as addictive as a cigarette has been an uphill battle.

So instead of making cigarettes less appealing, what about making them less addictive?

The idea was first proposed in 1994 by two American researchers, Benowitz and Henningfield, who were trying to convince the US Food and Drug Administration (FDA) that limiting the amount of nicotine in cigarettes to approximately 0.5 mg per cigarette (about 30 times weaker than usual) you could effectively render them non-addictive.

Unfortunately the Supreme Court shot down the idea because the FDA didn’t have “jurisdiction to regulate tobacco products” and, since then, the majority of research has – quite sensibly – focused on finding ways to reduce the demand for tobacco products.

However, a few studies have continued to look into the effects of changing the product itself.

Today, a new study published in the New England Journal of Medicine by Dr Michael Fiore and his colleagues adds to the growing body of work that looks at the effect of lowering the nicotine levels in cigarettes.

The results suggest this does reduce smokers’ dependence and the number of cigarettes they smoked. But is this really the way towards a smokefree society?

The study

The relatively large, and therefore fairly robust, study included 840 smokers who were randomly assigned to either smoke normal cigarettes or one of six types of modified cigarettes.

The modified cigarettes contained varying levels of nicotine ranging from 15.8 mg (a typical amount in a normal cigarette) to 0.4 mg (arguably a ‘non-addictive’ amount).

After six weeks, the findings showed that those who smoked cigarettes that contained less than 2.4 mg of nicotine had lower exposure to nicotine, measured using urine samples, as well as lower scores for nicotine dependence, cravings and they smoked fewer cigarettes.

The authors conclude that reducing the amount of nicotine in cigarettes could help people to cut down (although the evidence around cutting down, vs quitting, isn’t clear cut).

While Professor Linda Bauld, Cancer Research UK’s cancer prevention champion, thinks the study is “interesting” she points out some of the limitations.

Limitations

“This trial is at odds with some studies with longer term follow up,” she says, referencing a study published earlier this year by Benowitz.

That study looked at 135 smokers over two years (compared with six weeks in today’s study) and it didn’t find that smokers using reduced nicotine cigarettes smoked less, nor were they more likely to quit.

Bauld further highlights differences between the USA, where the study took place, and policy in other countries.

“The FDA can regulate aspects of the product that authorities in other regions cannot, or are not currently considering, despite it being recommended by the World Health Organisation’s Framework Convention on Tobacco Control,” she explains.

“From a UK perspective we don’t currently have a regulatory authority who can require these types of changes to products.”

In other words, there’s no one in the UK who can force the tobacco companies to make cigarettes with less nicotine in them.

“Also,” she points out, “cigarettes are a global product and you could speculate that, if all cigarettes in one country had reduced nicotine, smokers would just buy cigarettes from another country. This would be particularly the case in places like the EU. For this to make a real difference, the trans-national tobacco companies would need to agree to do this globally.”

Something she thinks is “highly unlikely.”

The final limitation, and possibly the biggest, is that reduced nicotine cigarettes may not help people quit, just cut down how much they smoke.

Bauld thinks more studies that look at changing the product would be a good thing but recommends prioritising what we know works: “existing evidence-based tobacco control interventions to reduce smoking, alongside new ones like standardised packaging.”

– Misha

Reference

Donny, E. C., et al (2015) Randomized Trial of Reduced-Nicotine Standards for Cigarettes. NEJM. DOI: 10.1056/NEJMsa1502403

Comments

Hasse Karlgreen

25 March 2016

Yes e-cigarette helps in quitting smoking. In e-cigarettes it uses nicotine in liquid form and also in less quatity. It is less harmful and dangerous for our body than cigarette smoking.
Clive Bates

1 October 2015

This really is the ultimate zombie idea – the research continues undeterred by fatal flaws in the logic and feasibility of the whole concept, and that is because the researchers behind these studies take a narrow perspective. Consider four objections:

