The Dark Horse: Tobacco/Nicotine

After posting several articles about the roundly debunked "gateway drug theory", we at Twenty-One Debunked felt we should also discuss in greater depth the particular case of tobacco, especially in the form of commercial cigarettes. While our organization does not generally view tobacco as a particularly high-priority issue, perhaps it is something we should be revisiting given recent evidence as well as the recent raising of the smoking age* to 21.

While the primary dangers of smoking tobacco (i.e. cancer, heart disease, stroke, emphysema, birth defects, etc.) have been well-known for decades, what has been much less appreciated is the neurotoxic properties of cigarettes.  The thing is, nicotine is a known neurotoxin, and it is likely that at least some of the thousands of other chemicals in cigarette smoke are also toxic to the brain as well.  One reported effect of nicotine is that it can "prime" the brain's reward system for addiction in general, including to other substances.  This seems to be particularly true for the early adolescent brain.  While these findings are based primarily on rodent studies, human studies seem to dovetail with this idea far more for tobacco than for cannabis or even alcohol.  Thus, the psychopharmacological aspect of the gateway hypothesis seems to hold true indeed for tobacco, and if there ever were such a thing as an actual gateway drug (which is a very big "if", if you ask us), tobacco would have to be it, hands down.  This appears to be particularly true for people who begin smoking or vaping before age 15 or so.

In contrast, the "reverse gateway" theory, namely that cannabis use causes later tobacco/nicotine use or dependence, does not appear to stand up to scrutiny.  Meanwhile, the traditional gateway theory that cannabis use per se increases the likelihood of using hard drugs ceteris paribus is most likely spurious.

Rodent studies suggesting such seem to be half-baked and not consistently replicated.

So why do some studies from 2012-2016 find that alcohol is the supposedly the number-one gateway drug then?  Well, given that teen tobacco use has plummeted so much, more so than alcohol has, and nicotine vaping was still at low ebb at that time, alcohol was likely the first substance to be experimented with at an even earlier age as a result, despite the drinking age being 21 and smoking age still being 18 in nearly all of the USA at that time.  But that does NOT mean that alcohol is necessarily a more potent gateway drug than nicotine.

As for the specious claim that nicotine is a cognitive enhancer, making its users smarter, well, it turns out that the opposite is most likely true, at least in the long run.  (In the short run, it can indeed briefly give the brain a modest boost, but it's one that you will ultimately have to pay back, with interest.)  The exact reason for this is not clear, but given that nicotine is a known neurotoxin, it's not really much of a shock that it could be a bit detrimental to brainpower, right?

Additionally, tobacco/nicotine is also emerging as a potential "dark horse" in the etiology of psychosis and schizophrenia as well.  This has been informally hypothesized for many years now while being overlooked by most researchers, and is only very recently beginning to be taken seriously by mainstream science.  Perhaps cannabis (which is often mixed with tobacco in many countries, and whose use is often predicted by prior and concurrent tobacco use in general) has been taking a major bum rap in that regard as well?  All while Big Tobacco has subtly and sedulously promoted tobacco smoking as "self-medication" for decades, of course.

Even the various harms associated with smoking weed while pregnant likely have tobacco/nicotine confounding to blame for at least a very large chunk of the association.  Note that the nicotine itself is known to be the primary culprit for most of tobacco's teratogenic (i.e. reproductive hazard) effects to the baby, so vaping nicotine or using chew, dip, snuff, snus, or even nicotine replacement therapy is likely not much safer than smoking cigarettes during pregnancy (despite being significantly safer for nonpregnant people hands down).  And while any kind of smoke is toxic by definition, tobacco (or dual tobacco and cannabis) smokers typically inhale far more smoke (and thus far more toxins) over time compared with typical cannabis-only tokers.  As the saying goes, "the dose makes the poison", after all.

And it's not just mothers-to-be that need to worry about tobacco/nicotine.  Fathers apparently aren't off the hook in that regard either.

