Reducing Nicotine Content of Cigarettes- Public Health Implications

Hannah Schmidt, Pharm.D., FirstLight Health System

Tobacco is the leading cause of preventable death not only in the United States but worldwide. The initiation of tobacco use is disproportionally high during one’s youth, starting with experimentation and leading to addiction due to the nicotine content of tobacco products.1 While smoking may be the cause of harm, addiction to nicotine sustains use and leads to a great burden on public health. Due to this, in July 2017, the FDA released an advanced notice of proposed rulemaking (ANPRM) to gain insight and opinions on requiring a reduced nicotine level in combustible tobacco products to discourage future addiction in our nation’s youth and to promote smoking cessation.2

To lend expert opinion to the ANPRM, a simulation model analysis published in the New England Journal of Medicine assessed the risk and benefits of reducing the nicotine content of combustible tobacco.1 Utilizing data from the 2015 Census estimates, National Health Interview Survey estimates, and the National Youth Tobacco Survey, the use of cigarettes and effect on tobacco-related mortality and life-years gained was assessed. The analysis also included the opinion of eight experts on the potential implications of reduced nicotine content over an 80 year span from 2020 to 2100.

The results of the expert opinion and simulation model analysis showed a substantial positive impact on reduction of both smoking initiation and continued use. The distributions of the expert opinions on reduced cigarette use varied, yet all estimated a reduction in cigarette use with a median reduction of 2% [12.8% to 10.8%] in the first year.1 By 2060, the median estimate of smoking prevalence dropped to 1.4%. It was also estimated by 2060, 16 million people who would have initiated smoking with current nicotine levels would not become addicted to smoking, which increases to 33.1 million by 2100. This equates to the prevention of 8.5 million tobacco-related deaths and 134.4 million life-years by 2100. While these are results are based off estimates of current baseline trends and expert opinion, they point towards the potential positive effects of this intervention.

The FDA is currently accepting comments on this topic until June 14th, 2018.2 Current literature, including the above analysis, point to the potential positive implications of reducing the nicotine content of combustible cigarettes. If enacted, maximum nicotine limits for combustible cigarettes may ultimately become a polarizing topic for smokers and non-smokers alike. The FDA decision remains to be seen, but will likely have a monumental impact on public health and millions of lives in the United States.


  1. Apelberg BJ, Feirman SP, Salazar E, et al. Potential public health effects of reducing nicotine levels in cigarettes in the United States. [published online March 15, 2018]. N Engl J Med doi:10.1056/NEJMsr1714617.

  2. Knox, L. Tobacco product standard for nicotine level of combusted cigarettes. Federal Register. 2018;83(52):11818-11843.