If cigarettes contained very little of the chemical that keeps people smoking, it could help smokers move away from these deadly products.
That’s the rationale behind a new rule proposed on January 15 by the U.S. Food and Drug Administration, which seeks to limit the amount of the addictive chemical nicotine in cigarettes. The reduced-nicotine cigarettes would have less than 5 percent of the amount of nicotine that’s generally found in regular cigarettes. The rule would also cap the nicotine in certain other products in which the tobacco leaves are burned.
The FDA rule is just one step toward reduced-nicotine cigarettes and other combusted tobacco products becoming the standard. This process would probably take many years, depending on the priorities of future administrations and whether the tobacco industry challenges the rule in court, as it has the FDA’s rule placing graphic warning labels on their products. The 2009 Family Smoking Prevention and Tobacco Control gave the FDA the authority to require graphic warning labels and to reduce nicotine in tobacco products.
The idea for a nicotine limit has been around for decades. And the evidence supporting drastically lowering the amount of nicotine in combusted tobacco products has grown during that time. Randomized controlled trials of reduced-nicotine cigarettes report that people using them end up smoking fewer cigarettes per day. That’s also the case for studies that focused on groups at higher risk for smoking, including people who are socioeconomically disadvantaged and people with mental health conditions.
By providing a path for people to reduce the number of cigarettes they smoke each day, there’s potential for smokers to eventually switch to less harmful noncombusted nicotine delivery options, to nicotine replacement therapy and to one day break their addiction altogether.
Here’s the science behind reduced-nicotine cigarettes and how they could be a stepping stone to quitting, which about two-thirds of the nearly 30 million adult smokers in the United States want to do.
What do we know about reduced nicotine cigarettes?
Nicotine, which is highly addictive, is what keeps people smoking. It’s other chemicals in cigarette smoke that can cause cancer. Cigarettes are designed to deliver as much nicotine as a person can tolerate without getting sick from the chemical, says Megan Piper, a director of research at the University of Wisconsin Center for Tobacco Research and Intervention in Madison. “Why? So that you can stay dependent.”
Regular cigarettes generally contain around 16 milligrams of nicotine per gram of tobacco. The FDA is proposing to reduce the amount to 0.7 milligrams in cigarettes and other combusted tobacco products.
There have been numerous randomized clinical trials looking at how smokers do when using reduced-nicotine cigarettes compared with regular cigarettes in terms of how much they smoke and other factors. For example, in a trial that followed close to 800 people for six weeks, researchers randomly assigned smokers — who were not planning to quit — to use regular cigarettes or one of several other cigarettes with varying lower amounts of nicotine.
At week six, people assigned to smoke cigarettes with 2.4 milligrams of nicotine or less smoked significantly fewer cigarettes per day than those assigned regular cigarettes, the researchers reported in 2015. Generally, it added up to about five or six fewer cigarettes per day, says study coauthor Jennifer Tidey, a behavioral scientist at Brown University’s School of Public Health in Providence, R.I.
Participants on lower nicotine cigarettes also had lower scores on tests for nicotine dependence at week six. And for those participants who took an abstinence assessment, for which they didn’t use any products containing nicotine for one day, people who had been assigned to lower nicotine cigarettes had significantly lower scores for nicotine craving.
Thirty days after the six week smoking period of the trial, around 80 percent of the participants took part in a follow-up phone call. Those who had been assigned 1.3-milligram and 0.4-milligram cigarettes were smoking significantly fewer cigarettes per day than those who had been assigned regular cigarettes.
Why is smoking so hard to quit and how might reduced-nicotine cigarettes help?
It’s not just the buzz from nicotine that keeps people using it. The symptoms people experience if they cut back on nicotine “make it incredibly difficult and uncomfortable, painful, to quit,” Piper says. Those withdrawal symptoms include feeling depressed, anxious, irritable and angry and having difficulty sleeping. “People have trouble dealing with stress, because their primary coping response has become using nicotine,” Piper says.
People who don’t smoke “don’t really appreciate how difficult it is” to quit, Tidey says.
Here’s how reduced-nicotine cigarettes could help. While the amount of nicotine in these cigarettes is much less than what smokers are used to, studies find that people don’t try to compensate by smoking more. Nor do they experience more cravings or more withdrawal symptoms, in part because the behaviors that signal a person is about to get nicotine continue. The behaviors of smoking — “getting the cigarette out of the box, lighting it, putting it up to your lips, smoking it, inhaling the smoke” — have been paired with nicotine delivery for so long, Tidey says, “you start to experience that mood boost just from doing those behaviors.”
Those reinforcing behaviors kind of cover for the smaller buzz the reduced-nicotine cigarettes offer. Meanwhile, taking in less nicotine starts to chip away at the dependence on the chemical. The research finding that cravings and withdrawal symptoms don’t increase even though the person is smoking less matters to the goal of eventually being able to quit. “That notion of self-efficacy, of, ‘I actually do have some control here,’” Piper says, “it’s a critical piece to being able to be successful.” The ability to cut back on smoking via reduced-nicotine cigarettes can help people see how they might be able to give up smoking entirely, she says.
Smokers who discussed what it was like to use low nicotine cigarettes as part of a study echoed that very sentiment, researchers reported in Drug and Alcohol Dependence in 2021. The study participants lodged at a hotel for five days, two times. For the first stay, they used regular cigarettes. For the second stay, which was nine days after the first, they only had access to cigarettes with 0.4 milligrams of nicotine. During the reduced-nicotine stay, researchers interviewed the participants about their experiences.
Several talked about feeling less dependent on cigarettes and more motivated to quit using them. As one participant put it, “I actually finally feel like the cigarettes aren’t controlling me.” Another said, “I honestly think I could probably quit, smoking these for a couple of weeks.”
What else do people need to know about reduced-nicotine cigarettes and trying to quit?
The goal is to help people stop smoking, rather than continue to use reduced-nicotine cigarettes, which still have the cancer-causing chemicals. That could mean people switch to noncombusted tobacco products that contain nicotine, such as e-cigarettes. There are also FDA-approved nicotine replacement therapies, including skin patches and chewing gum, to help people quit.
The availability of reduced-nicotine cigarettes would give smokers another approach to wean their dependence on nicotine. Considering how difficult quitting can be, the more options, the better. “Most people who successfully quit have had to try many times,” Tidey says. “It’s really hard. Keep trying.”