Cigarettes: Should the FDA Mandate a National Taper?

Addiction expert calls for reduced-nicotine tobacco.

For years now, nicotine researcher Neal Benowitz has been a man on a mission. Dr. Benowitz, a professor of medicine at the University of California in San Francisco, has been pushing a Big Idea about how to eliminate cigarette smoking in America: Reduce the amount of nicotine in cigarettes.

In essence, Benowitz is calling for a national nicotine taper. Whether the FDA is interested remains an open question. But the result, several years down the road, would be a nation of teenagers confronted with only weakly addictive tobacco products.

It is an old idea, often viewed with great suspicion because of the failure of “light” and “low-tar” cigarettes to reduce nicotine intake, and in fact causing smokers to smoke harder. But Benowitz, one of the nation’s premier tobacco scientists, believes that when it comes to the roughly one out of five Americans who still smoke, a new generation of so-called “low-nicotine delivery” cigarettes is the answer. 

In a controlled study of 135 smokers of various ages, participants smoked cigarettes with progressively lower nicotine over a two-year period, and did so “without evidence of compensation”—meaning that they did not smoke more cigarettes or smoke differently when using the low-nicotine offerings. This varies dramatically from the behavior associated with light cigarettes and special filters—innovations that were marketed as “safer” cigarettes—that simply increase ventilation. The light cigarettes themselves contain the same amount of nicotine as a “regular” cigarette. And smokers quickly learn to puff harder, or cover small holes in the filter paper with their fingers, in order to extract more nicotine from each cigarette.

But with low-nicotine delivery cigarettes, you can’t get more nicotine, no matter what kind of smoker’s gyrations you perform. And the result, according to a paper by Benowitz and coworkers in Cancer, Epidemiology, Biomarkers and Prevention, is that “when the nicotine content of cigarettes is progressively decreased at monthly intervals over 6 months there is a progressive decline in nicotine intake by smokers, with only a small degree of compensation at the lowest nicotine content levels.”

The two-year study was randomized but unblinded, in order to simulate situations in which smokers are fully aware of using cigarettes with progressively less nicotine. A control group smoked their usual brands of cigarettes throughout the study. Benowitz, who led the studied, said in prepared remarks that the U.S. Food and Drug Administration (FDA) now has the authority to regulate the nicotine content of cigarettes sold in the U.S. (Benowitz is a member of the FDA’s Tobacco Products Scientific Advisory Committee.) “The idea is to reduce people’s nicotine intake, so that they get used to the lower levels, and eventually get to the point where smoking is no longer satisfying.”

The study was small, and there were dropouts. As always, further long-term study will be needed to track smokers during this kind of long-term nicotine taper. Traditionally, tapering has not been an effective method of breaking a nicotine addiction. But the reason for that may have to do with the easy availability of full-strength cigarettes in every store and gas station. The obvious goal for Benowitz is the reduction of nicotine in cigarettes to the point where they are no longer addictive. But would a robust black market in strong cigarettes leap up if nicotine reduction were a federally mandated program?

“Progressive reduction of the nicotine content of cigarettes as a national regulatory policy might have important potential benefits for the population,” the authors write, adding that “some people who had no intention of quitting upon entry into the study had… either quit spontaneously or were thinking about quitting in the near future after smoking reduced-nicotine content cigarettes.” Low-nicotine cigarettes could be produced by extracting nicotine from existing tobacco, or by genetically engineering tobacco with a lower nicotine content.

“Adolescents initiate smoking for social reasons, with friends, and later begin to smoke for pharmacologic reasons related to dependence,” the authors conclude. “Presumably a cigarette with very low nicotine content would be less likely to support the transition from social to dependent smoking, although the threshold level of nicotine to prevent this transition is not yet known.”

Benowitz NL, Dains KM, Hall SM, Stewart S, Wilson M, Dempsey D, & Jacob P 3rd (2012). Smoking behavior and exposure to tobacco toxicants during 6 months of smoking progressively reduced nicotine content cigarettes. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 21 (5), 761-9 PMID: 22354905

Photo Credit: http://chronicle.uchicago.edu

Low-Nicotine Cigarettes: Deadlier Than Regular Brands?

More tars, more cancer.

Now that the U.S. Congress has passed legislation enabling the Food and Drug Administration (FDA) to monitor the tobacco industry for the first time in history (see my earlier post), one of the primary issues the agency must deal with are health claims on behalf of allegedly less-toxic brands of “low-nicotine” cigarettes.

It has long been understood, and demonstrated clinically, that people addicted to nicotine will smoke “light” cigarettes harder, and in greater numbers, in order to compensate and obtain the same amount of nicotine they are used to--thereby staving off withdrawal. [See graphic at right for the secret of why light cigarette smokers must puff harder.]

