Reducing the excess nicotine in cigarettes
Proposed
policy to reduce tobacco addiction
Aim Assist smokers and protect young
people by making cigarettes less addictive.
·
Most smokers know they ought to quit for
health reasons.
·
Tobacco addiction varies among smokers from
mild to fierce.
·
A less fierce addiction could make it
easier for many adolescents to quit before becoming regular smokers, and
make it easier for many older smokers to quit.
Feasibility.
The nicotine content of cigarettes can be reduced, without smokers
noticing, and safely, without compensatory smoking or increased harm to
smokers.
·
Manufacturers
can remove nicotine. Example: Quest low-nicotine-content cigarettes
sold in the US.
·
Without
smokers noticing: With a minimum of seven step-downs each at least
four months apart, with 90% of smokers not expected to notice any given
stepping down of nicotine. The reduction is applied to all brands
simultaneously. The reduction can be spread over a longer time frame, for
example six months per step. www.endsmoking.org.nz/nicfadeout.htm
·
Safely,
without causing compensatory smoking. Nicotine reduction is
safe. Health and tobacco company researchers8 9 have recently
shown that if the nicotine but not the tar yield is reduced, smokers will
not over-smoke (compensatory smoking). Thus nicotine can be safely
reduced without breathing more toxicant gases, and addiction can be
reduced also.
Perceived problem: Reducing nicotine content can reduce nicotine
yield (the nicotine in mainstream smoke), which in turn can persuade the
smoker to inhale more smoke to obtain sufficient nicotine (compensatory
smoking). Compensatory smoking leads to increased inhalation of smoke
whenever low tar low nicotine cigarettes are smoked. This would be
harmful if nicotine was decreased.
Solution:
Leading scientists both outside8 and inside9 the
cigarette manufacturing industry, have recently found that compensatory
smoking only occurs when tar is also reduced. It does not occur for
example, with Quest (low nicotine medium tar) cigarettes (Vector Tobacco
Company).8
Compensatory smoking is thus
something that manufacturers know about and can produce or eliminate by
their control of the engineering design and tobacco blend used for each
cigarette brand. Regulations can require manufacturers to retain
sufficient tar deliveries, or otherwise demonstrate to the Ministry of
Health as regulator, that a reduced nicotine content cigarette will not
produce compensatory smoking. As most of the harm comes from gases not
tar,12 the overall effect of reducing nicotine content is not
harmful.
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Figure 1. Nicotine content and nicotine
absorbed per cigarette, versus threshold (minimum) required daily to
sustain addiction
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Content per brand: Blakely T et al. ESR 1997. NZ Publ Hlth Report
Threshold: Benowitz, Henningfield NEJM 1994;
Absorbed: Djordjevic et al.
Doses of nicotine and lung carcinogens delivered to cigarette smokers.
JNCI 2000; 92: 106-111.
Two to three cigarettes daily
provide enough nicotine to maintain addiction.
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Cigarettes
provide more than sufficient nicotine for smoking pleasure, whether
measured by nicotine content or by yield. Even when nicotine content
has been reduced by 30% over five years to 9 mg per cigarette, and the
amount absorbed reduced in proportion, it would only require 2 to 3
cigarettes a day to stay addicted.
Rationale
for a national nicotine reduction policy
This policy is aimed to particularly assist
the 34% of smokers that are most addicted, who smoke 10 or more
cigarettes a day and who smoke a cigarette within half an hour of waking.2
If the addiction was less fierce, they could be free to enjoy life more,
and have a real choice to quit if they wished.
Those most addicted are most at risk.
Lung cancer patients for example, have a higher addiction score.3
Cigarette nicotine is excessive -higher
than in other countries. New Zealand
cigarettes contain on average 12.8 mg nicotine per cigarette,4
higher than reported from the UK,
US and Canada.5
Cigarette nicotine is higher than needed
to maintain addiction Of the
12.8 mg cigarette nicotine, 15% is found in mainstream smoke (1.9 mg).6
Thus 3 cigarettes a day will provide the 5 mg nicotine daily needed to
maintain addiction.6 Intensely smoked, one or two cigarettes
could maintain addiction.
All cigarettes contain excess nicotine.
Even “low nicotine yield” cigarettes sold in New
Zealand contain excess nicotine. (11
mg).4 In May 2005 New Zealand smokers could not buy any brand
which is truly low nicotine, to help them “taper” or wean
themselves off nicotine.