Firstly, this requires a regulator to enforce it – it won’t happen by free choice and low nicotine cigarettes have never sold well. Given that the reason for smoking is to use the recreational drug nicotine, regulating removal nicotine from cigarettes amounts to a prohibition of the most popular way of taking the drug by far. When will they reflect on the implications of mandating a prohibition? It didn’t go well with alcohol, and it is an utter disaster with illicit drugs. A simple point: banning something people want does not stop them using it. The effect is to substitute a criminal supply chain for a legal supply chain, to switch users to other substances, or to otherwise subvert regulation (would the also limit nicotine in loose tobacco, cigars, pipe tobacco etc). A few may even quit as intended, but they need to count the costs arising from those who don’t and the new patterns of supply and demand that would arise in response. There is an extensive literature on this, but it has not so far troubled the proponents of this idea.

The second major objection to this strategy is the likelihood that during a transition, which may need to last for several years, the toxic exposure to users of reduced nicotine products may increase due to well-known titration and compensation effects (i.e. users increasing their smoking intensity to achieve a satisfactory nicotine dose from reduced nicotine products). Given the sensitivity of the cardiovascular system to cigarette smoke, it may even cause additional avoidable deaths. The idea that a regulatory agency could get away with making a dangerous product more dangerous, even temporarily, for the greater good of deterring its use is absurd. If the evidence showed unambiguously that this didn’t happen, then maybe they’d have a chance. But it doesn’t, and nor should we expect it too given what is known about nicotine-seeking behaviour.

Thirdly, the issues above become slightly more tractable if there are alternative ways of taking nicotine that are both low-risk and satisfactory alternatives for nearly all users (possibly vaping products of the future). But this strategy does not eliminate nicotine use, it reduces harm. So the proponents of the reduced nicotine idea need to be clear on what they are doing: are they trying to eliminate nicotine use or reduce harm? If it’s the latter, then their focus should be on having a vibrant market in low-risk alternatives to smoking, with plenty of innovation that will create viable alternatives to smoking for most users. In fact, that would be a priority before you even considered reducing the nicotine in cigarettes.

Finally, the proponents of this idea never seem to reflect on the underlying question of the appropriate relationship between the citizen and the state. When should the state ban something you do for your own good, rather than to protect others? Horse riding? Rock climbing? Does the state become authoritarian when it goes beyond discouraging smoking, helping people to quit, giving them good reliable information about risks, and enabling a range of products and techniques to be available to smokers who want to quit? If the state does all that, then perhaps the ‘coerced quitting’ implicit in the reduced-nicotine idea would be rejected as both unnecessary and excessive.
Alan Beard

1 October 2015

I am writing this as an ex-smoker of 40/day over 45 years
This whole concept is flawed,by all means encourage tobacco co to offer as part of their range a lower nicotine alternative or as a specialised reduction package for people who are actively attempting to quit.
However,if the suggested route is to make this a mandatory avenue for tobacco cigarette manufacturers to follow (lower nic cigarettes) I would strongly argue that would be injurious to the smokers health. Professor M Russell correctly stated that smokers :- ‘smoke for the nicotine but die from the tar’ , this is the obvious outcome here, many smokers will simply smoke more to get to the nicotine level to satisfy their dependence or source black/grey market alternatives.
To me this seems like research going down a blind alley in an attempt to find a solution to an undoubted problem. Low nicotine products were available in the 70’s onwards (the brand Silk Cut with perforated holes in the filter) they did not enjoy a huge commercial success
To summarise,I do not totally disparage this research,but see a very limited role for a ‘quitting package’ of increasingly reduced nicotine cigarettes offered to willing clients. in a SSS scenario. To propose this to existing smokers with no intention to quit would have very harmful consequences ie increased smoking (with the associated tar and chemicals),thus totally counter-productive.