That said, Twenty-One Debunked nonetheless strongly opposes any attempts to raise the smoking age any higher than 18. And those places that have already raised the smoking age should lower it back to 18 yesterday.  Instead, we (along with the TSAP) believe that we should deal with ready-made combustible cigarettes the way we would deal with any other defective product such as the historical examples of the Ford Pinto, lawn darts (Jarts), leaded gasoline and paint, PCBs, DDT, incandescent light bulbs, certain kinds of weapons, and old-style refrigerators.  Either 1) require the defects to be sufficiently fixed, or 2) failing that, remove such products from the market.  And yes, commercial cigarettes as they exist today are indeed defective by design in that they addict, enslave, and kill far more people than they have to.  Worldwide, they kill about 6 million people per year, hence the name of Robert N. Proctor's bombshell of a book, Golden Holocaust.

Since 2013, the endgame strategy that the TSAP (and Twenty-One Debunked) currently supports has been to let tobacco phase itself out by gradually reducing the nicotine content of combustible cigarettes to a (relatively) non-addictive level.  Since 2009, the FDA now has the authority to set a legal limit on the nicotine content of tobacco products, as long as the limit is not zero.  And as of 2022, they are currently at least considering doing so.  Much research indicates that there is a threshold level of nicotine required to create and sustain addiction, and if all cigarettes were to fall below this threshold, smoking rates would plummet precipitously.  In fact, one tobacco executive was quoted as saying, "‘If our product was not addictive we would not sell a cigarette next week."  This idea was originally proposed by Henningfield and Benowitz in 1994, and has been endorsed by the American Medical Association and several other experts including Proctor himself.  Malcolm Gladwell also discussed it in his aptly-titled 2000 book The Tipping Point.   Thus, the TSAP recommends reducing the maximum nicotine content (not delivery) of cigarettes from the current level of 1-2% to less than 0.1% within a few years, and doing the same for quasi-cigarettes (i.e. little cigars) and perhaps roll-your-own tobacco (but no other products).  That alone would reduce smoking prevalence by as much as 80% within a fairly short timeframe, with further reductions possible in the more distant future.  Alternatively (or in addition), the FDA could require the pH of such products to be raised to 8 or higher to discourage deep inhalation, as is naturally the case for most typical cigars and pipe tobacco currently, and/or simply ban the addition of all anti-tobacco ingredients. 

A 2018 RCT study attempted to ascertain the effects of gradual vs. immediate reduction of nicotine content in cigarettes to non-addictive levels over a 20 week period.  And there are pros and cons of both approaches. More recent RCTs also concur, as does a 2019 literature review paper as well.

The TSAP and Twenty-One Debunked also recommend that the following measures be taken as well:

• Ban the use of additives in cigarettes, especially those that are harmful or increase the addictiveness of tobacco.
• Ban the use of any radioactive fertilizers or harmful pesticides for growing tobacco.
• Phase-out the practice of flue-curing tobacco, which is a major resource hog and bad for the environment.
• Improve the quality control standards for tobacco products (and electronic cigarettes) to be at least as high as for food.
• End all government subsidies for tobacco farming and production.
• Divest completely from Big Tobacco at all levels of government.
• Vigorously enforce the current age limit of 18 for tobacco and vape sales to achieve at least 95% retailer compliance. 
• Implement tough tobacco retail licensing (TRL) laws with frequent inspections and quotas on outlet density.
• Continue to allow widespread availability of reduced-harm tobacco and nicotine products (i.e. snus, vape products, etc.) so that smokers can easily switch to less dangerous alternatives (but cap the nicotine content of vape products down to European and Israeli levels.)
• Improve education and smoking cessation programs, funded by tobacco tax revenues.
• Give out free nicotine patches, gum, etc. to any smokers who want to quit.  NYC already does this. 

