The Biden administration’s 11th-hour proposal to force tobacco manufacturers to slash nicotine levels — made just days before President Biden’s exit — was viewed as a political stunt by many public health officials.
Meanwhile, tobacco reduction experts like Jed Rose, the head of the Rose Research Center, say the opportunity for real progress in the fight to get more Americans to stop smoking is on the horizon. More science is needed and more accurate information provided to the public.
It starts with understanding why people smoke.
“Smokers don’t just value the nicotine in their bloodstream,” Rose said, referring to the chemical behind the addiction. “There are sensory cues that become pleasurable to smokers. People who get IV feedings do not feel their hunger satisfied. Likewise, a smoker wants to smoke a cigarette to feel satisfied.”
Rose knows what he’s talking about. More than 40 years ago, he fell into a career working on smoking cessation by accident when he took a temporary job while awaiting a fellowship connected to his doctorate in learning processes underlying anxiety.
In the 1980s, he was named the lead inventor of the nicotine skin patch, along with his physician brother Daniel and the late Murray Jarvik. Rose says he’s studied the most effective strategies for smokers who want to quit.
(Spoiler alert: cold turkey is not one of them, Rose says.)
It turns out, Rose says, the old saw about quitting smoking cigarettes being harder than quitting hard drugs isn’t too far off the mark.
“It’s a really difficult question: Why it’s so much harder to quit smoking,” Rose said. “On a behavioral level, smoking actually helps people to behave more normally. It helps you concentrate better on tasks, helps thinking, reduces anxiety under stress. It enables people to feel they can cope more normally in life. That is harder to give up than ‘feeling high’ such as you get with cocaine.”
Rose was involved in the development of the medicine varenicline, commercially known as Chantix, which the National Institutes of Health indicates has an effective rate of 40 percent to 60 percent in helping people quit smoking.
Throughout the years, Rose’s research has focused primarily on developing practical tools to help people quit smoking. Giving smokers nicotine replacement methods to wean themselves away from nicotine in cigarettes is only part of the equation. It is essential to replace the sensory and behavioral aspects of smoking with less harmful substitutes.
That’s why it’s so confounding that health regulators keep throwing up roadblocks against electronic delivery devices that research shows improve the likelihood that a person will quit smoking traditional cigarettes.
“It takes more than nicotine to address the addiction,” Rose said. “It’s the feeling of inhaling something. There’s a holistic approach. It’s not just substituting nicotine or another drug but also the behavioral substitution.”
The Food and Drug Administration has approved several pharmaceutical products for nicotine replacement therapy, such as skin patches, chewing gum and lozenges. There are also nicotine sprays and inhalers.
FDA’s population modeling shows that stopping smoking by reducing nicotine in cigarettes is predicated on a 67 percent increase in the use of non-combusted nicotine products as off-ramps from cigarettes.
The day after publishing the cigarette nicotine reduction standard, the FDA authorized 10 flavors of a nicotine pouch product as a less harmful alternative for adults who smoke.
For those looking for a non-drug approach, the FDA has blessed companies to market transcranial magnetic stimulation (TMS) in which a magnetic coil held over one’s head delivers magnetic pulses to the brain. TMS can be used to treat obsessive-compulsive disorders, depression and addictions such as smoking.
However, the agency has authorized marketing only for a limited number of heat-not-burn devices or other electronic delivery systems such as e-cigarette cessation — despite evidence from Rose and other researchers showing they can get smokers to quit.
In February 2024, Nancy Rigotti published an editorial in the New England Journal of Medicine calling on U.S. public health agencies and the medical community to recognize the value of electronic cigarettes. She based her opinion on comments on research done in Switzerland, which found that study participants who had access to e-cigarettes were more likely to abstain from traditional cigarettes than those who received just smoking-cessation counseling. A recent independent review of the evidence by the Cochrane Library concluded that e-cigarettes were more effective than traditional nicotine replacement methods such as the nicotine patch or gum.
“It is now time for the medical community to acknowledge this progress and add e-cigarettes to the smoking-cessation toolkit,” Rigotti wrote. “U.S. public health agencies and professional medical societies should reconsider their cautious positions on e-cigarettes for smoking cessation. The evidence has brought e-cigarettes to a tipping point. The burden of tobacco-related disease is too big for potential solutions such as e-cigarettes to be ignored.”
However, unintentional and intentional misperceptions about e-cigarettes are rampant, and Rose said the FDA, which regulates such products, is doing little to correct the record. The results are devastating: Surveys show that 80 percent of smokers mistakenly believe that e-cigarettes are just as harmful or even worse than traditional cigarettes.
“Many smokers will not avail themselves of products that can save their lives because nobody is correcting their misperceptions of e-cigarettes,” he said. “It’s costing lives.”