Feasibility. Cigarette makers can
supply low nicotine cigarettes. In the United States, Vector Tobacco
Company manufactures one brand (Quest), a truly low nicotine content
cigarette and sells it in northwestern states. Smokers wishing to quit
can switch to Quest 1 which contains 8.9 mg nicotine, then to Quest 2
which contains 4.9 mg; then to Quest 3, containing 0.5 mg nicotine. (www.vectortobacco.com )
Acceptability A significant minority
of smokers will switch to truly non-nicotine cigarettes if both are
available, but not to gum.10 Regulation would allow sale only
of only low nicotine cigarettes.
Misleading packet labeling. Mild, extra-mild, and light
labels, and low nicotine ratings on packets indicate that smokers get
less tar and nicotine. However, nicotine yield on smoke test, as stated
on cigarette packets, bears no relation to the amount of nicotine
absorbed by smokers.11 Current regulations, the Smoke-free
Environments Regulations 1999, also require or permit the same misleading
nicotine smoke yield labeling.
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Figure 2. Once nicotine content per cigarette falls below 2
mg, smoking prevalence falls rapidly.
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·
Current trend The upper plot line is the current trend.
·
Giving smokers access to smokeless nicotine
or tobacco. The middle plot
line represents the accelerating effect of making addictive nicotine
available as an alternative to smoking. In addition, cigarette nicotine
content is reduced by one eighth (12.5%) each year.
·
Reduced nicotine content. From 2012, when nicotine content falls
below 2 mg per cigarette, smoking is no longer attractive, so smokers
either switch to smokeless forms of nicotine or tobacco which now seem
more appealing, or quit altogether. The percentage still smoking
dwindles, aiding any ban on cigarette sales.
Current government policy
·
Nicotine replacement therapy (NRT) as gum
and patches are subsidized through the Quit programme.
·
Nicotine yield of cigarette smoke is
tested by the manufacturer but not audited, and printed on the
packet.
·
There is no requirement to state the
nicotine content of the tobacco or cigarette to the smoker.
·
There is no regulation controlling how
much nicotine is in the cigarette.
·
Nicotine keeps smokers smoking (dirty or
smoke nicotine). Nicotine in other products is seldom lethal.
Why strengthening this policy is high priority
·
Addiction to smoking tobacco kills
- by causing smokers to keep on smoking – for 20 years or more,
until smoking causes fatal diseases for over 4000 smokers annually (12
per day). Pure nicotine (gum) seldom addicts, and can be chewed daily for
five years without ill effect.1
·
84% of NZ smokers said their smoking is
a form of addiction2 – a much higher percentage than
for alcohol or other drug users.
The proportion of smoking their first cigarette of the day within
half an hour of rising was 78% of those smoking over 20 cigarettes a day,
43% of men, 43% of women, 37% of white collar, 41% of blue collar
workers, 50% of those not in paid work, 43% of European, 41% of Maori,
and 34-38% of those age 20-34, 45% of those age 35 years and over.2
·
Addiction is perpetuating tobacco smoking.
Most New Zealand
smokers have tried to quit but almost as many as quit, relapse. This
explains why adult smoking decreases slowly despite some quitting
activity.
Proposed national cigarette nicotine
policy
Nicotine content reduction to make it
easier for smokers trying to quit. That Ministry of Health develop a
national policy to reduce tobacco addiction with the aim of making it
easier for smokers to quit, with new regulations to take effect in 2006.
Nicotine content labeling. Following its 2005 regulatory
review, that Ministry of Health draft new regulations under the Smokefree Environments Act to update cigarette packet
labeling so that it informs smokers of nicotine content.
In detail: the
policy would be multi-faceted
1 Regulation
(under existing powers of Section 31 of the Smokefree
Environments Act) to gradually remove the excess nicotine in New Zealand cigarettes, simultaneously across all brands
sold. Manufacturers control the nicotine content of their brands,
directly or indirectly. Government can monitor nicotine content of
cigarettes and tobacco sold by requiring spot testing (at
manufacturers’ expense) of cigarettes sold. The maximum permitted
nicotine content of all cigarettes sold in New Zealand can and should be reduced gradually towards
zero. Done gradually, this
should not interfere with smoking pleasure until the 6th
reduction, provided steps are at least four months apart. Its gradual
reduction would tilt the balance and make it easier for many to quit
smoking.
