To the Editor,
On June 21, 2022, the US Food and Drug Administration (FDA) published plans to develop a product standard requiring tobacco manufacturers to dramatically lower nicotine levels in all cigarettes sold in the United States.1 Over a decade of research demonstrates when people smoke cigarettes with very low nicotine levels when compared to cigarettes with normal nicotine levels, they experience reductions in the number of cigarettes smoked per day, harmful toxicant exposure, dependence and increases in quit attempts.2–4 The estimated impact of a low nicotine product standard for cigarettes indicates upwards of 5 million quit attempts within the first year of implementation and by the year 2100 a reduction of the overall smoking prevalence from 12.5% to 1.4%, and prevention of over 8 million deaths.5
Although the public health impact is potentially groundbreaking, we must also ensure the benefits are equitably distributed. For example, clinical trials examining the impact of cigarette nicotine reduction among populations suffering disproportionately from smoking (e.g. individuals with mental health conditions or of lower socioeconomic status) have found positive benefits,4,6 albeit potentially attenuated for some populations.6 Such data are encouraging and a critical step towards understanding how such a policy affects populations suffering disproportionally from smoking. However, to maximize the benefits for these populations, prioritizing health equity and intentional actions are required.
A nicotine product standard could serve as a major catalyst towards achieving health equity, but likely only if an equity lens is applied to every level of implementation by the FDA as well as public health professionals and organizations at the tribal, federal, state, and local levels. An equity lens means ensuring the following for populations most burdened by smoking: Continued investment in tobacco prevention and control strategies, availability of FDA-approved smoking cessation medicines, authentic community engagement and listening to concerns regarding the nicotine product standard and resource needs, the development of targeted health communication describing the standard in advance, and potentially the availability of alternative, less harmful tobacco products for those who still want or need nicotine. Recently, New Zealand also announced its intent to implement a low nicotine product standard.7 The Smokefree Aotearoa 2025 Action Plan prioritizes health equity and provides a useful blueprint for an equity-focused implementation plan for the United States.7 Focusing on and developing a health equity approach should not, however, delay implementation given the countless deaths a nicotine product standard could avert.
Supplementary Material
A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.
Contributor Information
Dana Mowls Carroll, Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
Dorothy Hatsukami, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Minnesota, Minneapolis, MN, USA.
Rachel Denlinger-Apte, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Funding
This work was supported by National Institute of Drug Abuse and the Food and Drug Administration’s Center for Tobacco Products, grant number U54DA03165 and the National Institute on Minority Health and Health Disparities, grant number K01MD014795. This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.
Declaration of Interests
None declared.
References
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