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To reduce cigarette caused diseases and deaths, US health advocates and 
members of Congress would be wise to heed this commentary in considering 
FDA tobacco regulatory legislation.
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The Future of the Nicotine Addiction Market

Commentary: By Nigel Gray 1, Peter Boyle1
The Lancet
Volume 362 Issue 9387 Page 845

Nicotine-seeking behaviour underlies the continued popularity of the 
cigarette, which is the most widely used and effective nicotine-delivery 
device. Such behaviour also underlies other forms of tobacco use, most 
of which, but perhaps not all, cause cancer.

Walton Sumner recently(1) used a computer model to estimate the health 
consequences of replacing cigarettes with nicotine inhalers. He 
considered "partial nicotine deregulation" as a policy solution. We 
believe a more radical approach is needed: a clean addictive 
recreational nicotine delivery.

In 1991 a Lancet editorial(2) stated: "There is no compelling objection 
to the recreational and even addictive use of nicotine provided it is 
not shown to be physically, psychologically, or socially harmful to the 
user or to others". A decade later there is no competitive form of clean 
nicotine to substitute for nicotine from tobacco use (here, competitive 
means delivering a dose of nicotine to the brain with the same speed and 
efficiency as cigarette smoking or chewing tobacco). Health risks 
associated with clean nicotine are minor compared with those of tobacco, 
although effects on the fetus cannot be taken lightly.(3)

Addiction to tobacco-derived nicotine will probably not diminish until 
there is available on the market a competitive nicotine source which is 
"clean" in the sense that it does not deliver carcinogens or toxins to 
the consumer in the wake of the nicotine. Undoubtedly such a product 
would have addictive potential-to be an acceptable alternative, it would 
have to. The product would also need to be as available as the 
cigarette, and (preferably) cheaper than cigarettes. Recreational 
addictive clean nicotine is a necessary product that does not exist 
despite two decades of development of nicotine-replacement therapy.

There are probably several reasons why no such product has appeared. One 
is that regulators have no mandate to approve new addictive recreational 
drugs and would require political direction to accept such a concept. 
The second is that the drug industry has insufficient incentive to 
produce such drugs without clear indications that they would be 
acceptable. A third reason is that the antismoking lobby has not 
embraced or seriously debated this issue, which is essentially a 
political matter and should be in their remit.

The idea of harm reduction (reduction of exposure to tobacco toxicants) 
has been around, probably, since the introduction of the filter to the 
cigarette. In reality, however, there has always been a spectrum of 
degrees of risk with tobacco products, varying from the risk of the 
unfiltered very high tar wartime cigarette to Snus (a snuff sold in 
Sweden that is low in nitrosamine content) at the other. Also the 
constituents of cigarette smoke vary greatly;(4) some cigarettes are 
worse (in that they deliver higher doses of carcinogens)

The range of tobacco harm-reduction products is incomplete without a 
clean addictive source of nicotine that can compete commercially with 
cigarettes. Non-addictive nicotine-replacement therapy is a partial 
answer only, as evidenced by the fact that it has subsumed only a minor 
portion of the nicotine market.

There are lessons to be learned from the real-world experiment in harm 
reduction with Snus.(5) The most important is that nicotine addiction 
can be diverted from cigarettes to an orally absorbed nicotine-delivery 
product, which is competitive with cigarettes as a nicotine source. The 
second is that if Snus is a gateway drug, it is more likely to be an 
exit from cigarette addiction than an entry point.(6).

If it is accepted that nicotine addiction is here for the foreseeable 
future, a new and better range of addictive recreational nicotine is 
needed. Any risks linked with such a product are dwarfed by the 
magnitude of the tobacco problem. This product will not be achieved 
without political acceptance of the concept.

1. Division of Epidemiology and Biostatistics
European Institute of Oncology,
Via Ripamonti 435,
20141, Milan, Italy.

All Correspondence to Doctor Nigel Gray, Division of Epidemiology and 
Biostatistics, European Institute of Oncology, Via Ripamonti 435, 20141 
Milan, Italy. (telephone +39 02 574 89 815 and fax +39 02 574 89 922. E 
Mail nigel.gray@ieo.it)

1 Sumner W. Estimating the health consequences of replacing cigarettes 
with nicotine inhalers. Tob Control 2003; 12: 124-32.
2 Editorial. Nicotine use after the year 2000. Lancet 1991; 337: 1191-92.
3 Treatobacco.net: Database & educational resource for treatment of 
tobacco dependence. Safety. 
http://www.treatobacco.net/[...]ety/key_findings.cfm 
<http://www.treatobacco.net/safety/key_findings.cfm> (accessed July 31, 
2003).
4 Gray N, Zaridze D, Robertson C, Krivosheeva L, Sigacheva N, Boyle P. 
Variation within global cigarette brands in tar, nicotine, and certain 
nitrosamines: analytic study. Tob Control 2000; 9: 351.
5 Henningfield JE, Fagerstrom KO. Swedish Match Company, Swedish snus 
and public health: a harm reduction experiment in progress? Tob Control 
2001; 10: 253-57.
6 Ramstrom L. Nicotine and public health. Washington: American Public 
Health Association, 2000: 159-78.