Substantial
reduction in nicotine content
will require parliamentary approval by amendment to the Smoke-free
Environments Act. www.endsmoking.org.nz/lawchanges.htm
2.
Enhanced quitting services- These will be needed more than ever
once nicotine content decreases.
3.
Use of cigarette manufacturers’ knowledge as to how
to add or subtract nicotine as required.
4.
Ban on import of cigarettes for personal use. Personal import of
cigarettes would circumvent the requirement for reduced nicotine content. This ban would therefore have to
apply to the duty free tobacco and cigarette allowance for returning
residents.
5.
Supportive policies Support for gradually reducing nicotine to
low levels will require
·
Access to nicotine products once
cigarettes no longer satisfy smokers’ nicotine addiction.
· Monitoring; Regular surveys
of smokers and their level of addiction are needed before during and
after the intervention goes into effect.
· Policy research.
·
Research to determine whether this type of
cigarette (Reduced nicotine cigarette or RNC) helps smokers to quit when
given Quest 1, 2 and 3. The Clinical Trials Research Unit, School
of Population Health, University
of Auckland, funded by Health
Research Council of NZ, will recruit participants to this trial in 2008.
·
Acceptability trials for smokers staying
on Quest 1, compared with acceptability of nicotine substitutes.
· Public
education; particularly before the law is passed, and again before it
is implemented;
· Sale
of nonsmoking nicotine products alongside cigarettes can be required
by regulation;
· Regulatory
approval of more effective nicotine products that would provide a
nicotine fix without the dangers of smoking
Expected consequences. Smoking prevalence, at 21% initially,
would be largely unaffected until 20 months, when it would fade rapidly
to a new low plateau of approximately 5% still smoking. Demand for
nicotine patches and gum (and personal mail orders for smokeless tobaccos
perhaps) would likely increase greatly for a few months, and then
decrease to a new steady level.
______________
1. Murray
RP, Bailey WC, Daniels K, et al. Safety of nicotine polacrilex
gum used by 3,094 participants in the Lung Health Study. LHS Research
Group. Chest 1996; 102: 438-45.
2. National
Research Bureau. Environmental Tobacco Smoke survey for Ministry of
Health. Wellington: MoH 1996. www.ndp.govt.nz/tobacco/documents/1996etspdf.pdf
3. Kunze U, Schoberberger R, Fagerstrom KO et al. High nicotine dependence among lung cancer
patients. Eur Respir
J 1996;9:23.
4. Blakely
T, Laugesen M, Symons R, Fellows K. New Zealand cigarettes have a high nicotine content. NZ
Public Hlth Rep. 1997; 4: 33-4, and 85.
5.
Kozlowski, LT.
Mehta NY, Sweeney, CT. et al. Filter ventilation and nicotine content of
tobacco in cigarettes from Canada,
the United
Kingdom,
and the United
States. Tob. Control, Dec 1998;
7: 369 - 375.
6. Baker RR.
Smoke chemistry. In Tobacco, production, chemistry and technology. ed. Layten Davis, Mark T Nielsen. Blackwell Publishing
1999, p.410
7. Benowitz NL, Henningfield
JE. Establishing a nicotine threshold for addiction. The implications for
tobacco regulation. N Engl J Med 1994; 331:
123-5.
8. Benowitz NL, Hall SM, Dempsey D et al. Safety of a
nicotine reduction strategy. Abstract PA6-4. SRNT Conference Arizona 2004.
9. Dixon M, Kochhar N, Prasad K. et al.
Psychopharmacology 2003; 170: 434-42.
10. Johnson MW, Bickel WK, Kirschenbaum AP. Substitutes for tobacco smoking: a behavioural economic analysis of nicotine gum, denicotinised cigarettes, and nicotine-containing
cigarettes. Drug Alcohol Depend 2004 74: 253-64.
11. Hedges
B, Jarvis MJ. Cigarette smoking. In Prescott-Clarke P, Primatesta P. eds. The Health Survey for England: the health of young people
’95-’97. London UK. The Stationery Office. 1998. p.191-221.
12 Laugesen M. Fowles
J. Scope for regulation of cigarette smoke
toxicity according to brand differences in published toxicant emissions. http://www.nzma.org.nz/journal/118-1213/
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