Many Americans take a dark view of nicotine. The stimulant, which occurs naturally in tobacco plants, is what makes cigarettes so addictive, with smoking responsible for 490,000 American deaths each year. When people try to quit smoking, it’s often cravings for nicotine, and the surge of dopamine it releases in the brain, that foil their attempts.
In this sense, nicotine is responsible for many health problems. But public health experts say that while nicotine poses risks, some nicotine products are safer than cigarettes — and they worry popular misconceptions about the chemical’s effect on the body are doing more harm than good.
A majority of people in the U.S. wrongly believe that nicotine is the substance in cigarettes that causes cancer. In fact, “the harm from smoking comes from the burning of the ingredients in a cigarette, not from the nicotine itself,” said Jamie Hartmann-Boyce, a health policy researcher at the University of Massachusetts Amherst. More than 70 carcinogens have been identified in the cigarette smoke produced by the combustion of tobacco, which can damage people’s DNA and lay the groundwork for cancer.
For many years, cigarettes were the main way that most Americans consumed nicotine. That meant it wasn’t a big problem from a public health perspective if people conflated the dangers of smoking with the dangers of that particular chemical, so long as that helped deter them from lighting up.
Now, thanks to the more recent introductions of smoke-free options like e-cigarettes and nicotine pouches, “we are in a totally different landscape when it comes to commercial nicotine products,” Hartmann-Boyce said.
Evidence suggests pouches and vapes authorized by the Food and Drug Administration, while not risk-free, significantly reduce people’s exposure to harmful chemicals compared to cigarettes. And tobacco researchers generally support e-cigarettes in particular as alternatives for people looking to quit cigarettes. Nicotine gum and patches, which are well-established tools for smoking cessation, carry even less risk. (Chewing tobacco, while smokeless, has been linked to oral cancers because it contains tobacco leaf, which means carcinogens in the leaf can be absorbed through the mouth. The e-liquids used in vapes, as well as nicotine pouches, gums, and patches, contain nicotine but not tobacco leaf.)
The problem: “If you believe that nicotine causes cancer, not only are you going to be less likely to try to switch from smoking to e-cigs, you’re going to be less likely to try and use nicotine gum or nicotine patches or nicotine pouches,” said Jonathan Foulds, a professor at Penn State University’s Cancer Institute. Surveys from 2016 and 2018, for example, found that daily smokers who believed nicotine products like patches and vapes were much less harmful than cigarettes were more likely to use those products when trying to quit smoking. Studies also suggest that people are more likely to quit smoking successfully with the help of e-cigarettes that contain nicotine and nicotine replacement therapies because they help ease withdrawal symptoms.
“When I did focus groups with young adults who smoke cigarettes, they talked about addiction being something that was a significant harm, and they did not want to trade one addiction for another by quitting cigarettes by using e-cigarettes, or quitting cigarettes using nicotine replacement therapy,” said Andrea Villanti, deputy director of the Rutgers Institute for Nicotine and Tobacco Studies.
The issue now faced by addiction and public health experts is how to correct the narrative about nicotine for the sake of harm reduction. They want people who smoke to know that switching to smoke-free nicotine products like vapes would likely benefit their health, without going so far as to encourage people who don’t currently use tobacco products from picking up a Zyn or Juul habit.
Recent headlines suggest there is potential for nicotine’s reputation to tip in the opposite direction. An article in Slate explored early research on nicotine as a treatment for people with long Covid dealing with brain fog. Meanwhile, social media users touting Zyn nicotine pouches as “gas station Ozempic” say it helps with weight loss.
Recovering nicotine’s reputation would also provide a clear commercial benefit to tobacco companies, many of which are betting on smoke-free products as their future given global declines in smoking rates. Philip Morris International’s Stacey Kennedy, head of the company’s U.S. division, told Axios earlier this year that the substance, while addictive, had some “cognitive benefits.” Other kinds of businesses may also be looking to get on the bandwagon: The company Nic and Jet Fuel recently announced a line of energy drinks with “microdosed nicotine to boost focus.”
There’s reason to be concerned about nicotine getting situated within the world of wellness, said Olivia Wackowski, an associate professor at Rutgers School of Public Health. History is replete with examples of companies marketing light, low-tar, or “natural” cigarettes, like Natural American Spirits, in ways that have created misperceptions about them as lower-risk.
“I don’t think it’s a health tonic,” said Villanti, noting that the conversation about nicotine needs to have nuance. “The priority is really educating people about nicotine rather than repackaging it as a healthy product.”
What we know about nicotine
Anti-tobacco organizations tend to take a firm stance against nicotine, emphasizing its impact on adolescent brain development. Indisputably, nicotine use comes with real risks. Women who use smokeless tobacco while pregnant have babies with lower birth weights than women who do not use nicotine, and research in mice suggests vaping while pregnant may also hurt babies’ lung development.
The substance is also highly addictive, particularly for people who start using it at a young age. But it doesn’t directly cause the cancer associated with smoking, and when it comes to questions about whether nicotine causes other serious differences in brain development, “the jury is definitely still out,” said Hartmann-Boyce.
According to Foulds, the evidence that nicotine is harmful to the developing brain is of about the same quality as evidence on the impact of caffeine on young people. Both are stimulants that may plausibly have an adverse effect on brain development, he said. “But the same people who are out there saying nicotine causes brain damage, they’re giving their kids pocket money to putt around to Starbucks and buy whatever they like.” (In a sign of growing concerns about the health effects of caffeine on young people, the U.K. recently announced plans to join a growing number of countries in banning the sale of high-caffeine energy drinks to anyone under 16.)
It’s no easy task to change popular misunderstandings about nicotine at a time when Americans are suspicious of health information shared by both the tobacco industry and the government, Hartmann-Boyce said. “So who is a trusted knowledge broker in that situation?”
One solution is to educate physicians — more than 60% of whom believe that all tobacco products are equally harmful — about nicotine. Research shows that healthcare providers are consistently rated as the most credible source of information on tobacco and health, said Wackowski. Position statements from health organizations like the American Heart Association or the American Medical Association would help too, she said.
Better public communication about the effects of nicotine could also help ward off confusion about low-nicotine cigarettes, which would become a particularly pressing issue if the U.S. ever acts on a Biden-era Food and Drug Administration proposal to curb levels of the ingredient. The goal of the rule change would be to make cigarettes less addictive. But researchers warn that if people think, inaccurately, that lower-nicotine cigarettes pose a lower risk of cancer, they might not be motivated to reduce their smoking in the same way.
“If we don’t start correcting public perceptions on nicotine, we could have a situation where someone would think that a cigarette with very low nicotine is going to be less harmful to them than a nicotine pouch,” said Hartmann-Boyce.
Differentiating between the risks of nicotine addiction and the risks of combustible tobacco isn’t a simple message to convey. But Wackowski and Villanti both say research suggests that more comprehensive approaches that take time to walk people through the science on the underlying causes of tobacco’s harms are most effective in reducing false beliefs.
“We try to tell more of the story,” said Villanti. “I think that was important in helping people understand that bigger picture and challenging their beliefs.”
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
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