Tobacco is addictive, primarily because of the presence of nicotine.1 Although nicotine itself is not the direct cause of most smoking-related diseases, addiction to nicotine in tobacco is the proximate cause of these diseases because it sustains smoking behavior.2,3
Thus, the magnitude of public health harm that is caused by tobacco is inextricably linked to its addictive nature.
There is a continuum of risk for products that deliver nicotine, ranging from the most harmful combusted products (e.g., cigarettes) to medicinal nicotine products. As the most widely used tobacco products, cigarettes are the leading cause of preventable death and disease in the United States.4 In 2014, the Surgeon General estimated that approximately 480,000 deaths annually are caused by cigarette smoking.4
The majority of cigarette smokers in the United States began smoking during their youth,4-6 which is a cause for concern. The age at which people begin smoking can greatly influence how much they smoke per day and how long they smoke, which ultimately influences their risks of tobacco-related disease and death.7-9 Addiction to nicotine in tobacco is critical in the transition of smokers from experimentation to sustained smoking and in the continuation of smoking for those who want to quit.4,10
In July 2017, in an acknowledgment of the link between smoking-related harms and the addictive qualities of nicotine, as well as the disproportionate effect of nicotine addiction on children and teenagers, the Food and Drug Administration (FDA) announced a regulatory plan to explore lowering the nicotine level in cigarettes.11,12 To enact a regulation lowering the nicotine level in cigarettes, the FDA must consider scientific evidence regarding “the risks and benefits to the population as a whole, including users and nonusers of tobacco products,” along with “the increased or decreased likelihood that existing users of tobacco products will stop using such products” and “the increased or decreased likelihood that those who do not use tobacco products will start using such products.”13
Simulation models can be used to project the potential population-level effects of regulatory actions.14 The purpose of this analysis is to quantify the potential public health effects of enacting a regulation in the United States that makes cigarettes minimally addictive by setting a maximum level of nicotine in cigarettes. Using a simulation model with inputs derived from empirical evidence and expert opinion, we estimated the effect of such a policy on the prevalence of tobacco use, tobacco-related mortality, and life-years gained.
Apelberg BJ, Feirman SP, Salazar E, Corey CG, Ambrose BK, Paredes A, et al. – New England Journal of Medicine – 2018-05-03.
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