Highlighted content

Comments

Hasse Karlgreen

25 March 2016

Yes e-cigarette helps in quitting smoking. In e-cigarettes it uses nicotine in liquid form and also in less quatity. It is less harmful and dangerous for our body than cigarette smoking.
Clive Bates

1 October 2015

This really is the ultimate zombie idea – the research continues undeterred by fatal flaws in the logic and feasibility of the whole concept, and that is because the researchers behind these studies take a narrow perspective. Consider four objections:

Firstly, this requires a regulator to enforce it – it won’t happen by free choice and low nicotine cigarettes have never sold well. Given that the reason for smoking is to use the recreational drug nicotine, regulating removal nicotine from cigarettes amounts to a prohibition of the most popular way of taking the drug by far. When will they reflect on the implications of mandating a prohibition? It didn’t go well with alcohol, and it is an utter disaster with illicit drugs. A simple point: banning something people want does not stop them using it. The effect is to substitute a criminal supply chain for a legal supply chain, to switch users to other substances, or to otherwise subvert regulation (would the also limit nicotine in loose tobacco, cigars, pipe tobacco etc). A few may even quit as intended, but they need to count the costs arising from those who don’t and the new patterns of supply and demand that would arise in response. There is an extensive literature on this, but it has not so far troubled the proponents of this idea.

The second major objection to this strategy is the likelihood that during a transition, which may need to last for several years, the toxic exposure to users of reduced nicotine products may increase due to well-known titration and compensation effects (i.e. users increasing their smoking intensity to achieve a satisfactory nicotine dose from reduced nicotine products). Given the sensitivity of the cardiovascular system to cigarette smoke, it may even cause additional avoidable deaths. The idea that a regulatory agency could get away with making a dangerous product more dangerous, even temporarily, for the greater good of deterring its use is absurd. If the evidence showed unambiguously that this didn’t happen, then maybe they’d have a chance. But it doesn’t, and nor should we expect it too given what is known about nicotine-seeking behaviour.

Thirdly, the issues above become slightly more tractable if there are alternative ways of taking nicotine that are both low-risk and satisfactory alternatives for nearly all users (possibly vaping products of the future). But this strategy does not eliminate nicotine use, it reduces harm. So the proponents of the reduced nicotine idea need to be clear on what they are doing: are they trying to eliminate nicotine use or reduce harm? If it’s the latter, then their focus should be on having a vibrant market in low-risk alternatives to smoking, with plenty of innovation that will create viable alternatives to smoking for most users. In fact, that would be a priority before you even considered reducing the nicotine in cigarettes.

Finally, the proponents of this idea never seem to reflect on the underlying question of the appropriate relationship between the citizen and the state. When should the state ban something you do for your own good, rather than to protect others? Horse riding? Rock climbing? Does the state become authoritarian when it goes beyond discouraging smoking, helping people to quit, giving them good reliable information about risks, and enabling a range of products and techniques to be available to smokers who want to quit? If the state does all that, then perhaps the ‘coerced quitting’ implicit in the reduced-nicotine idea would be rejected as both unnecessary and excessive.
Alan Beard

1 October 2015

I am writing this as an ex-smoker of 40/day over 45 years
This whole concept is flawed,by all means encourage tobacco co to offer as part of their range a lower nicotine alternative or as a specialised reduction package for people who are actively attempting to quit.
However,if the suggested route is to make this a mandatory avenue for tobacco cigarette manufacturers to follow (lower nic cigarettes) I would strongly argue that would be injurious to the smokers health. Professor M Russell correctly stated that smokers :- ‘smoke for the nicotine but die from the tar’ , this is the obvious outcome here, many smokers will simply smoke more to get to the nicotine level to satisfy their dependence or source black/grey market alternatives.
To me this seems like research going down a blind alley in an attempt to find a solution to an undoubted problem. Low nicotine products were available in the 70’s onwards (the brand Silk Cut with perforated holes in the filter) they did not enjoy a huge commercial success
To summarise,I do not totally disparage this research,but see a very limited role for a ‘quitting package’ of increasingly reduced nicotine cigarettes offered to willing clients. in a SSS scenario. To propose this to existing smokers with no intention to quit would have very harmful consequences ie increased smoking (with the associated tar and chemicals),thus totally counter-productive.