Nearly 29 million Americans regularly smoke cigarettes, a drastic decline from 1964, when more than 40 percent of adults smoked and the surgeon general first linked tobacco to cancer. Still, that’s a lot of people hooked on nicotine. In an effort to end these addictions and prevent new ones, the Food and Drug Administration in the Biden administration’s last days proposed a plan that, if finalized, would require tobacco companies to reduce the level of nicotine in their cigarettes to doses below those associated with addiction.
Slashing nicotine levels in cigarettes could save millions of lives. But it creates a conundrum for regulators. If they make cigarettes less satisfying without offering appealing alternatives, smokers who can’t quit may turn to illicit markets. At the same time, regulators fear that the very products that help smokers quit — such as vapes or oral nicotine pouches — also attract young people. In response, the F.D.A. has imposed strict regulations on these products, banning flavors and slowing the approval of new vapes (also known as e-cigarettes). As a result, most vapes sold in the United States are unauthorized, posing safety risks to users. Many are imports from China.
What Americans really need is access to safer products. Controversially, this will require approving more vapes and oral nicotine products, and making them more affordable than cigarettes via sales taxes. It will also mean aggressively communicating to the public that what kills smokers is primarily smoking itself, not nicotine.
Many anti-tobacco activists understandably want to vanquish nicotine addiction entirely, not just cigarettes. Their concerns intensified as vaping among teenagers surged, peaking in 2019 when more than a quarter of 12th graders reported using vapes in the past month. That number has since fallen to 15 percent, yet fears persist that vaping could lead more teenagers to smoking or make quitting harder.
However, those fears haven’t materialized. In fact, some studies suggest the opposite — vaping may be replacing smoking rather than encouraging it. Cigarette smoking among teenagers is at an record low: In 1976, more than a third of high school seniors smoked; by 2024, just 2.5 percent did.
Regulators may need to accept that wider access to vaping could mean more young people use these products. But if vaping continues to displace smoking rather than fuel it, that trade-off could ultimately be a public health win.
Unfortunately, government agencies and anti-tobacco activists sometimes foster false perceptions about the risks of nicotine compared with the risks of cigarette smoke, which can impede good policy. Misinformation is rampant. Nearly two-thirds of smokers either believe that nicotine causes cancer or say that they don’t know. More than half think that e-cigarettes are at least as dangerous as smoking, if not more.
In reality, what kills most smokers is smoke and tar in regular cigarettes. While nicotine isn’t benign, its contribution to cancer and cardiovascular disease is far smaller than the danger incurred by frequently inhaling toxic cigarette smoke. More than half of all long-term smokers will die a smoking-related death. But research so far suggests that alternative nicotine delivery systems like regulated vapes and some oral products are significantly safer.
While we don’t yet have long-term data on vaping because it was invented only in 2003, the studies so far have led health authorities in Britain to conclude that vaping is “at least 95 percent less harmful” to smokers and of “negligible risk” to bystanders. A 2018 review by the National Academies of Sciences, Engineering and Medicine more cautiously warns that long-term risks are unknown but nonetheless states that vapes are likely “far less harmful” than cigarettes. These studies may not fully account for risks from unauthorized products that may contain unknown toxic ingredients — underscoring the need for more effective regulation.
E-cigarette vapor contains far fewer cancer-causing chemicals than cigarette smoke. Vapes also seem to be easier on the lungs: Studies find that when smokers with lung disease switch to vaping, symptoms like coughing and wheezing improve, just as much as in those who quit. (Vaping can worsen asthma, though.)
Data from Sweden suggests that if other nicotine delivery systems, such as appropriately regulated oral pouches, pose any cancer risk, it is small compared with the dangers of cigarette smoke. Some 15 percent of Swedes use an oral tobacco product called snus daily. Yet the country has the lowest rate of tobacco-related mortality in Europe among men, including the lowest rate of lung cancer.
When it comes to cardiovascular disease — the largest killer of smokers — the cardiologist Neal Benowitz (who, in 1994, first proposed the nicotine-reduction policy that the F.D.A. now wants to adopt) says nicotine itself isn’t strongly associated with atherosclerosis, which clogs arteries and increases risk of heart attack and stroke. Nicotine does increase heart rate, he says, which can worsen pre-existing heart disease and the damage from strokes or heart attacks.
The F.D.A. should devote much-needed resources to tackling the backlog of vaping products awaiting approval and actively let smokers know that vapes and oral pouches are genuinely less risky to their health. Public health authorities have made enormous progress in driving down cigarette-related deaths. It may seem counterintuitive that elevating other nicotine products can save lives. But that may be what we need to finally end the harms caused by smoking.
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