Breaking the powerful pull of nicotine

Sometime in the next few years, the 30 million smokers in the United States may wake up one day to find that cigarettes sold at gas stations, convenience stores and tobacconists contain such a minuscule amount of nicotine that they won’t get their usual dose of the substance. when lighting a cigarette.

Will they delve into the excruciating suffering of nicotine withdrawal and go looking for their favorite brand of cigarette, with normal nicotine content, in illicit markets? Or will they opt for e-cigarettes, nicotine gum, or other less harmful ways to achieve that calming effect?

Scenarios like this came closest to becoming possible in June, when the Food and Drug Administration (FDA) announced that it would reduce the levels of nicotine in cigarettes in an effort to reduce the harmful effects of an addiction that causes 480,000 deaths. each year.

The agency has set May next year as the date on which it will present a fully developed proposal. But many experts expect regulators to advocate an immediate 95% reduction in nicotine levels. This is the level that federally funded studies have found to be most effective in helping smokers overcome addiction.

It could take years for any new policy to take effect if it survives opposition from the tobacco industry. Even so, health experts say any effort to reduce the nicotine content of cigarettes to non-addictive levels will be a radical experiment, something never before done in any other country.

Scientific knowledge of nicotine addiction has come a long way since 1964, when the US Surgeon General (the federal government’s chief public health spokesperson) first linked smoking to cancer and lung disease. But another two decades would be needed for the mechanics of nicotine addiction to be understood and widely recognized.

Tobacco contains over 7,000 chemicals, many of them harmful when burned and inhaled, but it’s the nicotine that keeps smokers wanting more. Nicotine stimulates a surge of adrenaline in the brain and at the same time indirectly produces a surge of dopamine, the substance that causes feelings of contentment and relaxation. But the effects are short-lived, which is why heavy smokers need a new dose a dozen or more times a day.

Eric Donny is a tobacco specialist at Wake Forest University School of Medicine and has experimented with low-nicotine cigarettes. He said many scientists adhered to the proposal of a 95% reduction in nicotine levels as being ideal for helping study participants to smoke less. More than that, he also can encourage participants to practice what is called compensatory smoking: inhaling more deeply or smoking more often.

The studies that Donny and other scientists recently conducted used tobacco that was genetically modified to contain less nicotine. Reducing the level of nicotine to zero is not an option under the Tobacco Control Act of 2009, which gave the FDA the power to regulate the manufacture and marketing of tobacco products.

“When you reduce the nicotine in tobacco to a low enough level, you don’t have enough nicotine left over to maintain addiction,” Donny said. “Smoking more cigarettes has adverse effects, like nausea, because there’s a limit to how much the lungs can handle a burned substance.”

But while they welcomed the FDA announcement, tobacco control researchers acknowledged that any move to reduce nicotine in cigarettes will be tremendously difficult for heavy smokers, even the 70% who have already said they would like to quit. quit smoking. Fewer than one in ten adults who try to stop smoking succeed. It is a reflection of the addictive power of nicotine and the limitations of nicotine replacement treatments.

Dr. Nora Volkow, director of the National Institute on Drug Abuse, expressed confidence in studies advocating an immediate reduction in nicotine levels, as opposed to a gradual reduction. But she said scientists and regulators still had to deal with the multitude of unforeseen consequences that could cause determined smokers to suffer and fuel the emergence of black markets for normal nicotine cigarettes. “It is not possible to completely predict outcomes based on a randomized clinical trial,” she commented. “Biology and life are not so accurate.”

Some scientists urge caution against any plan to cut nicotine levels suddenly, all at once. They caution that existing research on low-nicotine cigarettes is flawed, given the large number of participants in studies who cheat. Skeptics, including executives at cigarette companies, warn that banning the sale of conventional cigarettes will lead heavy smokers to import cigarettes from Mexico and Canada.

They also argue that some smokers, teenagers among them, may develop a habit of smoking e-cigarettes or chewing nicotine gum interspersed with low-nicotine cigarettes. These two other options are just as carcinogenic as traditional cigarettes.

