May 19, 2023. By Dana Rubenstein.

Smoking cigarettes is the deadliest habit. It has been the number one preventable cause of death and disease for decades and remains rampant despite recent tobacco control efforts. Furthermore, this habit disproportionately affects priority groups such as racial/ethnic minorities, sexual/gender minorities, and people with mental illness and disability. Despite widespread knowledge of the harms of tobacco, many people struggle to quit due to the addictive pull of nicotine and lack of cessation support. 

One solution to decrease cigarette smoking in the United States is to decrease nicotine levels in cigarettes. The 2009 Family Smoking Prevention and Tobacco Control Act [DR1] gave the Federal Drug Authority (FDA) the power to implement standards to improve public health, including by regulating cigarette nicotine levels. Since this seminal randomized controlled trial [DR2] in 2015 published in the New Internal Medicine demonstrated the benefit of these reduced nicotine content cigarettes, countless other studies have confirmed that decreasing nicotine content below the addictive threshold leads to substantially increased smoking cessation rates.

The New Zealand Parliament has followed this evidence and recently passed a strong tobacco endgame law[DR3] including the mandated nicotine reduction of all cigarettes to below the addictive threshold, and other policies focused on decreasing tobacco use, especially among the most at-risk populations. Nevertheless, despite the clear evidence in favor of a nicotine reduction standard, a US nicotine reduction standard is still far from reach.

The FDA announced a proposed product standard [DR4] in June 2022 that would decrease nicotine levels in all cigarettes sold in the US. This is promising, however, the processes required before this is enacted may take years, leading to unnecessary smoking-related death and disease. A different proposed tobacco control policy banning characterizing flavors (such as menthol) in cigarettes and other combusted tobacco products is also moving through the FDA system, and while farther along in the process, it has already been two years since the initial proposed product standard[DR5] . This policy has direct implications for disparities in smoking cessation, specifically among African Americans, and the lack of urgency in implementing this standard indicates that a nicotine reduction policy may also be years in the making.

We must do everything we can to support the swift implementation of a nicotine reduction policy. Anyone from the public can participate in public comment periods offered by the FDA, as well as public listening sessions where opinions can be shared. It is essential to have the voices of the general population represented in these forums, as the tobacco industry often has a dominating presence. It is not enough for researchers to share our work; in order to outweigh the industry voices, people can share their personal experiences with tobacco and desires for this policy to help the nation, or they can simply be in support of the policy. Even while we are waiting for the national policy, individuals can also engage with local and state governments to encourage regional nicotine reduction standards. Many of us are concerned about the current state of public health in this country– contribute to the present and future health of the nation by supporting a cigarette nicotine reduction standard.

Dana Rubenstein

2022-23 NC Schweitzer Fellow

Duke School of Medicine, Class of 2024