Lynn Kozlowski makes a persuasive case for caution about a nicotine reduction strategy. I think this caution is warranted. While nicotine reduction might appeal to those with a preference for top-down solutions, the history of problematic behaviours shows that unless these are integrated with bottom up strategies and the support of the affected population (in this case smokers, particularly those dependent on nicotine), success is unlikely.

At best, nicotine reduction is likely only a partial solution to the tobacco problem and, in my view, a secondary or potentially facilitating intervention, not the main game. What is needed for a nicotine reduction strategy to work effectively? First, the strategy would need to be spelled out in more detail: for example, what levels of nicotine should we aim for, and should we reduce gradually or in one or two large steps? However, the main consideration, and that focused on here, is what will existing smokers do? This is because this has consequences for how such regulation could be implemented and enforced.

If legal cigarettes have the nicotine reduced so they are no longer satisfying, smokers will stop using them, some will quit (at least temporarily), while others will either seek acceptably satisfying alternative products, either legally or via black markets. As there are a lot of smokers who cannot quit or still do not want to, the numbers forced towards the latter two options are likely to be large, and disproportionately the dispossessed and mentally ill, making this in part an issue of equity.

The main reason we are looking for new strategies in tobacco control is that, while we have been successful in getting smokers to try to quit, we have been far less successful in helping them to succeed long term1; there are no demonstrably effective strategies for preventing relapse beyond the end of active smoking cessation therapy2 although this may be beginning to change.3 Quit rates increase with intensity of help up to some point, for behavioural and pharmacological aids, but long-term success rates remain modest.4 Many existing smokers are dependent on smoking due to some combination of biological and psychological factors, and have no reasonable prospect of quitting nicotine use in the short to middle term, and many will never succeed without more help than they are currently getting. Currently, the best prospect for preventing longer term relapse in those unable to quit is some form of nicotine maintenance. However, to achieve long-term use requires suitably satisfying and appealing products, which are then open to recreational use rather than purely therapeutic use.

This analysis suggests that we need to be considering long-term nicotine use regardless of whether there is a nicotine reduction strategy for cigarettes, making nicotine reduction for cigarettes a subsidiary strategy to nicotine maintenance. This is the ‘elephant in the room’ that many people do not want to name, because use of any form of nicotine is anathema to some elements within tobacco control, and recreational use especially so.

Without consumer acceptable alternatives, the nicotine reduction strategy is de facto prohibition, as Kozlowski notes. In the context of many places in the world, reducing restrictions on access to cannabis, effectively banning use of clean nicotine, which is almost certainly way less harmful than cannabis, is anomalous. We know from the ‘War on Drugs’ that prohibition does not solve the problem of recreational use of psychoactive substances. Where there is demand, as there is for psychoactive forms of nicotine, it will result in a thriving black market if it is not available legally. Illegality creates social problems as well as greater risks to the users from contaminated or otherwise dangerous products. Based on experiences from the prohibition of alcohol, there may be a modest overall direct benefit for public health in a premature approach to nicotine reduction, but at a very likely significant net cost for society overall.

Nicotine reduction should only be pursued in the context of society providing adults with access to suitable alternative forms of nicotine. To contain use of such products, especially among youth, will require constraints on their marketing. I believe this is the only credible strategy that has any serious chance of effectively eliminating smoking in the next 50 years, but I am also well aware that it may not be powerful enough. However, if it is not a major part of the solution, it is likely to fade away and risks of addicting a new generation are most likely exaggerated.

There is still a very strong case to make cigarettes less appealing as this will help move smokers to cleaner forms of nicotine, but this can be accomplished in other less radical ways than nicotine reduction; for example, bans on filter venting. Professor Kozlowski first warned us about the deception of filter venting, in 1980,5 a warning no country has yet acted on, 36 years later. As then, we would be prudent to listen carefully to his wise counsel.