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Nicotine continues to get the blame for smoking-related health risks, rather than combustion and harmful by-products. Photo credit: Geri Tech, Pexels.
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Capping nicotine levels in cigarettes may lead to unintended consequences such as compensatory smoking. Photo credit: Gauthier Pierre, Pexels.
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Sweden became one of the first countries to achieve smoke-free status, due to the widespread use of snus. Photo credit: Lisa Risager, CC2.0.
Regulatory bodies have long sought to curb smoking-related illnesses by targeting nicotine, of-ten through policies aimed at limiting its levels in cigarettes. However, those within the tobacco industry and scientific communities understand that nicotine itself is not the primary driver of smoking-related diseases. A growing body of research continues to demonstrate that combustion, not nicotine, is responsible for the most serious health consequences associated with smoking.
The science behind combustion and smoking-related illnesses
Numerous studies have reaffirmed that it is the burning of tobacco that generates harmful by-products, rather than nicotine itself. The comprehensive report Public Health Consequences of E-Cigarettes (2018), published by the National Academies of Sciences, Engineering, and Medicine and edited by Kathleen Stratton, Leslie Y. Kwan, and David L. Eaton, highlights that the most significant harm from smoking comes from inhaling combustion by-products rather than nicotine exposure. Similarly, the Royal College of Physicians’ 2016 report Nicotine Without Smoke: Tobacco Harm Reduction states that while nicotine plays a role in maintaining smoking behavior, it is not responsible for smoking-related diseases.
Further supporting these findings, a study titled Exposure to Harmful and Potentially Harmful Constituents in Cigarette Smoke: A Comparison Between Smokers and Users of Reduced-Risk Products (2017), published in the Journal of the American Medical Association (JAMA), analyzed toxicant exposure among smokers and users of alternative nicotine products. The research, conducted by Neal L. Benowitz et al., concluded that smokers who transitioned to non-combustible nicotine products exhibited significantly lower levels of harmful biomarkers, reinforcing the argument that combustion – not nicotine – is the primary driver of health risks.
US FDA’s nicotine reduction policy
Despite clear scientific evidence distinguishing nicotine from combustion-related harms, the US Food and Drug Administration (FDA) recently introduced a policy aimed at capping nicotine levels in cigarettes. The proposal would mandate a drastic reduction to just 0.7 milligrams per gram of tobacco, a fraction of the current levels. FDA’s stated objective is to make cigarettes less appealing and reduce dependence.
However, the effectiveness of this policy remains highly contested. Critics argue that reducing nicotine levels may lead to unintended consequences, particularly compensatory smoking—where smokers consume more cigarettes or inhale more deeply to satisfy their nicotine needs, thereby increasing their exposure to combustion by-products. A review published in the International Journal of Drug Policy (2017) by Lynn T. Kozlowski and Kenneth E. Warner examined historical efforts to reduce nicotine in cigarettes and found that such approaches often resulted in smokers adjusting their consumption habits in ways that increased their overall toxicant exposure.
Additionally, past research on low-nicotine cigarettes, such as the Reduced Nicotine Content Cigarette Studies (2015) conducted by Eric C. Donny et al. and published in the New England Journal of Medicine, has shown that while lower-nicotine cigarettes may reduce dependence in some users, they also lead to compensatory smoking in others.
Harm reduction strategies that work
Unless effective harm reduction alternatives are widely available, policies aimed at reducing nicotine content in cigarettes may fail to achieve their intended public health benefits. A more effective strategy for reducing smoking-related illnesses involves providing smokers with lower-risk alternatives to combustible products. Several countries have implemented harm reduction policies that prioritize non-combustible nicotine delivery, with significant public health benefits.
Sweden: the snus model
A study published in Nicotine & Tobacco Research by Lars Ramström and Coral E. Gartner (2018) highlighted the role of snus in Sweden’s declining smoking rates and its lower incidence of lung cancer and cardiovascular disease compared to other European nations. Despite the European Union banning snus sales in most member states, Sweden, where it remains legal, continues to report some of the lowest smoking-related disease rates in the region. So much so, in fact, that Sweden became one of the first countries to achieve “smoke-free” status, with smoking rates dropping below 5%—far ahead of its target, showcasing the effectiveness of harm reduction. This success is largely attributed to the widespread use of snus that has helped many smokers transition away from combustible cigarettes.
Japan: heated tobacco products (HTP)
Japan has taken a different approach by embracing heated tobacco products (HTP), significantly reducing harmful emissions. The rapid uptake of HTP has led to a dramatic decline in cigarette sales. Research titled Biomarker Differences in Smokers Switching to Heated Tobacco Products (2020), published in Tobacco Control by Kaname Uno et al., found that HTP users had substantially lower levels of toxic biomarkers compared to cigarette smokers, further reinforcing their harm reduction potential.
Vaping as a harm reduction tool
The use of e-cigarettes as a harm reduction tool has gained significant support in countries such as the UK and New Zealand. Public Health England’s landmark report E-Cigarettes: An Evidence Update (2015), led by Ann McNeill and Peter Hajek, concluded that vaping is at least 95% less harmful than smoking. Similarly, New Zealand has integrated vaping into its national smoking cessation programs, resulting in a sharp decline in smoking rates. A longitudinal study titled The Impact of Vaping on Smoking Cessation: Evidence from New Zealand (2019), published in Addiction by Jamie Hartmann-Boyce et al., found that smokers who switched to e-cigarettes had a significantly higher success rate in quitting compared to those who used nicotine replacement therapy alone.
Regulatory and public perception challenges
Despite the clear benefits of harm reduction, regulatory and public perception challenges persist. Misinformation about alternative nicotine products continues to shape public opinion. A study in Health Communication (2020) by Sarah E. Evans-Polce et al. found that a significant percentage of smokers mistakenly believe that e-cigarettes and HTP are as harmful as traditional cigarettes, a perception that can slow harm reduction efforts.
Regulatory barriers also pose significant obstacles. The European Union’s continued ban on snus outside Sweden prevents wider adoption of a product with proven harm reduction potential. Meanwhile, stringent advertising and flavor bans on e-cigarettes in various jurisdictions may reduce their appeal to smokers seeking alternatives to combustible cigarettes.
A more pragmatic path forward
The evidence overwhelmingly indicates that reducing exposure to combustion by-products should be the central focus of tobacco control efforts, rather than targeting nicotine itself. Countries that have embraced harm reduction strategies—whether through snus, heated tobacco products, or vaping—have demonstrated significant public health benefits. Policymakers must take these lessons into account and adopt a more pragmatic approach that prioritizes harm reduction over nicotine reduction.
As regulatory frameworks continue to evolve, the challenge will be to balance public health objectives with consumer choice and industry innovation. Ensuring that reduced-risk products remain available and accessible to smokers is critical to driving down smoking-related illnesses without unintended consequences such as compensatory smoking or the growth of illicit markets.
Ultimately, the future of tobacco regulation should be guided by science rather than ideology. By shifting the focus away from nicotine content and toward reducing the harmful effects of combustion, policymakers can create a more effective and evidence-based approach to reducing smoking-related disease while maintaining consumer access to lower-risk alternatives. This strategy, supported by scientific research and real-world case studies, provides a sustainable and scientifically sound path forward for the industry and public health alike.