From October 1, Australians who use e-cigarettes and other vaping products containing nicotine will need a doctor’s prescription to buy them from a local pharmacy or to order them from overseas.
But there’s another evidence-based way to help more smokers quit, which Australia is yet to act on: reducing the nicotine in cigarettes to non-addictive levels. And e-cigarettes could play an important role in this policy.
If you know someone who’s ever tried to stop smoking and failed, nicotine addiction is likely the reason they found it so hard. While nicotine itself is not a significant direct cause of the health harms from smoking, it makes tobacco products highly addictive. In 1963, tobacco industry lawyers wrote:
We are […] in the business of selling nicotine, an addictive drug.
So what are other countries doing to reduce nicotine addiction? What role could alternative nicotine products including e-cigarettes play, and how could reducing nicotine in cigarettes backfire if not managed well? And how much potential does a new very low nicotine standard for cigarettes have to end Australians’ addiction to smoking?
How other countries are tackling a global killer
Most people know someone who has died or developed serious health problems from smoking.
Even today, smoking remains the leading preventable cause of early death in Australia, causing the deaths of more than 20,000 Australians every year. It also costs the Australian economy $136.9 billion annually.
That’s why many countries, including Australia, are setting targets to reduce smoking to very low levels. But new approaches are needed to achieve this goal.
Reducing the nicotine levels in cigarettes to non-addictive levels was first proposed by the US Food and Drug Administration in 1994. While it was not implemented at that time, there has been renewed interest in this policy.
New Zealand recently proposed a nicotine reduction strategy as an option for its Smokefree Aotearoa 2025 Action Plan.
US President Joe Biden’s administration is also considering the US Food and Drug Administration’s proposal to reduce nicotine levels to “give addicted users the choice and ability to quit more easily”.
The World Health Organization supports a global nicotine reduction strategy and has provided recommendations for implementing it.
The good news is that it’s possible to reduce nicotine levels in cigarettes, and such cigarettes have already been tested in clinical trials.
Results show people smoke fewer cigarettes when given ones where the nicotine level has been reduced by 95% or more compared to regular cigarettes. They are also more likely to quit smoking. This is because those who smoke regularly find cigarettes with very low levels of nicotine less enjoyable and rewarding.
While it is not ethical to conduct similar studies with young people who do not already smoke, reducing nicotine levels is also expected to reduce the number of adolescents who become addicted to smoking, with promising results from animal studies.
How could alternative nicotine products help?
Allowing only very low nicotine content cigarettes to be sold would require increased investment in smoking cessation services and support, such as nicotine replacement therapies (including patches and gum), prescription medicines, and behavioural support from health professionals.
A nicotine reduction policy for tobacco products has also been made more feasible by the Australian government’s changes to how smokers can access nicotine-containing e-cigarettes from October 1 2021.
While not harmless, e-cigarettes are likely to be significantly less harmful than smoked tobacco products. They can provide an alternative source of nicotine for those who are nicotine dependent, and have been shown to increase quitting compared to nicotine replacement therapy.
Ensuring access to lower risk forms of nicotine is central to the policies being considered by both New Zealand and the USA.
But there are possible unintended consequences of a nicotine reduction policy. Many people hold misconceptions about nicotine and one risk is that people may believe reduced nicotine cigarettes are less harmful than regular cigarettes. This could reduce motivation to quit smoking.
That’s why we would also need a health education campaign encouraging people to quit tobacco smoking, and warning of the harms of continued smoking regardless of nicotine content.
Another risk is a growth in the illicit tobacco market, which would need to be monitored with increased enforcement effort.
Policymakers may also be concerned about the tobacco industry mounting legal challenges. However, Australia’s successful defence of tobacco plain packaging laws show that such industry challenges can be overcome.
Making it easier to quit — and stop kids ever getting hooked
Michael Russell, a founder of medical approaches to help people quit smoking, famously said if nicotine was removed from cigarettes, people would “be little more inclined to smoke cigarettes than they are to blow bubbles or light sparklers”.
Modelling suggests that mandating very low nicotine levels for cigarettes would give New Zealand a “realistic chance” of reaching its target of less than 5% of the population smoking. It has been estimated that 24 million deaths in the USA would have been prevented if nicotine in cigarettes had been reduced decades ago.
If we make tobacco smoking less addictive, we could prevent a new generation becoming addicted to smoking and help people who currently smoke to quit. And that’s a good thing, given the high cost of cigarettes and their contribution to health inequalities in Australia.
Australia led the world in tobacco policy by introducing tobacco plain packaging laws. Taking a leading role in new tobacco control policies, such as reducing the addictiveness of tobacco products, could help us achieve a smoke-free Australia.
But does Australia have the critical ingredient — political will — to finish the task?