WHO Study Group on Tobacco Product Regulation (TobReg) Advisory Note recommends global nicotine-reduction strategy

One can expect that the WHO Framework Convention on Tobacco Control (FCTC) Conference of the Parties may well be influenced by the recent WHO TobReg ‘Advisory Note’1 that supports, albeit with a host of caveats, recommendations to implement product regulations requiring reduction of nicotine levels in cigarettes.2–4 Note that these cigarettes are not the same as conventional lower yield cigarettes that were subject to compensatory smoking that maintained tar and nicotine exposures to smokers.5 To quote from the report's conclusions, the first two ‘regulatory recommendations’ are:

• Mandated reductions in nicotine to minimally addictive levels should be supported by comprehensive regulation of all nicotine- and tobacco-containing products.

• Mandated reductions in nicotine to minimally addictive levels must be part of comprehensive tobacco control, including increased taxes on cigarettes, comprehensive smoking bans, antismoking educational campaigns and graphic warning labels or plain packaging (ref. 1, p. 28).

The next four regulatory recommendations concern precautions related to how to do this in the context of comprehensive tobacco control. The Advisory Note and its conclusions clearly appreciate and assume that (1) the nicotine-reduced cigarette will be challenging to traditional smokers and (2) alternative sources of nicotine are likely to be needed, used and monitored. The last recommendation warns: ‘A strategy to reduce the addictiveness of tobacco is not recommended in the absence of developed capacity for market surveillance and product testing.’ (ref. 1, p. 29).

Research to date

The recent, high-profile, randomised controlled trial is arguably the most substantial study until now and has been viewed as supportive, but one should look at it closely and critically.6 The report's introduction summarises the prior literature: ‘The results of several relatively small studies suggest [emphasis added] that cigarettes with very low nicotine content are associated with a desirable set of outcomes…’ (p. 1341). The article itself concludes: ‘This study …