At the same time, the TSAP most certainly does NOT support outdoor smoking bans or any other policy that treats smokers like criminals or second-class citizens.  Smokers are NOT the villains here, as that dubious honor belongs to the merchants of death known as tobacco companies.  In fact, we have repeatedly pointed out that, far from being a drain on society, smokers actually save society money in the long run since they more than pay their way as far as taxes go, as well as by dying younger.  Cigarette taxes, especially in NYC where they are extremely high, have basically become a "reverse Robin Hood" way to rob from the poor and give to the rich, since smoking has increasingly become a poor man's vice.  And the wide disparity in cigarette taxes across states has led to a serious black market for untaxed/low-tax/counterfeit/stolen cigarettes, with the main beneficiaries being organized crime syndicates and even terrorists.  Thus, we recommend that the handful of states with cigarette taxes higher than $2.50-$3.00/pack reduce their tax to $2.50/pack or lower, and the several states with taxes of less than $2.00/pack raise it to around $2.00-$2.50/pack.  NYC and NYS should both cut their taxes in half, as should Chicago as well.  At the federal level, we would have much preferred another (modest) tax hike rather than raising the smoking age any higher than 18, and given a choice between the two, we at Twenty-One Debunked will always take the tax hike every time.  After all, cigarette tax hikes are one of the most effective ways to reduce smoking for all ages, especially for young people, and even with contraband tobacco smuggling, the net effect is less smoking and more revenue on balance.  No wonder Big Tobacco hates tobacco taxes so much!

Alternatively, the late Mark Kleiman's idea of raising the federal cigarette tax to $4 per pack, and using it to fully rebate all state and local cigarette taxes would also work to greatly narrow the price differentials between states.  Ditto for setting a national price floor as well.

Furthermore, we ought to be careful not to tax vaping excessively, lest we inadvertently steer vapers back to smoking.  Vape taxes should be about 5-10 cents/mL of e-liquid, only apply to nicotine-containing e-liquid, and ideally be proportional to nicotine content (i.e. $1.00-$2.00 per 40 mg nicotine) so as to disincentivize the super-concentrated (and thus more addictive) nicotine vapes like JUUL.  True, nicotine vaping contains, well, nicotine, which is hardly benign.  And of course there are also concerns about other constituents of vape juice, and even potential heavy metal exposure from the heating coils of some devices as well (though, like anything, the dose makes the poison).  But it is still the lesser evil compared to smoking combustible cigarettes, and the taxes should reflect that.  (Of course, it can be raised quite high as long as the cigarette and other tobacco taxes are raised even higher still.)

The tobacco industry has basically dug its own grave.  Time to push them in there, yesterday.

AND NOW FOR A HISTORY LESSON

For a variety of reasons, Americans keep forgetting to remember to forget that there was a time when cigarettes were banned in 15 states, and many states did in fact set the age limit at 21 at some point, for decades in some cases.  And yet, neither of these measures were able to prevent the tobacco epidemic, and the states that took such measures ultimately succumbed to it just like the states that did not do so.  In other words, it was basically a wash overall, regardless of what the smoking age was.

• 1883-1920:  Due to growing concerns about smoking, particularly among young people, the first age limits on the sale of tobacco were passed by states.  Most were 16-18, though a few were lower and some were as high as 21.
• 1890-1921:  Starting with Tennessee, 15 states had banned cigarettes by 1921, some of which banned all tobacco products.  
• 1920s-1930s:  More and more states set the age limit for tobacco at 21.  Eventually half of all states did at one point or another, and fully one third of states was the peak that had a 21 smoking age at any given time.
• 1927:  All cigarette bans were repealed by then, under pressure from Big Tobacco and of course the lure of tax revenues.  (Some local-level bans remained into the 1930s.)
• 1950-1980:  The states that set the age limit at 21 all lowered their age limits down to the 15-18 range, mostly done after 1950.  By 1963, only five states were still 21, and those were lowered to 18 or less by the end of the 1970s, and four states even got rid of age limits entirely.
• 1980-1992:  Some states begin raising age limits again, but no higher than 18 or 19.
• 1992-1993:  The federal Synar Amendment passes, requiring all states to raise their age limits for sale of tobacco products to at least 18.  By 1993, all states and territories were at least 18, and a very few states and localities were 19.
• 2005:  Needham, MA raises their age limit to 21, the first place in the USA to do so since 1963, and the only one until 2013.  Also, New Jersey raises their age limit to 19, as do Nassau and Suffolk County in New York.
• 2009:  The Family Smoking Prevention and Tobacco Control Act sets a non-preemptive federal age limit of 18 for the sale of tobacco products.
• 2013-2015:  More localities raise the age limit to 21, most notably NYC in 2014, though no states did until 2016. 
• 2016-2019:  Starting with Hawaii and California in 2016, more and more states (19 total as of December 2019) raised the age limit to 21, along with more and more localities as well.  Tobacco 21 laws really explode from 2018 onwards.
• 2019-2020:  As of December 20, 2019, Congress raised the federal tobacco and vape product sale age from 18 to 21, which has taken full effect by September 2020.  Age limit for Synar Program also raised to 21.
• 2020-2022:  More states raise their age limits to 21. All but a handful of states and territories now officially set their smoking and vaping ages at 21 as of 2023, and most grandfather clauses (if any) have ended.  And even there, the federal law supersedes state law.

