Intended for healthcare professionals

Rapid response to:


Key tobacco control report focuses on children

BMJ 2022; 377 doi: (Published 15 June 2022) Cite this as: BMJ 2022;377:o1457

Rapid Response:

Tobacco control without a maximum nicotine level in products is a smokescreen.

Dear Editor,

Agrawal rightly titled that tobacco control must focus on children when commenting on Khan’s report on tobacco control policy that challenged the feasibility of the government’s ambition to reduce smoking prevalence to below 5% by 2030.(1) However, the subtitle highlighting that “lack of political will threatens progress” deserves comment.

Certainly, political inertia, as with alcohol and junk foods, is an issue. However, among Khan’s 15 recommendations some are naïve and others are flying in the face of evidence. On one hand, while raising the legal age of sale of tobacco products is a prerequisite, its effectiveness will be limited as the ban will be hardly implemented, not to account for the marketing tricks of the industry and for sales on the Internet. On the other hand, the “active promotion of vaping as a quit smoking tool”(1) denies that electronic cigarettes are a Trojan horse of the tobacco industry, fooling experts with the harm reduction mantra as previously with filters and low tar products. Electronic cigarettes’ devastating consequences on the youngest in the real life setting has been repeatedly documented from the robust prospective PATH cohorts, without added value for cessation in adults.(2,3)

Rather than promoting nicotine, a gateway to addiction, the solution must be a requirement for a maximum nicotine content. New Zealand will be the first government to decrease cigarette nicotine content, a key action to reduce daily smoking prevalence to under 5% by 2025.(4) Similarly, the Biden administration just said that the Food and Drug Administration intends by May 2023 to develop a proposed standard “that would establish a maximum nicotine level in cigarettes and certain finished tobacco products.” (5) This will prevent young people from becoming regular smokers. Indeed, in the 1960s Sano marketed a cigarette with the lowest nicotine level on the US market, the only commercial failure of the tobacco business ever! Meanwhile, Malboro used ammonia to freebase nicotine (crack nicotine) and became number one in sales far before the previous leader Winston.(6)


1 Agrawal S. Key tobacco control report focuses on children. BMJ. 2022;377:o1457. doi: 10.1136/bmj.o1457.
2 Sun R, Mendez D, Warner KE. Can PATH Study susceptibility measures predict e-cigarette and cigarette use among American youth 1 year later? Addiction. 2022;117:2067-2074. doi: 10.1111/add.15808.

3 Osibogun O, Bursac Z, Maziak W. Longitudinal transition outcomes among adult dual users of e-cigarettes and cigarettes with the intention to quit in the United States: PATH Study (2013-2018). Prev Med Rep. 2022;26:101750. doi: 10.1016/j.pmedr.2022.101750.

4 Agrawal S, Britton J. New Zealand's bold new tobacco control programme. BMJ. 2022 Jan 18;376:o62. doi: 10.1136/bmj.o62.

5 McGinley L. Biden administration says it plans to cut nicotine in cigarettes. The Washington Post. June 21, 2022 available at accessed 22 June 2022.

6 Proctor RN. The golden holocaust: origins of the cigarette catastrophe and the case for abolition. Berkeley (CA): University of California Press; 2011

Competing interests: No competing interests

22 June 2022
alain braillon
retired senior consultant
Amiens, France