Does Lowering Nicotine Levels in Tobacco and Nicotine Products Really Help Curb Addiction?

While proposals to cap nicotine levels in cigarettes and novel nicotine products keep popping up, most studies indicate that for smokers seeking to quit, being able to obtain their preferred nicotine intake from safer alternatives, would prove more effective than an imposed lowered amount.

A recent study published in The Lancet Regional Health examined the potential public health benefits of introducing low-nicotine cigarettes. The research aimed to determine how smokers would respond to very low nicotine content (VLNC) cigarettes in a real-world environment where regular or normal nicotine content (NNC) cigarettes and alternative nicotine delivery systems (ANDS) like e-cigarettes are readily available.

Titled “Reduced nicotine in cigarettes in a marketplace with alternative nicotine systems: randomized clinical trial,” the study involved six sites where smokers were randomly assigned to smoke either NNC or VLNC cigarettes. The participants, all adults over 21 who smoked between five and 40 cigarettes daily, could also purchase e-cigarettes and medical nicotine from an online experimental marketplace, and were observed for 12 weeks to assess their smoking behaviour and health outcomes.

The results suggested that participants in the VLNC group smoked significantly fewer cigarettes by the end of the study, averaging seven cigarettes per day compared to 13 in the NNC group. The study also found that VLNC users were three times more likely to attempt quitting, with 20% of VLNC participants abstaining from smoking for at least seven days, compared to 7% in the NNC group.

The paper also reported that while the availability of ANDS did not seem to significantly increase the likelihood of quitting, it did support VLNC users in reducing or quitting smoking. The fact that non-combustible tobacco use increased over time among VLNC users, suggested that these products can aid in the transition away from cigarettes/combustible tobacco.

The researchers concluded that introducing VLNC cigarettes in the market, coupled with the availability of ANDS, could significantly reduce cigarette consumption, promote quitting efforts, and lower exposure to tobacco-related toxins. These measures could serve as an essential public health strategy to reduce smoking prevalence and associated health risks.

The down side of lowering nicotine in cigarettes
Other studies have reported similar findings, however some experts argue that smokers tend to compensate for lower nicotine levels by smoking more cigarettes or inhaling more deeply, potentially increasing exposure to harmful tar and chemicals. Moreover, studies have concluded that reducing nicotine content in cigarettes does not lead to a sustained reduction in nicotine dependence or increased quit rates among smokers not initially interested in quitting.

The study “Effect of reducing the nicotine content of cigarettes on cigarette smoking behavior and tobacco smoke toxicant exposure: 2-year follow up,” aimed to determine the long-term effects of reducing nicotine content in cigarettes on smoking behaviour and nicotine intake. The research involved 135 smokers not interested in quitting, who were divided into two groups. One group smoked their usual brand, followed by progressively lower nicotine content cigarettes for seven months, then continued at the lowest nicotine level (0.5 mg/cigarette) for six months, and finally had no intervention for 12 months. While the control group smoked their usual brand throughout.

Key measurements included smoking behaviour, biomarkers of nicotine intake, and tobacco smoke toxicant exposure. The results indicated that after seven months of smoking very low nicotine content cigarettes (VLNC), nicotine intake was significantly reduced compared to baseline levels (plasma cotinine 149 ng/ml versus 250 ng/ml, P<0.005). However, there was no significant change in the number of cigarettes smoked per day or in expired carbon monoxide (CO) levels.

Moreover, during the 12-month follow-up, nicotine intake among the reduced nicotine content group returned to baseline levels, similar to the control group. Quit rates were low and not significantly different between the groups (7.5% for the VLNC group versus 2% for controls).

The results of allowing smokers to adjust nicotine levels according to their needs
Analysing this pattern from a different angle, a 2019 study led by Queen Mary University of London suggested that allowing smokers to control their nicotine intake while trying to quit can significantly aid in their efforts to stop smoking. This research involved 50 participants and represented the first study to tailor nicotine dosing based on individual smoker preferences during their quit attempt.