As prominent tobacco researcher N.L. Benowitz wrote in a National Cancer Institute (NCI) monograph:

“In brief review—when faced with lower yield cigarettes, smokers can smoke more cigarettes per day, can take more and deeper puffs, can puff with a faster draw rate, and/or can block ventilation holes. Using these last four techniques, a smoker can increase his or her smoke intake from a particular cigarette several fold above the machine-predicted yields.”

In the description of a patent for a low-tar and low-nicotine technique in 1995, Duke University Researchers wrote:

“Unfortunately, it has been discovered that only a small proportion of the total smoking population (e.g., less than 25%) has substituted low tar cigarettes (e.g., cigarettes that deliver less than 10 milligrams of tar) for conventional and more hazardous cigarettes. Also of note, only about 2.0-3.0% of total cigarette sales are accounted for by very low tar cigarettes (e.g., cigarettes that deliver less than 3 milligrams of tar). Moreover, even among the cigarette smokers who have substituted low tar cigarettes for conventional cigarettes, it has been discovered that these individuals will tend to smoke low tar cigarettes more intensively in order to extract more tar and nicotine than the nominal values listed on the pack. This, of course, defeats part of the objective of the low tar cigarettes.”|

Moreover, there has never been any significant body of evidence to suggest that switching to lights or ultra-lights in a way actually contributes to the success of smoking cessation efforts. According to the National Cancer Institute, there are no health benefits for smokers of light cigarettes, period.

In a letter published in the August 21 issue of Science, Marshall E. Deutsch argues that cigarettes with reduced nicotine may in fact “increase tobacco related death and disease” and are therefore potentially more dangerous than regular smokes.

Deutsch’s argument is that by smoking more cigarettes with lower concentration of nicotine, smokers “will be subjected to more of the ‘tars’ (the cancer-causing ingredients of the smoke) in their attempts to get their usual dosage of nicotine, (the ingredient responsible for heart disease and stroke). In the end, smokers of low-nicotine cigarettes will remain at the same risk for heart disease and stroke but increase their chances of developing cancer.”

It’s never too late to quit, and the earlier the better: The National Cancer Institute tells us that smokers who quite before age 50 cut their risk of dying by 50 % over the next 15 years, compared to those who keep smoking.

Graphics Credit: www.tobaccoinaustralia.org.au

addiction drugs smoking nicotine

Supreme Court Lights Up

Unlikely to let states sue over low tar cigarettes.

Can states sue tobacco companies for marketing one of the most addictive products known to man? Not if the claim hinges on deceptive claims about “light” cigarettes, the U.S. Supreme Court seemed to say last Monday.

The Court began its new term by taking up the tobacco case, in which three residents of Maine filed suit against Altria Group Inc. and its subsidiary, Philip Morris USA, under a state law barring unfair marketing practices. According to an Associated Press report, the plaintiffs argued that Philip Morris had long known that smokers of low tar cigarettes compensate by taking longer puffs and smoking more cigarettes.

After being thrown out by a federal district court, a U.S. Circuit Court of Appeals allowed the suit to proceed. Several similar cases are in progress around the country, pending a decision. If the Supreme Court finds against Philip Morris and its parent company Altria, states could initiate a new round of lawsuits as tobacco manufacturers once again face the prospect of huge class-action settlements.

Industry Week reported that Altria’s defense is that “cigarette packaging falls under the domain of the U.S. Federal Trade Commission (FTC), which failed to act despite being aware that light cigarettes were no less a health hazard than regular cigarettes.”

In other words, Altria knew that its advertising was deceptive—but so did the FTC, which approved it. Judge Samuel Alito summed up this thinking when he told an FTC attorney that by allowing cigarette ads to display tar and nicotine levels, “You have misled everyone who has bought these cigarettes for a long time.”

Chief Justice Roberts, according to the AP report, questioned why the case was focused on deception rather than the relationship between cigarettes and health: “How do you tell it’s deceptive or not unless you look at smoking and health?”

At the heart of the argument is the question of whether the 1966 federal legislation governing cigarette labeling and advertising takes precedence over more recent state legislation. Representing Altria, conservative attorney Theodore Olson found himself in the odd position of arguing that federal law should take precedence over state law.

Clifford E. Douglas of the University of Michigan’s Tobacco Research Network, told the New York Times in May that the difficulties of pushing forward with cases against light cigarettes “underscores the need to combat the light cigarette scam in the public policy arena.” Douglas said he supported legislation that would give the U.S. Food and Drug Administration (FDA) authority to regulate tobacco.

The New York Times reported that a bill under consideration in Congress “would ban the use of terms like light and low-tar in marketing such cigarettes, which contain the same tobacco as other cigarettes but have filters that allow more air to mix with the smoke, diluting it.”

smoking nicotine