Lowering nicotine in cigarettes

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When I was about 10 years old, my mother had me take a puff on an unfiltered Camel cigarette in an effort to discourage me from smoking in the future. Well, needless to say, it worked. After coughing and sputtering for what seemed like hours, I have never touched another cigarette.

While I am in no way suggesting that parents follow in my mother's footsteps (in fact I would strongly discourage it), as a pediatrician and parent myself I want to ensure that children and teens never take that first puff. But in fact, the majority of smokers in the US begin smoking in their youth.

According to the Centers for Disease Control and Prevention, cigarette smoking remains the leading cause of preventable disease and death in the United States, and tobacco kills more than 480,000 Americans every year. Cancer, heart disease, stroke, chronic lung disease, infertility, pregnancy complications, fractures, cataracts, gum disease — the list of diseases caused or complicated by tobacco use goes on and on. So why do people continue to smoke? Because they can't quit.

The role of nicotine

Cigarettes contain nicotine, a highly addictive substance found naturally in tobacco. When inhaled, nicotine travels quickly to the brain, causing a variety of pleasurable sensations. Many report an adrenaline "kick." Others report a feeling of relaxation and improved mood. Some say it makes them more alert and improves their ability to concentrate.

The downside is that nicotine is highly addictive, and once you start smoking it becomes increasingly hard to stop. People who do try to quit can experience profound withdrawal symptoms including cravings, anxiety, depression, irritability, and inattention.

Other than telling young people to stay away from tobacco products, how can we make them less attractive? Less addictive? That is where the US government is now stepping in.

Reducing nicotine in cigarettes

In July 2017, the FDA announced a regulatory plan to explore lowering nicotine levels in cigarettes, and just last month the agency took what FDA Commissioner Dr. Scott Gottlieb called a "historic first step." It released an "advance notice of proposed rulemaking" which marks the beginning of the agency's effort to reduce nicotine levels in cigarettes.

To support the effort, the agency pointed to data from an FDA-funded analysis published in the New England Journal of Medicine on March 15, 2018. The statistical model found that cutting nicotine levels to "minimally addictive levels" could slash smoking rates from 15% to as low as 1.4% and lead to a substantial reduction in tobacco-related deaths. In fact, the researchers estimate that such an initiative "could save millions of lives and tens of millions of life-years over the next several decades."

Previous studies have found that use of cigarettes with very low nicotine levels could result in greater efforts to quit smoking and a decrease in the number of cigarettes smoked per day. This most recent analysis provides even more evidence.

Critics say that smokers will simply compensate by smoking more cigarettes, but some research suggests that's unlikely. The levels of nicotine will be so low that smokers will no longer have the drive to smoke more.

The "nicotine notice" is just the beginning of the FDA's effort to regulate tobacco products and protect citizens from the harmful effects of nicotine, and the planned rollout will most certainly take time. The FDA is encouraging public comment for 90 days before further steps are taken.

In the meantime, I hope parents will continue to discourage their kids from using tobacco products like my mom did with me, but perhaps with open dialogue instead of an unfiltered Camel.