Moves by regulators to limit the nicotine content of cigarettes would encourage people to buy full-nicotine cigarettes from illegal sources, according to a new study by researchers at Johns Hopkins University. But the availability of affordable vape products, the paper also suggests, would curb that migration to the illicit market.
In June 2022, the Biden administration announced a proposal to “establish a maximum nicotine level to reduce the addictiveness of cigarettes and other combusted tobacco products,” The US Food and Drug Administration (FDA) has authority to set nicotine limits under the 2009 Tobacco Control Act.
“While nicotine is not what makes smoking cigarettes so toxic, it’s the ingredient that makes it very hard to quit smoking,” the FDA said last year, noting that nearly half a million (480,000) people die prematurely each year in the United States from smoking-attributed disease.
The proposal is controversial, with some tobacco harm reduction advocates opposing it because of that illicit-market migration—or because of the potential of people “drawing harder or smoking more” to consume the desired amount of nicotine.
In contrast, the authors of the new study—published in May as an accepted manuscript in the journal Nicotine and Tobacco Research—believe that a nicotine limit “may pose a significant public health benefit.” But they wanted to learn more about how it might influence people’s choices.
So the researchers recruited people who smoke cigarettes (adults smoking at least five a day) to complete an online series of hypothetical purchasing tasks to simulate how they might respond. And they concluded that nicotine vapes, which are far less harmful than cigarettes of any kind, would play a key role in determining how the situation unfolded.
“Our findings suggest e-cigarettes may reduce combusted cigarette consumption and limit harms posed by the illicit tobacco market by potentially reducing engagement in it,” the authors wrote.
“When available for a lower price than illicit cigarettes, e-cigarettes were purchased to a greater degree.”
They sought to determine whether people who smoke would opt for lower-nicotine cigarettes if those were the only ones legally available—or whether, instead, they would rather seek out illegal full-nicotine cigarettes. And would that behavior change if nicotine vape alternatives were available at higher or lower prices?
“The big picture is that, yeah, if you restrict the nicotine, a lot of folks are going to go to the black market to buy cigarettes,” Matthew W. Johnson, a psychiatry and behavioral sciences professor at Johns Hopkins University School of Medicine and a co-author of the study, told Filter. “However, you do see a large reduction in that to the degree that you make e-cigarettes available at a lower price.”
More than three-quarters of participants gave either “yes” or “maybe” responses when asked whether they would be willing to purchase “black-market, normal-nicotine cigarettes in a marketplace where the only legally available cigarettes had reduced-nicotine content,” the study found. “Furthermore, illicit cigarette purchasing was independent of reduced-nicotine content cigarette price.”
Things changed when nicotine vaping products were added into the mix. “When available for a lower price than illicit cigarettes, e-cigarettes were purchased to a greater degree, suggesting that when they are inexpensive relative to black-market prices, e-cigarettes are better substitutes than illicit cigarettes,” the authors write.
Funding for the research came from the National Institute on Drug Abuse.
The findings reinforce existing evidence that when vape products are available at lower prices, people become more willing to substitute them for combustible cigarettes, Johnson explained. “If they were $12 a pod, then they didn’t step in and serve as a substitute” in the study, he said. “But if you introduce them at $4 a pod, they do.” He elaborated that “when illicit cigarettes are the only [other] substitute for reduced-nicotine cigarettes, the availability of the $4 pod (cheaper price) caused about a 19 percent decrease in the amount of reduced-nicotine cigarettes smoked on average.”
From a public health standpoint, he said, that suggests that any action by the FDA to set a lower nicotine limit in smoked tobacco “should be done in conjunction with our policy for regulating vaping,” especially with regard to the levels at which different products are taxed.
“We’ve got to be realistic. It’s not going to go away overnight,” Johnson said of nicotine use. He called it “a huge blind spot” for regulatory authorities to overlook the likely growth of illicit-market sales that would come with an FDA move to limit nicotine. And compared to the “off-the-charts” harm associated with combustible cigarettes, he added, “it seems pretty clear that the long-term harms associated with vaping are going to be substantially less.”
“Arguably, given the right policy environment, a mandate requiring all cigarettes contain very low nicotine would be unnecessary.”
“Before implementing a reduced-nicotine standard, coordination among governing bodies to standardize the regulatory approach for e-cigarettes at federal, state, and local levels based on empirical evidence will be essential to mitigate harms and maximize public health benefits,” the paper states.
Alex Clark, CEO of the Consumer Advocates for Smoke-Free Alternatives Association (CASAA), told Filter it’s “no surprise that giving vapor products a competitive edge over combustible cigarettes leads to more interest and more substitution by people who smoke.”
“Arguably, given the right policy environment such as, for example, low-to-no taxes on smoke-free alternatives and a diversity of products, a mandate requiring all cigarettes contain very low nicotine would be unnecessary,” he added in an email. “People are always up for saving money, whether it’s avoiding long-term medical costs or saving a couple of bucks at the check-out counter. We can do both if regulations were more aligned with science.”
Photograph by Lindsay Fox via Flickr/Creative Commons 2.0