People who switch to cigarettes with dramatically reduced nicotine levels are unlikely to smoke more cigarettes or inhale more smoke to compensate for the lower nicotine content, according to a new study led by researchers at Wake Forest University School of Medicine and published in JAMA Network Open.
The systematic review examined 17 randomized clinical trials involving more than 5,500 adolescents and adults. Researchers found little evidence that smokers compensated for reduced nicotine by increasing their smoking behavior. In fact, researchers found most of the study participants smoked fewer cigarettes after switching to low nicotine. The findings are relevant to a proposed U.S. Food and Drug Administration product standard that would reduce nicotine levels in cigarettes and certain other combusted tobacco products to minimally or nonaddictive levels. The proposed rule remains under FDA review.
“Cigarette smoking is at a historic low, a public health victory, but that’s still 25 million people who smoke,” said lead author Rachel Denlinger-Apte, Ph.D., M.P.H., assistant professor of social sciences and health policy at Wake Forest University School of Medicine.
Data from the Centers for Disease Control and Prevention shows more than 40% of adults in the U.S. smoked in the mid-1960s. That number has dwindled to just under 10% in recent years.
“The prevalence is down, but the numbers are still high, and tobacco is still one of the leading causes of premature and preventable death,” she added.
Public health efforts to further reduce smoking have recently included “very low nicotine content” cigarettes, which contain about 95% less nicotine than conventional cigarettes. Because nicotine is the addictive chemical in cigarettes, lowering nicotine levels could help prevent future generations from becoming dependent on tobacco and support people trying to quit by easing withdrawal symptoms, according to researchers.
However, confusion between low-nicotine cigarettes and so-called “light” cigarettes has fueled concerns.
Unlike low-nicotine cigarettes, “light” cigarettes are not low in nicotine and rely on ventilated filters to dilute inhaled smoke. Developed decades ago, amid growing awareness of tobacco’s health risks, “light” cigarettes resulted in a behavior known as “compensatory smoking,” whereby smokers smoke more or inhale more deeply.
The concern is that lower-nicotine products – if similar to “light” cigarettes – might lead to the same compensatory smoking behavior, ultimately increasing exposing to harmful ingredients over time.
The research shows the opposite.
“Our findings suggest that widespread compensatory smoking is unlikely to occur if a low-nicotine product standard is implemented,” Denlinger-Apte said. “The concern has been that people would smoke more cigarettes or inhale more deeply to get the nicotine they are used to receiving. Across 17 clinical trials, we found minimal evidence that this happens.”
In the systematic review, Denlinger-Apte and colleagues examined clinical trials published between 2010 and 2024 and also performed an analysis using data from more than 2,400 smokers enrolled in seven U.S. studies. They found that none of these trials reported increases in the number of average cigarettes smoked per day among people assigned to the very low nicotine cigarettes. Sixteen of the 17 trials also found participants smoking low nicotine cigarettes actually smoked fewer cigarettes per day than those smoking traditional cigarettes. Many even made spontaneous attempts to quit, Denlinger-Apte said.
Additional findings showed no evidence of reported increases in average carbon monoxide exposure. After six weeks, fewer than 1% of participants were predicted to smoke more.
Denlinger-Apte said evidence like the recent analysis could bolster the chances of proposed FDA policies and ultimately lead to fewer smokers.
“While smoking rates are down, the toll of tobacco use remains substantial, and there is still an urgent need for policies that help prevent nicotine addiction and support people who want to quit,” she said. “Modeling studies have suggested that a nationwide nicotine product standard could substantially reduce smoking over time, including by prompting millions of people to quit.
“It could be one of the most impactful public health policies of this century,” she said.
This research was supported by the National Institutes of Drug Abuse and the FDA’s Center for Tobacco Products grants U54DA031659, U54DA036114, R01DA058264, R01DA046320, K01CA189300 and K01MD014795.
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About Wake Forest University School of Medicine
Wake Forest University School of Medicine is the academic core of Charlotte, North Carolina-based Advocate Health and a recognized leader in experiential medical education and groundbreaking research. It directs the education of nearly 1,900 students and fellows, including physicians, basic scientists and allied clinical professionals. The school of medicine also strategically investigates opportunities that will expand basic and clinical research, resulting in nationally and internationally recognized excellence in biomedical research. The school has two campuses, each co-located with leading-edge innovation districts, The Pearl, in Charlotte, and Innovation Quarter, in Winston-Salem, North Carolina. These affiliated life-sciences innovation districts focus on advancing health care through new medical technologies and biomedical discovery.
About Advocate Health
Headquartered in Charlotte, North Carolina, Advocate Health is the third-largest nonprofit, integrated health system in the United States. A preeminent academic health system at the forefront of clinical excellence, innovation and research, it delivers care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin and Michigan, and Wake Forest University School of Medicine is its academic core. Nationally recognized for expertise in heart and vascular, neurosciences, oncology, pediatrics and rehabilitation, Advocate Health is also a pioneer in the delivery of virtual health care. It is accelerating discovery by making research participation part of the standard-of-care through its one-of-a-kind National Center for Clinical Trials, plus two affiliated life-sciences-focused innovation districts and one of the nation’s largest graduate medical education programs. With more than 165,000 teammates serving patients at 69 hospitals and over 1,000 care locations across eight states, Advocate Health reinvests over $6 billion each year to improve community health, making it one of the nation’s largest providers of community benefit.