The man in charge of tobacco regulation at the Food and Drug Administration says we “need a national debate on nicotine.” Good idea. But first we need to understand what nicotine is – and what it isn’t.
It isn’t the stuff that can cause serious illness and death from cancer, lung, and heart disease. Those culprits are the tar and toxic gases that are released from burning tobacco when you smoke.
Nicotine is a chemical that is dangerous not because it causes cancer but because it can addict you to cigarettes. As Michael Russell, the father of tobacco harm reduction theory and the developer of nicotine gum, put it in 1976: "People smoke for nicotine but they die from the tar."
Mitchell Zeller, director of the Center of Tobacco Products, a division of the FDA, made his comments about nicotine in an interview with New York Times columnist Joe Nocera on the eve of his agency’s recommendations for regulating electronic cigarettes.
The nature of e-cigarettes is that, like Russell’s gum, they contain nicotine and thus satisfy the cravings of smokers, but vaping – as puffing on an e-cigarette is called – doesn’t burn tobacco and release those carcinogens. Unfortunately, many Americans don’t understand that nicotine itself isn’t the villain.
Adolescents in the early 1980s encountered an evil character called Nick O'Teen, created by DC Comics in collaboration with the Sacramento-based Health Education Council. Nick O’Teen sparred with Superman, who tried to guard Gotham’s children against cigarettes.
But nicotine is only a menace when it can addict people to conventional cigarettes – that is, tobacco wrapped in paper. By contrast, in the process of vaping, nicotine carries little risk by itself. Negative health consequences have not materialized within the seven years e-cigarettes have been used in the U.S. – though it’s essential to keep monitoring.
In the 1960s, most psychologists, psychiatrists, and pharmacologists viewed smoking as a psychological and social habit. “Habit” was also the language used in the landmark 1964 Surgeon General’s report on smoking. At the time, some researchers suspected that nicotine played a role in cigarettes’ appeal. Drugs such as alcohol, barbiturates, and heroin are considered addictive (as opposed to habitual) based on their ability to intoxicate, cause social damage, and produce dramatic physical withdrawal syndromes. But smoking was considered neither a pharmacological nor biological phenomenon.
Not until 1988 did the U.S. Surgeon General designate smoking as an addiction, driven primarily by nicotine, which is a nitrogen-containing chemical, or alkaloid. Nicotine was deemed to have addictive properties based on three fundamental features: (1) in the initial stages of use, more of it is required to produce the same effect in the smoker, a phenomenon called “tolerance”; (2) it is “reinforcing,” meaning that it is sufficiently rewarding to spur self-administration; and (3) abrupt cessation can lead to powerful craving and a recognizable withdrawal syndrome.
Nicotine is a mild stimulant and poses negligible risks in healthy people. It enhances the performance of some tasks, especially those involving vigilance and rapid visual cue processing. It can also sharpen memory, concentration and attention in the short term.
Also, because nicotine receptors appear to regulate other receptor systems, its effect can vary according to one’s mood and level of arousal. A smoker who feels anxious or stressed can be calmed with nicotine, and a smoker who is tired will perk up with nicotine.
When nicotine binds to receptors in the brain, it releases dopamine, a primary neurotransmitter. Dopamine plays an important role in modulating attention, concentration, appetite suppression, and movement. Dopamine’s effects on movement could explain why nicotine has shown some promise in ameliorating a disorder like Parkinson’s disease in primates. In humans, in fact, large epidemiological series have found lower levels of the Parkinson’s in older smokers. Also, patients with early stages of Alzheimer’s disease show some improvement with nicotine when delivered via a patch.
By contrast, there’s no debate about the dangers of smoking. As the biggest preventable cause of mortality in the developed world, smoking can affect fetal development and significantly increase the chances of certain cancers, heart attack, and stroke. Smoking also worsens pre-existing diabetes.
But it’s essential to note that, in addition to nicotine, there are roughly 6,000 chemicals in cigarette smoke, so it is hard to know which components pose the greatest damage to health. For example, the carbon monoxide, nitrogen oxides and other gaseous constituents of cigarette smoke have been shown to reduce oxygen transport to cells, promote growth of atherosclerotic plaques in blood vessels, and make blood platelets sticky so that they clump together and form clots.
The relative safety of nicotine alone is clear from animal studies and long-term observations of people who have used medicinal nicotine for years. As a result, researcherscan be far more definitive when they conclude that gum, patches, lozenges, inhalers, and sprays – all of which contain medicinal nicotine -- are not carcinogenic and do not increase the risk of heart attack or stroke, even in people with pre-existing cardiac disease.
Although nicotine is an addictive substance, e-cigarette vapor appears to be less addictive than cigarette smoke. According to work by Jonathan Foulds of Penn State University College of Medicine published[i] recently in Nicotine and Tobacco Research, vapers reported being less irritable when they did not have access to an e-cigarette compared to their feelings of frustration when they could not smoke.
Vapers also claimed they were less eager to get to the first puff of the day than they did when they were smokers. They were also less likely to wake up in the middle of the night to vape than they were, in the past, to smoke.
Many e-cigarettes deliver less nicotine per puff and generally produce lower blood nicotine levels (and, thus, brain levels) than cigarettes do. However, with access to increasingly sophisticated devices and more experience as a vaper, the user can attain a blood level of nicotine that is comparable to that produced by smoking. Still, it takes longer for vaped nicotine to reach its peak level than for tobacco-burned nicotine.
These two variables – how high the level of nicotine is in the bloodstream and how fast that level is achieved -- are important in determining the addictiveness of any abused drug. As expected, Foulds’s team found that subjects who used weak “ciga-likes” (first generation e-cigarettes that physically resemble actual cigarettes) had among the lowest scores on a test of “dependency,” or addiction. Also, the length of time as a vaper was positively correlated with the strength of dependence. As Foulds suggests, “we might actually need e-cigarettes that are better at delivering nicotine because that's what's more likely to help people quit.”
There’s no doubt vapor technology will improve the nicotine delivery of e-cigarettes. Indeed, a brand new type of e-cigaretteusesnicotine extract that includes natural nicotine salts that are part of the tobacco leaf, approximating the nicotine delivery of a conventional cigarette. As this and other technologies develop and spread, nicotine delivery will become better and vaping will become more attractive to more smokers.
Believers in harm-reduction theory see that as a good thing. If current tobacco smokers and likely new tobacco smokers choose vaping, they’ll cut their health risks – despite, or actually because of, nicotine.
In his interview with Nocera, Zeller said that “when nicotine is attached to smoke particles, it will kill.” Conversely, when there is no smoke, nicotine alone will be far safer, even a net benefit.
The question now is whether this reality can be translated into government rules that enable existing e-cigarette manufacturers to continue to innovate, to advertise to adult smokers, and to reassure the public that their products have been subject to high levels of quality control. After all, governments should regulate products according to the harm they pose, so the distinction between smoked and vaped nicotine really matters.
If policy makers reject the scientific truth about nicotine and make e-cigarettes more scarce, then the likely result is that more Americans will die from smoking.