It is true that the tobacco industry historically pressure states to lower their age limits and steadily fought to keep them from going back to 21.  But they also managed to cynically use existing age limits (whatever they were) as leverage in their marketing strategy to make tobacco seem more "adult" (read: for kids) and trigger the "forbidden fruit" effect.  And of course they did not support enforcement against vendors, but rather cynically supported purchase, use, and possession (PUP) laws to shift the onus onto young buyers rather than the sellers.  So this thing has levels and layers.

And it is far from obvious that an age limit of 21 actually reduces youth smoking any more so than an age limit of 18, since the states that had age limits of 21 for decades failed to prevent such smoking, and both then and now, the vast majority of adult smokers began before 18, often well before.  Smoking among high school students peaked in 1976, dropped until 1992, rose again until 1997, and plummeted since then, already reaching a record low before the recent push to raise smoking ages to 21.  And NYC did see a further decrease after raising the age limit to 21 in 2014, but no faster than the rest of the country did.  Ditto for Hawaii in 2015-2017.  And while California saw a faster than average decrease in teen smoking from 2015-2017, they also raised their cigarette tax by $2.00 per pack in 2017, and saw a slower decrease than Pennsylvania who raised their tax by $1.00 per pack in 2016 to a level just below California's but kept their age limit at 18.

Note also that, apart from a brief, half-hearted, and ultimately unsuccessful attempt in the late 1970s to try to stop Michigan from raising their drinking age to 21 (and then briefly trying in vain to lower it back to 18 or 19), the alcohol industry at all levels has been surprisingly quiet and nonchalant about the drinking age, especially since that fateful and ominous year of 1984.  Once they saw that it was essentially a "big nothing" in terms of their profitability while still being good for PR nonetheless, they have since cynically supported the 21 drinking age while actively fighting and lobbying against real threats to their power and profits, namely tax hikes, advertising restrictions, and tougher DUI laws.  That should really say something indeed!

And come to think of it, since 2018 Big Tobacco, especially Altria Group (formerly known as Philip Morris) who also owns JUUL openly supports Tobacco 21 laws, even at the federal level.  Such quislings indeed.

* NOTE:  The fairly ambiguous term "smoking age" can refer to the minimum legal age limit for tobacco in either 1) sale-to-underage (STU) laws and/or 2) purchase-use-possession (PUP) laws.  The former puts the onus on the seller, while the latter puts the onus on the buyer/user.  In this article, we use the term interchangeably to refer to whichever age limit is higher in a given jurisdiction.

UPDATE:  There has been some interest in studying whether nicotine can successfully treat COVID-19, as an apparent "smokers' paradox" has emerged with that particular disease.  But as Dr. Dmitry Kats has noted, that may actually be because some of the nicotine (when combusted, or when metabolized in the liver via oxidation) turns into nicotinic acid, better known as NIACIN (Vitamin B3).  So it would make more sense to cut out the middleman and go straight for niacin itself (immediate-release, flush, nicotinic acid) at doses of 500-1000 mg orally once or twice a day, on a full stomach, with twice as much Vitamin C simultaneously to boost it, and staying well-hydrated.  And don't forget Vitamin D, Vitamin A, Vitamin K, zinc, quercetin, resveratrol, selenium, magnesium, and the amino acid lysine as well.

For current smokers (or vapers):  Not ready to quit for good just yet for whatever reason?  Apparently, a review of studies simply cutting back, with or without nicotine replacement products, can actually increase the chances of quitting, even unexpectedly in those with no intention to quit.  This was from 2006, before the advent of vaping, but the results should still hold true to this day.  Baby steps indeed move mountains. 

2023 UPDATE:  Beware of any attempts to ban tobacco outright.  It was a miserable failure in Bhutan, so much so that the ban was recently lifted, and also in South Africa during the pandemic.