Lynn T. Kozlowski of the University at Buffalo is a tobacco researcher who since 1981 has contributed to four US general surgeons’ reports on tobacco use. He said that nicotine is a highly addictive drug, exerting a hold on its users comparable to cocaine or heroin. For him, the FDA needs to consider how a broad reduction in the level of nicotine in cigarettes will affect the behavior of smokers.

“I’m scared of the idea of ​​a national experiment with very low-nicotine cigarettes that would be done without some real-life previous testing,” he said. The studies cited by many experts when proposing a 95% drop in nicotine levels were done with paid participants, he pointed out, adding that some of them secretly smoked cigarettes from their preferred brands at the same time the researchers gave them low-nicotine cigarettes. .

Respondents, smokers who heard about the FDA announcement said they were divided at the prospect of being forced to give up their addiction, despite knowing full well that cigarettes are harmful to their health and likely to shorten their lifespan.

Mike Harrigan, a stockbroker who was taking a smoke break outside the Chicago Chamber of Commerce, said that if cigarettes became much lower in nicotine, he fears he will end up smoking more. “It might help newer smokers, but it will hurt people who are used to a certain level of nicotine,” said the 55-year-old who has smoked a pack a day for three decades.

Kozlowski said he was especially concerned about the FDA’s mixed messages and its seemingly contradictory stance on e-cigarettes, which deliver tar-free nicotine and many other toxins that are inhaled when tobacco is ignited. While the long-term impacts of vaping (e-cigarette smoking) remain unknown — although health experts agree that teens should be discouraged from trying it — the growing consensus is that these products are useful in helping adult smokers quit. habit.

The FDA has so far only approved six products for vaping and banned more than 1 million others, including those made by Juul Labs. Earlier this summer, the agency ordered the removal of Juul products from store shelves, citing the potential harm from chemicals that could leak from their liquid cartridges. Since then, however, the FDA has announced that it will conduct a further review of the company’s products.

Dr. Judith Prochaska of Stanford University is an expert in chemical dependency and operates a clinic where cancer patients and their families are taught how to overcome addiction. She noted that lighting a cigarette during a stressful phone call, while having a drink or after a meal, generates a powerful memory that conditions the mind to associate the cigarette with the stimulus or help received from the nicotine rush.

“All these everyday behaviors signal to your brain that nicotine is on the way,” she explained. “It’s basically the effect of Pavlov’s dog, but conditioned here to a highly addictive drug.”

Nicotine addiction deepens over time. Regular smoking promotes the formation of additional dopamine receptors, sometimes millions more. When a smoker suddenly quits, these unrequited receptors trigger the anxiety, irritability, and depression that can make nicotine withdrawal so difficult to bear.

Nicotine patches, nicotine gum, and e-cigarettes may help satisfy some of the craving, but they’re not a substitute for cigarette rituals: going out for a smoke with someone else, the feel of cellophane and foil when you open a new pack, the injection. heady rush of adrenaline from that first drag.

Bruce Holaday, 69, is a retired pedagogue, lives in Mill Valley, California, and knows all too well the power of nicotine. Holaday calculates that over the past five decades he has made at least 100 attempts to quit smoking, many of them using nicotine replacement products. But he invariably returned to his daily pack of Marlboro Lights.

The last time, last August, he tried to quit suddenly, without nicotine replacement. This set off a whirlwind of burning desires that lasted for several months. “It was like a sudden earthquake of longing and need, then I’d have tremors for the next 10 or 15 minutes,” he said.

But this time Holaday joined a Stanford Health Care support group, and it introduced a powerful social component to her effort. He described the effect as “not wanting to let the gang down”. He said he learned to avoid situations that cause him stress, like watching the news. He found that if he could face the initial waves of cigarette cravings, they invariably passed.

At the end of June it was a year since he took his last drag.

Holaday has gained weight, but he no longer loses his breath as easily when he goes for walks. And he is determined never to smoke again.

Asked about the prospect of drastic government intervention to force Americans to give up cigarettes, Holaday paused to recall the first puff he took, half a century ago, as a freshman in college.

“Without that shot of adrenaline coming from the nicotine, I probably would never have smoked another cigarette,” he said. “It will be difficult for smokers, but anything we can do to stop a new generation from getting addicted will be worth it.”

^{Translation by Clara Allain}