Toward a Real Understanding of Nicotine: Addressing Misperceptions that Obstruct the Path to a Post-Cigarette America

In the waning days of the previous administration, a lot of news was generated around the announcement by the FDA of a proposed rule to substantially reduce the nicotine in combustible cigarettes. Now, just a few months later, that proposal’s future is in doubt as it faces political and legal challenges, compounded by a new administration that may not be inclined to push the rule forward.

A recent article in the New England Journal of Medicine highlights just how many ways approval of this rule could get caught up in the crosshairs. It’s tempting to focus on the ins-and-outs of why the rule was proposed when it was, how different actors are seeking to advance or defeat it, how different courts might rule on it, etc. But at the end of the day, what matters is the actual goal, which is not creating a lower-nicotine cigarette. The real goal is making cigarettes obsolete.

Viewed through that lens, the question to consider is whether a singular focus on regulating nicotine levels in combustibles is actually the most direct route to the goal or whether we must widen the aperture of our efforts to focus on a more holistic approach providing alternative products and education. I am concerned that these fights about nicotine run the risk of inadvertently fueling public misperceptions about the health risks of nicotine and ultimately hinder progress toward eliminating cigarettes.

Reviving the First Trump Administration’s Comprehensive Plan

The FDA's recent proposal to limit nicotine in cigarettes to 0.70 mg per gram of tobacco—roughly 4% of current levels—wasn’t a new idea from the Biden administration. In fact, it builds on the foundation laid during President Trump’s first term and then-FDA Commissioner Scott Gottleib’s 2017 Comprehensive Plan to reduce harm from tobacco. That plan recognized a crucial distinction: nicotine's addictive properties should not be conflated with the lethal impacts of combustible tobacco.

The Comprehensive Plan acknowledged that making cigarettes less addictive was just one leg of what needed to be a multi-legged stool. The second leg was making less harmful nicotine alternatives, as well as cessation products, readily available and accessible to the millions of adults who smoke. Encouragingly, the proposed rule holds space for this leg and does not include lowering nicotine in smoke-free alternatives. And the third leg was making sure those adults had access to clear, reliable information about nicotine and the relative risks of smoking versus alternatives.

This three-legged stool envisioned in the Comprehensive Plan was never realized.

I’ve already written about the urgent need to return FDA regulation to the original ethos of the Comprehensive Plan and reform the review process for innovative alternatives to build a robust, authorized market while simultaneously cracking down on the illegal and untested products that have proliferated in the interim. So here let’s turn our attention to the third leg of the stool: ensuring adults who smoke have access to honest information about nicotine from the FDA and public health authorities so they can make informed decisions to improve their health.

Messaging, perceptions and behavior

A frequently overlooked aspect of the public conversation around smoking cessation is the impact of perceptions about nicotine. A study published in Nicotine & Tobacco Research last month provides compelling evidence that an accurate understanding of the relative risks of smoking cigarettes and using alternative nicotine products influences the likelihood of smoking cessation.

Researchers found that young adults who smoke and who correctly perceived vaping as less harmful than smoking were significantly more likely to switch to vaping over a six-year period. This finding complements years of research showing that misperceptions about the relative risks of different nicotine products create barriers to switching away from smoking combustible cigarettes.

When public health messaging fuels misperceptions about the relative risks, it reduces the likelihood of those who smoke transitioning away from cigarettes. And when that leg of the stool is kicked away, the whole policy construct articulated in the Comprehensive Plan is undermined.

Clarity on Nicotine

The problem we collectively face is that misunderstanding of the relative risks of different nicotine delivery products is rampant. Moreover, the messages adult smokers hear from public health authorities can deepen their confusion. Even physicians are not immune, with recent surveys finding the vast majority incorrectly believe nicotine causes cancer. Much of this stems from the fact that public messaging frequently conflates the risks of smoke-free nicotine use with the deadly risks of smoking combustible cigarettes.

Some may argue that “anti-nicotine” messages are necessary to reduce the risk of those who don’t currently smoke from initiation, especially those underage.

While the concern is legitimate, it ought not become an excuse for perpetuating dangerous misperceptions among people who smoke - misperceptions that may keep millions of them smoking when they would otherwise try and likely transition to less harmful alternatives.

Communicating such nuanced information is at the heart of public health and is becoming an increasingly critical function in the era of social media and widespread misinformation. That effort must be rooted in sound science and evidence, delivering a set of clear and understandable messages.

The message need not be beyond the ability of adults to understand: nicotine is addictive - and the best choice for those who have never started using a nicotine product is to refrain from doing so. But for adults who smoke, the most important step they can take for their health is to stop using combustible cigarettes. If a less harmful alternative that delivers nicotine is their best means of transitioning away from cigarettes, then they should try those alternatives until they find one that works for them.