Advice to WHO nations to consider mandatory low-nicotine cigarettes is premature, UB researcher says

BUFFALO, N.Y. – A panel of tobacco researchers that guides 180 World Health Organization countries on developing constructive new regulations for tobacco products recently advised the group to consider a “global nicotine reduction strategy.”

This strategy would require that very low nicotine cigarettes could be the only cigarettes sold legally. These cigarettes would have so little nicotine in the tobacco that they would not create an addiction to cigarettes. This advice also warned that only countries with extensive tobacco-control programs should try this.

But the scientific evidence to date doesn’t support such a recommendation at this time, even for countries with very strong tobacco control programs, a University at Buffalo researcher writes in a new paper published online July 1 in the journal Tobacco Control.

Lynn T. Kozlowski, a professor of community health and health behavior in UB’s School of Public Health and Health Professions, cautions that much more needs to be known about the effects of such an untested prohibition or ban of traditional cigarettes before any WHO nations implement the recommendation.

“Countries need to appreciate that such a ban or prohibition of traditional cigarettes has not yet been assessed anywhere in a community with a representative sample that includes individuals with mental health or other substance abuse issues,” says Kozlowski, PhD.

The WHO Framework Convention on Tobacco Control in 2003 was the first international treaty created by the WHO. Some 180 countries — including Afghanistan, Austria, Bangladesh, Belize, France, Greece, Nigeria, Spain, Sweden and Zimbabwe — have ratified the treaty. WHO has a panel of tobacco researchers, known as “TobReg,” that offers recommendations to members of the Framework Convention.

In addition to advising that members sell only low-nicotine cigarettes, TobReg also advises that it would be important to have alternative, safer forms of nicotine products available.

However, Kozlowski says, the reality in the world right now is that many countries ban less-harmful products. For example, Canada prohibits nicotine-containing e-cigarettes, while the European Union (outside of Sweden) bans snus, a low-nitrosamine Swedish-style oral smokeless tobacco. Both products are estimated to be more than 90 percent less harmful than cigarettes.

“The so-far very preliminary, suggestive research in non-representative samples does not yet justify TobReg’s qualified recommendations for global deployment of such product regulations,” said Kozlowski. “The effects of prohibitions on traditional cigarettes by means of mandatory low-nicotine cigarettes need to be assessed in better samples and in real-world communities before being disseminated.”

Think of it this way, Kozlowski says: “Imagine a coffee lover who likes caffeine in his coffee. If only decaffeinated coffee — which has a little caffeine in it — could be legally sold, the aforementioned coffee drinker would perceive a prohibition on the product he prefers, even though decaffeinated coffee was still available.”

Banning a desired product could create contraband markets, as well as costs associated with enforcing the ban, Kozlowski points out.

Moreover, Kozlowski says, the scientific evidence on the effectiveness of reduced-nicotine cigarettes “shows quite small effects of doubtful clinical significance” and has been conducted on samples that aren’t representative of smokers overall.

“Evidence of very small good effects on a few smokers should not be used to justify a disruptive and coercive cigarette prohibition,” he says.

“The recommendations are not warranted until long-term studies on representative samples of smokers show this is good for public health overall,” he said. “A country needs to try this and see what happens before others follow suit. Having an optional low-nicotine cigarette that some smokers might want to use is very different than making such cigarettes the only legal cigarettes. When these low-nicotine cigarettes have been on the market and heavily promoted, they have proven to be commercial failures.”

Reduced-nicotine cigarettes would also represent a far different tobacco-control strategy than previous ideas, such as plain packaging and graphic warning labels, which, Kozlowski notes, don’t change the product itself.

“On balance, it is very hard to see that we are close to having an evidence base that would support any government to embark upon implementation of a mandatory regulation for all their smokers — no matter how advanced their tobacco-control programming,” Kozlowski writes in the paper.