Dunja Przulj from Queen Mary’s Wolfson Institute of Preventive Medicine explained that while smokers typically control their nicotine intake through smoking, recommended dosages of nicotine replacement therapies (NRTs) for quitting may be too low for some individuals, potentially leading to relapse. The study indicated that medicinal nicotine products might be under-dosing smokers, which could contribute to the limited success seen with conventional treatments like nicotine patches and gum. Przulj emphasized that smokers should feel reassured in using higher nicotine doses if they find them helpful.

The study explored a novel approach to nicotine dosing. Historically, low doses of nicotine were used in NRTs due to concerns about toxicity and addictiveness. However, later evidence suggested that nicotine, when separated from tobacco products, has limited addictive potential and that higher doses are both safe and well-tolerated. Despite this, existing stop-smoking medications have not increased their nicotine levels accordingly.

Published in the journal Addiction, the study recruited participants from a tobacco dependence clinic in Argentina who underwent a combined approach of ‘pre-loading’ nicotine before their quit date and adjusting nicotine levels based on their feedback. They initially used one 21mg nicotine patch daily, starting four weeks before their quit date. The dosage was increased weekly by an additional 21mg patch, up to a maximum of 84mg/day, unless adverse effects were reported or the participant chose not to increase the dose. After the quit date, the dose was reduced weekly by 21mg until it reverted to the standard 21mg/day four weeks later. Throughout the pre-quit period, participants were encouraged to smoke as desired and were provided with additional oral NRTs.

This study’s findings suggest that smokers can tolerate significantly higher nicotine doses than currently recommended, potentially leading to more effective quit attempts by tailoring NRTs to individual needs.

High-nicotine vapes are the most effective at helping smokers quit
Similarly, a recent study from University College London (UCL) has found a significant rise in the number of vapers opting for the highest-strength e-cigarettes legally available. Published in the journal Addiction, the study reviewed data from nearly 8,000 vapers over the period from 2016 to 2024. Researchers observed that the proportion of vapers in England using high-strength vapes increased from an average of 3.8% between July 2016 and June 2021 to 33% by January 2024.

Dr. Sarah Jackson, the study’s lead author from the UCL Institute of Epidemiology and Health Care, pointed out the sharp rise in the use of high-strength nicotine e-liquids since 2021. In line with countless smoking cessation experts, Jackson highlighted that while nicotine is addictive, it is not the primary cause of harm from smoking. For smokers attempting to quit, higher-strength nicotine vapes can be more effective in curbing cravings and alleviating withdrawal symptoms.

The study revealed that 93% of those using the highest-strength vapes were consuming nicotine at the maximum legal limit of 20mg/ml. The increase was particularly noticeable among young adults aged 18-24 and those using disposable vapes. Significant rises were also seen among current smokers and recent ex-smokers, though not among long-term ex-smokers.

Why taxing products according to nicotine level is counterproductive
Researchers suggested that the rise in high-strength vapes corresponds with the growing popularity of disposable vapes. Referring to the UK government’s plans to introduce a new tax on vapes, they went on to caution against taxing vaping products based on nicotine strength.

Dr. Jackson warned that taxing higher-strength nicotine products could make the most effective quitting tools less affordable, potentially driving vapers toward lower-strength e-liquids and undermining smoking cessation efforts. The study highlighted that around 40% of smokers who had quit within the last year and were vaping used products that would attract the highest proposed tax rate.

Deborah Arnott, chief executive of Action on Smoking and Health (ASH) and a co-author of the study, emphasized the need to balance efforts to curb underage vaping with maintaining the effectiveness of vapes as a quitting tool for adults. Arnott suggested making all vapes less appealing and increasing their price at the point of sale, regardless of nicotine content, to deter youth usage while not discouraging adult smokers from using higher nicotine vapes for cessation.