A large systematic review and pooled meta-analysis suggests that smokers who switch to very low nicotine content (VLNC) cigarettes are unlikely to compensate by smoking more cigarettes or increasing smoke exposure, addressing a longstanding concern surrounding proposed federal nicotine-reduction policies.1
The findings, published in JAMA Network Open by Rachel Denlinger-Apte, PhD, MPH, Assistant Professor, Social Sciences and Health Policy, Public Health Sciences (Winston-Salem) and colleagues, come as the US Food and Drug Administration (FDA) considers a product standard requiring cigarettes and other combusted tobacco products to contain minimally addictive or nonaddictive nicotine levels.
VLNC cigarettes contain about 95% less nicotine than conventional cigarettes. While previous studies have found reductions in cigarette consumption and nicotine dependence among users, concerns have persisted that smokers might respond by smoking more or inhaling more intensely, a behavior known as compensatory smoking.
Commenting on the findings, Hasmeena Kathuria, MD, Director of the University of Wisconsin Center for Tobacco Research and Intervention and a member of CHEST’s Tobacco/Vaping Work Group, said the study adds to the growing body of evidence supporting reduced-nicotine cigarettes.
“These findings are consistent with and provide further support that [VLNC] cigarettes do not lead to substantial compensatory smoking,” Dr. Kathuria said. “The concern about compensatory smoking largely stems from the experience with ‘light’ cigarettes. Although ‘light’ cigarettes were marketed as lower-yield products, people could often compensate through changes in smoking behavior. In contrast, VLNC cigarettes contain dramatically less nicotine in the tobacco itself, making meaningful compensation much more difficult.”
Investigators reviewed 17 randomized clinical trials published between 2010 and 2024 involving 5,500 adolescents and adults in the United States and New Zealand. Participants included those who smoked daily and nondaily, people with and without quit intentions, and populations with psychiatric disorders or socioeconomic disadvantages.
Across all 17 trials, none reported an increase in average cigarettes smoked per day among participants assigned to VLNC cigarettes. Sixteen studies found significantly lower cigarette consumption, with reductions ranging from about 1.6 to 14.9 fewer cigarettes per day. Carbon monoxide (CO) exposure, a marker of smoke inhalation, also generally declined. Nine of 13 studies reporting CO outcomes found significant reductions, while four found no significant difference. None reported increased average CO exposure.
The pooled meta-analysis included individual participant data from seven US trials involving 2,454 participants who smoked. At six weeks, switching to VLNC cigarettes was associated with smoking 5.7 fewer cigarettes per day, on average. Researchers estimated that only 0.8% of participants would increase cigarette consumption after six weeks, with a maximum projected increase of 3.3 cigarettes daily.
CO exposure also declined overall, with an average reduction of 2.7 parts per million at six weeks. Researchers estimated that 8.1% of participants might experience higher CO levels, with a maximum projected increase of 4.2 parts per million.
Among participants who used only VLNC cigarettes, an analysis intended to approximate a nationwide nicotine-reduction standard predicted that 1.3% would increase smoking and 2.5% would increase CO exposure.
Researchers found some evidence of short-term compensation during the first week after switching. An estimated 22.9% of participants increased cigarette consumption and 30.8% showed increased CO exposure, but these effects largely disappeared over time. By six weeks, fewer than 1% were predicted to continue smoking more cigarettes.
Investigators found no demographic or smoking-related subgroup more likely to compensate. Factors including age, sex, race, education, dependence measures, smoking history, and socioeconomic characteristics were not associated with systematic increases in smoking or CO exposure after nicotine reduction.
Dr. Kathuria said the growing evidence base has helped clarify concerns about compensatory smoking and that policy discussions can now turn to how best to maximize the public health impact of a nicotine reduction standard.
“There is now a substantial body of evidence showing that sustained compensatory smoking is unlikely with very low nicotine content cigarettes,” she said. “The focus should now be on how to maximize cessation, prevent youth addiction, address product substitution, and ensure effective implementation of a nicotine reduction standard.”
According to Dr. Kathuria, key uncertainties involve how those who smoke and the tobacco industry would respond over the long term.
“The major questions now center on real-world implementation and how to maximize the policy’s public health impact,” she said. “Key questions include how many people quit completely, how many people transition to noncombustible nicotine products, whether long-term dual use becomes common, and whether illicit markets or nicotine analog products emerge to circumvent the policy.”
If the FDA adopts a national nicotine-reduction standard, researchers and regulators should monitor cessation rates, transitions to alternative nicotine products, youth initiation, retail compliance, and attempts to evade the rules.
“An important goal of the policy is to reduce nicotine addiction and help adults who smoke stop using combustible tobacco products,” Dr. Kathuria said. “One of the most important projected long-term benefits of a nicotine standard is reducing the likelihood that young people become addicted to combustible tobacco products.”
References
1. Denlinger-Apte RL, Ji Z, Harwood EA, et al. Compensatory smoking with very low nicotine content cigarettes: a systematic review and meta-analysis. JAMA Netw Open. 2026;9(7):e2622543. doi:10.1001/jamanetworkopen.2026.22543
