Low-nicotine Cigarette Smokers and Compensatory Smoking

Despite concerns that reducing nicotine levels in cigarettes could have unintended effects on smoking behavior, findings from two recent studies suggest that smokers do not smoke more cigarettes or smoke more intensely when using low-nicotine cigarettes.

Smoking is the number one preventable cause of death worldwide, according to the U.S. Centers for Disease Control and Prevention (CDC), and is a major risk factor for lung cancer. 

The presence of nicotine in cigarettes makes smoking highly addictive. To help combat the addictiveness of cigarettes, the U.S. Food and Drug Administration (FDA) is considering a policy that would require the nicotine content in cigarettes to be reduced to a minimally addictive level. 

Two studies recently published in Cancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research (AACR), examined how reducing the nicotine content of cigarettes might affect the way that cigarettes are smoked.

“It is important to understand how a policy such as the one proposed by the FDA might impact the smoking behaviors of current smokers,” said Tracy Smith, PhD, assistant professor at the Medical University of South Carolina and Hollings Cancer Center and the lead author on both studies.

One of the concerns associated with lowering the nicotine content of cigarettes is that this may lead to compensatory smoking, such as smoking more cigarettes and/or smoking differently to acquire more nicotine. 

“If using low-nicotine cigarettes results in compensatory smoking, there could be a negative impact on public health due to increased exposure to harmful constituents in the smoke,” Dr. Smith said. “The purpose of our studies was to determine if smokers engaged in compensatory smoking when using low-nicotine cigarettes.” 

In the first study, Dr. Smith and her colleagues asked whether smokers using low-nicotine cigarettes changed the way they smoked, such as increasing intensity of their puffs, to obtain more nicotine. The researchers utilized data from a larger clinical trial in which participants were randomly assigned to receive either cigarettes with normal nicotine content or one of four different low-nicotine content cigarettes. Participants were asked to smoke only the provided cigarettes and to collect and return their used cigarette butts for analysis. The study duration was six weeks, and cigarette butts were collected during weeks two and six. 

The authors found no significant differences between the observed nicotine intakes and the expected intakes, suggesting that participants using low-nicotine cigarettes most likely had not increased the intensity of their puffs to obtain more nicotine. 

“The data from this study are important because they suggest that smokers do not engage in compensatory smoking by smoking each cigarette more intensely when switching to low-nicotine cigarettes,” said Dr. Smith. 

“However, we know that some participants smoked non-study cigarettes with normal nicotine levels, even though we asked them to smoke only the cigarettes we provided,” she added. “Since we were only able to analyze the butts of the provided study cigarettes, we don’t know the nicotine intake or smoke exposure from these other cigarettes.” 

It is possible that participants smoked non-study cigarettes more intensely.

In the second study, Dr. Smith and her colleagues asked whether smoking low-nicotine cigarettes would impact the number of cigarettes that participants smoked per day. Unlike the previous study, participants in this study did not have access to non-study cigarettes since all 16 participants were isolated to a hotel where they could only purchase the cigarettes provided by the study. All study subjects participated in two four-night hotel stays, separated by one week. During the first stay, the study cigarettes had a normal nicotine content, while the study cigarettes during the second stay had a low nicotine content. Participants collected and returned used cigarette butts, which were counted to determine the number of cigarettes smoked per day. 

The researchers found that there were no significant changes in the number of cigarettes smoked per day when participants switched to low-nicotine cigarettes. 

“Together, these studies show that when smokers switch to low-nicotine cigarettes, there is no evidence of stable compensatory smoking,” Dr. Smith said. “These data provide critical information about the effects we might observe if the FDA were to implement a policy mandating the reduction of nicotine in cigarettes to a minimally addictive level.”