| The Food and Drug Administration created waves last month when it announced it would ban menthol cigarettes. But that might be just the start when it comes to tobacco regulation. The agency has discussed the possibility of reducing the level of nicotine in cigarettes, a proposal that could have a seismic impact on the tobacco industry and public health. "Reducing nicotine in cigarettes to nonaddictive levels would bring about the most fundamental change in the tobacco market in history," said Matt Myers, the president of the Campaign for Tobacco-Free Kids and a proponent of nicotine reduction.  Cigarette butts in an ashtray in New York. (Jenny Kane/AP) | The discussions come amid a growing global push to end tobacco sales.More than 140 organizations released a letter today calling on governments to begin plans to phase out the sale of all cigarettes. Signatories include the Association of American Cancer Institutes and schools such as the Johns Hopkins Bloomberg School of Public Health. And New Zealand is soliciting feedback on a proposal that would slash nicotine levels in cigarettes by 95 percent and eventually phase out the legal sale of cigarettes. "We've allowed ourselves to think of tobacco deaths as a normal part of the fabric of society," said Chris Bostic, the policy director of Action on Smoking & Health, one of the organizers behind the letter. "Over 8 million deaths a year is anything but normal." In the United States, the Food and Drug Administration can't ban cigarettes but it can require companies to lower nicotine levels to minimally addictive levels, as long as it's not zero. Some experts think that alone would trigger a dramatic reduction in use, especially given that nearly 70 percent of American smokers say they want to quit.
"The aim of this is basically to reduce or eliminate addiction. What drives cigarette smoking is becoming addicted to smoking," said Neal Benowitz, a tobacco addiction researcher at the University of California at San Francisco.  A restaurant owner smokes a cigarette in Bangkok. (Chalinee Thirasupa/Reuters) | FDA acting commissioner Janet Woodcock has confirmed nicotine reduction is "on the table." Woodcock made the comments in a media briefing last month. An FDA spokesperson confirmed the agency is continuing to review comments it received in response to a 2018 nicotine-reduction proposal put forward under former FDA commissioner Scott Gottlieb. That proposal, which announced that the agency would explore reducing nicotine to minimally addictive levels, stalled after Gottlieb left the Trump administration in 2019, but it could still form the basis for future rulemaking. It also reflects years of government-backed research into the potential impacts of regulating nicotine levels. One FDA-funded analysis published in the New England Journal of Medicine in 2018 predicted that lowering nicotine to minimally addictive levels would result in 5 million smokers quitting within a year and 13 million within five years. The smoking rate in the United States, which is currently at 14 percent in U.S. adults, would drop to 1.4 percent by 2060, according to this model.  Cigarettes displayed on a store shelf in New York. (Mark Lennihan/AP) | Still, it may not be the FDA that needs convincing."The issue is not the FDA. The issue is what do the American people want. In America we elect politicians, and they make the decisions. The FDA is a regulatory body," said Robert Califf, a cardiologist who served as FDA commissioner under President Barack Obama. Eric Lindblom, a former FDA executive focused on tobacco policy under the Obama administration, says that officials at the agency's Center for Tobacco Products probably are supportive of nicotine reduction, but "without White House support, the nicotine rule will not happen, regardless of what FDA wants or tries to do." And nicotine reduction could be politically tricky. The tobacco industry spent more than $28 million on lobbying last year. Califf, who is supportive of nicotine reduction, cautioned that it would be "politically challenging" and "divisive." He referred to the New Zealand government's push to eliminate cigarettes: "If you rank countries on a scale of how highly they value individual freedom versus societal good, the U.S. and New Zealand are on very different ends of that spectrum." Critics have raised concerns that the policy would create a black market in cigarettes.Kaelan Hollon, a spokeswoman for the tobacco company Reynolds American, warns of a "high potential for a dangerous illicit market" if the United States bans all but very low nicotine cigarettes while the rest of the world allows higher nicotine content. Hollon also points out that lower-nicotine cigarettes would not, in themselves, be any safer than regular cigarettes. Even proponents of nicotine reduction, such as Califf, say that concerns about a black market need to be taken seriously. "So far in the history of the U.S. in dealing with addictive substances, an illegal market has happened a hundred percent of the time," he said. It's one reason some researchers argue that any policy to reduce nicotine would need to be accompanied by widespread availability of less harmful alternatives, including e-cigarettes.  A memorial for Eric Garner, who was killed in 2014 by a New York City police officer after police approached him on suspicion of selling illegal single cigarettes. Some critics of harsher regulations on cigarettes raise concerns about an underground market and negative police interactions. (John Minchillo/AP) | Still, those in favor say the benefits would outweigh the costs. About 480,000 Americans die of smoking each year — that's more than the number of Americans who died of covid-19, the disease caused by the coronavirus, last year. "A lot of smokers will quit. And the ones that quit completely will have big, big, big health gains, and the ones that switch to e-cigarettes will likely have some substantial health gains," Lindblom said. "At the same time, any kids still experimenting with cigarettes will not be addicted to nicotine." | 
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