Feldman: How can we bring tobacco use to its “endgame?”

My column last month discussed one of the “endgame” approaches to finally ending smoking.

This approach is the “date of birth-based phase-out” of tobacco use whereby people born after a certain date would never be able to legally purchase tobacco for their entire lives. Over time, this would result in the complete elimination of the sale and legal use of tobacco.

Here is another final approach: the reduction of nicotine in combustible tobacco, either gradually or abruptly, to non-addictive or minimally addictive amounts.

Combustible tobacco is the most toxic of tobacco products. According to the US Food and Drug Administration, this final strategy could result in 13 million smokers quitting within five years. It could prevent 33 million youth and young adults from becoming regular smokers and prevent eight million deaths from tobacco by the end of this century.

In 2009, Congress gave the FDA authority to comprehensively regulate tobacco and nicotine products, including limiting (but not to zero) the amount of nicotine, the addictive component of tobacco. Although nicotine is not the direct cause of smoking-related diseases, it is integral to the cause because nicotine addiction maintains smoking behavior.

Smoking usually begins in youth and nicotine addiction is important in the transition from adolescent experimentation to a lifetime of smoking.

In 2018, the FDA initiated a regulatory plan to investigate nicotine reduction in cigarettes by considering the risks and benefits for the entire population, both smokers and nonsmokers.

According to Havard public health professor Howard Koh, the tobacco industry has long argued that combustible tobacco use is a matter of choice, not addiction. One might think, then, that the industry would support reducing the nicotine content of tobacco. This is not the case.

A big question is whether to reduce nicotine to minimum levels abruptly or gradually. It seems counterintuitive, but smokers in a 2018 study in the Journal of the American Medical Association tolerated an abrupt change well. Abrupt reduction was also associated with greater reduction in smoking, dependence, and increased cessation.

Intuitively, one might also think that smokers who switch to very low nicotine cigarettes would smoke more and inhale more deeply to get the required dose of nicotine, thereby increasing their exposure to tobacco toxins and carcinogens.

However, the FDA points to studies showing that smokers who used low-dose nicotine cigarettes had difficulty discriminating between typical cigarette nicotine levels and minimally addictive levels, reducing their consumption.

For this strategy to work, nicotine would need to be reduced in all combustible tobacco products, not just cigarettes, to prevent product switching.

The exclusion of vaping products from the regulation should be noted. Although long-term studies on vapors are lacking, they are still believed to be less toxic than combustible tobacco. It would be important to have non-combustible nicotine products, possibly including vapors, for those who need transitional nicotine supplements.

The tobacco industry has been adept at manipulating the design and composition of cigarettes to maximize addiction. Caution must be exercised in the industry’s response to circumvent nicotine limitation and undermine its effectiveness.

A recent article in the New England Journal of Medicine describes these possible actions by Big Tobacco: physical and chemical redesign of filters; nicotine-laden wrappers; tobacco additives to enhance nicotine delivery, bioavailability, or binding of nicotine to brain nicotine receptors; addition of addictive nicotine derivatives without increasing actual nicotine; and the addition of substances that would inhibit the metabolism of nicotine or the reward neurotransmitter, dopamine, that nicotine turns on.

How this final strategy plays out will be fascinating.

Dr. Richard Feldman is an Indianapolis family physician and former Indiana State Health Commissioner. Email him at [email protected].

This article originally appeared in the Evansville Courier & Press: OPINION | Feldman: How can we bring tobacco use to its “endgame?”