Science Reflective of Real-World Experience is Essential to Effective Tobacco and Vapor Policy
Science and evidence should be the foundation of all public health policy. That might feel like an obvious statement, but the unfortunate reality is, it’s not always the case, particularly in debates over tobacco control and policies impacting potentially less harmful alternatives. We face a persistent challenge: separating scientific reality from deeply entrenched assumptions. Throughout my career in tobacco and tobacco alternative policy, I’ve observed decisions shaped not by evidence, but by preconceived (and often misguided) notions about nicotine, its consumption, the people who use it and the best ways to reduce the death and disease associated with smoking combustible cigarettes.
One persistent misconception that continues to influence policy discussions centers on nicotine consumption and potential health concerns for adults who transition from combustible cigarettes to vapor products. Regulatory decisions over nicotine caps in e-cigarette liquid and public health concerns over nicotine intake are impacted by a sometimes vague belief that adults who switch from cigarettes to vaping will wind up consuming "more nicotine." It then follows that this assumed increase in total nicotine consumption should be seen as a net negative from a public health perspective because that individual will be as addicted (or perhaps more addicted) to nicotine. These assumptions have been the basis for nicotine caps and other restrictions on vapor products that have limited the availability of products that adults who smoke would find sufficiently satisfying and lead to switching away from cigarettes.
It's a compelling story that fits neatly into existing narratives about addiction and misguided views about the dangers of nicotine in the larger conversation about the health threats driven by combustible cigarettes. There's just one problem: the scientific evidence doesn't support it.
And so, yet again, we find ourselves shaping public policy based on a flawed assumption that isn’t backed up by the scientific evidence. As President John F. Kennedy told the Yale class of 1962, the great enemy of truth is not the lie, but the myth, based in the human predisposition to “enjoy the comfort of opinion without the discomfort of thought.” When new information challenges entrenched beliefs with clear evidence, policies, and the practices that inform them, should be adjusted to reflect that information.
What the Science Actually Shows
Recent independent research published by Neal L. Benowitz, Hao-Yuan Yang, Peyton Jacob III, and Gideon St Helen in Chemical Research in Toxicology challenges assumptions about nicotine consumption from vapor products, and raises questions about how products should be studied to make informed regulatory decisions.
The study used JUUL e-cigarettes to examine nicotine delivery and absorption compared to combustible cigarettes in a "standardized session” (ten 3.5-second puffs over 5 minutes) and across a 4-hour ad libitum use session, where users were free to use products however they wished throughout the time. During the free-use session, participants absorbed similar amounts of nicotine whether using the JUUL system (4.08 mg) or combustible cigarettes (4.98 mg). Peak blood nicotine levels were also comparable: 11.2 ng/mL for JUUL users versus 15.6 ng/mL for cigarette smokers. In a lab controlled standard 10 puff over 5-minute session, there was a notable difference – 0.55 mg for JUUL and more than double, 1.15 mg for cigarettes.
The data demonstrates that when adults who smoke use alternative nicotine delivery systems like vapor products, they naturally regulate their nicotine intake to levels comparable to what they experience with cigarettes. In other words, adult former smokers aren't mindlessly ingesting more and more nicotine just because they can. Rather, they're seeking to satisfy their existing nicotine needs through a potentially less harmful delivery system. By obtaining nicotine satisfaction from an alternative product, these adults can have the experience they seek without using a combustible cigarette and inhaling the numerous disease-causing toxins in combusted tobacco smoke.
This isn't just theoretical. Vapor products have been extensively studied and shown to limit exposure to the same types or levels of toxins associated with combustible cigarettes. Independent research reported by scientists from Brown University found that people who switched completely from cigarettes to JUUL e-cigarettes showed significant reductions in exposure to harmful chemicals associated with cancer, heart disease, and respiratory conditions. Multiple other lines of evidence support this contention.
Breaking Free from Preconceptions
The nicotine consumption study illustrates a broader problem: when assumptions drive policy, we risk creating regulatory frameworks that don't serve public health goals. The research highlights two critical insights that challenge common preconceptions:
Ad lib usage that resembles real-world experience matters: Controlled laboratory tests (standardized puffing protocols) don't accurately predict how people actually use these products in real life. Free-use conditions provide much more realistic data that should inform regulatory decisions like caps on e-liquid nicotine concentrations. Benowitz and his co-authors put it best: “Assumptions used to establish nicotine limits in liquids as predictors of real-life nicotine self-administration are not valid.” Actual nicotine absorption depends on multiple factors and cannot be accurately estimated in standardized lab sessions alone.
Natural consumption adjustment: The data shows that users instinctively moderate their consumption patterns to achieve similar nicotine levels whether using vapor products or cigarettes, directly contradicting the assumption that vapor products lead to higher nicotine consumption. Users of the JUUL system in the study experienced nicotine intake close to levels obtained when smoking, a crucial need in the effort to help adult smokers switch from combustible cigarettes to less harmful alternatives.
The bottom line is that we cannot make good policy if we rely on assumptions or preconceived notions. Regulatory agencies should rely on protocols seeking to better reflect real-world experience and usage patterns when evaluating novel nicotine products. And we need more research that explores the direct policy implications of their findings. If we are truly committed to making cigarettes obsolete, our policies must fairly balance harm reduction with potential health concerns, guided first and foremost by accurate and evidence-based science. Details like nicotine concentrations in e-cigarette products matter and regulatory decisions on these details must account for the whole ecosystem of available research, evidence, and experiences of the adults who may transition away from smoking. Only then can we drive innovations that provide an effective offramp from cigarettes.