Compensatory Smoking With Very Low Nicotine Content Cigarettes: A Systematic Review and Meta-Analysis - Report - MDSpire

Compensatory Smoking With Very Low Nicotine Content Cigarettes: A Systematic Review and Meta-Analysis

  • By

  • Rachel L. Denlinger-Apte

  • Ziyu Ji

  • Emily A. Harwood

  • Darcy Lockhart

  • Neal L. Benowitz

  • Dana Mowls Carroll

  • Rachel N. Cassidy

  • Suzanne M. Colby

  • Eric C. Donny

  • Diann E. Gaalema

  • Brandy W. Hardy

  • Dorothy K. Hatsukami

  • Sarah H. Heil

  • Stephen T. Higgins

  • Xianghua Luo

  • F. Joseph McClernon

  • Stacey C. Sigmon

  • Tracy T. Smith

  • Andrew A. Strasser

  • Jennifer W. Tidey

  • David M. Vock

  • Cassidy M. White

  • Jack M. Wolf

  • Joseph S. Koopmeiners

  • July 15, 2026

Share

Systematic Review and Meta-Analysis of Compensatory Smoking in Response to Cigarettes with Very Low Nicotine Levels

Overview

This systematic review and meta-analysis examined compensatory smoking behaviors in response to very low nicotine content (VLNC) cigarettes. Findings indicate no significant increases in cigarettes smoked per day or exhaled carbon monoxide among participants assigned to VLNCs compared to normal nicotine content cigarettes.

Background

The FDA's proposed rule to cap nicotine levels in cigarettes aims to reduce addiction and promote smoking cessation. Compensatory smoking, where individuals increase their cigarette consumption or change smoking behaviors in response to lower nicotine levels, is a concern that needs to be understood for evaluating the implications of a low-nicotine product standard.

Data Highlights

OutcomeVLNCsNNCs
Cigarettes smoked per dayNo significant increaseBaseline
Exhaled CO levelsNo significant increaseBaseline
Estimated compensation (cigarettes/day)0.8%Not applicable
Estimated compensation (CO levels)8.1%Not applicable

Key Findings

  • No significant increase in mean cigarettes smoked per day among VLNC users compared to NNC users.
  • No significant increase in exhaled carbon monoxide levels among VLNC users compared to NNC users.
  • Estimated that 0.8% of participants could increase cigarettes smoked per day when assigned to VLNCs.
  • Estimated that 8.1% of participants could increase exhaled CO levels at 6 weeks if assigned to VLNCs.

Clinical Implications

The findings from this review provide data on the risk of compensatory smoking associated with VLNC cigarettes.

Conclusion

The systematic review and meta-analysis provide evidence that VLNC cigarettes do not lead to significant compensatory smoking behaviors.

Related Resources & Content

  1. FDA, FDA, 2025 -- FDA Proposes Significant Step Toward Reducing Nicotine to Minimally or Nonaddictive Level in Cigarettes and Certain Other Combusted Tobacco Products
  2. JAMA Network Open, JAMA Network, 2026 -- Compensatory Smoking With Very Low Nicotine Content Cigarettes: A Systematic Review and Meta-Analysis
  3. JAMA Network Open — Regulating the Level of Nicotine in Combustible Cigarettes
  4. Archives of Toxicology — A comprehensive evaluation of potential serious adverse health outcomes associated with nicotine replacement therapy
  5. Archives of Toxicology — Analysis of Specific Analyte Levels in Emissions from "Heat Not Burn" Tobacco Products Relevant to Human Health Risk Assessment
  6. Archives of Toxicology — Improvement of Chronic Effects Induced by Cigarette Smoke in Mice Following Transition to Electronic Cigarettes
  7. Regulating the Level of Nicotine in Combustible Cigarettes
  8. A comprehensive evaluation of potential serious adverse health outcomes associated with nicotine replacement therapy
  9. FDA Proposes Significant Step Toward Reducing Nicotine to Minimally or Nonaddictive Level in Cigarettes and Certain Other Combusted Tobacco Products | FDA
  10. Compensatory Smoking With Very Low Nicotine Content Cigarettes: A Systematic Review and Meta-Analysis | Public Health | JAMA Network Open | JAMA Network
  11. VA/DoD_Clinical_Practice_Guideline_for_Management_of_Stroke_Rehabilitation

Original Source(s)

Compensatory Smoking With Very Low Nicotine Content Cigarettes: A Systematic Review and Meta-Analysis

  • by Rachel L. Denlinger-Apte, Ziyu Ji, Emily A. Harwood, Darcy Lockhart, Neal L. Benowitz, Dana Mowls Carroll, Rachel N. Cassidy, Suzanne M. Colby, Eric C. Donny, Diann E. Gaalema, Brandy W. Hardy, Dorothy K. Hatsukami, Sarah H. Heil, Stephen T. Higgins, Xianghua Luo, F. Joseph McClernon, Stacey C. Sigmon, Tracy T. Smith, Andrew A. Strasser, Jennifer W. Tidey, David M. Vock, Cassidy M. White, Jack M. Wolf, Joseph S. Koopmeiners

  • July 15, 2026

Related Content

Language Disparities in the PFT Lab: Implications for PFT Lab Quality Performance

High-flow nasal oxygen in perioperative and critical care: a bibliometric analysis

Breath, brain, and performance: investigating the effects of respiratory patterns on anxiety and cognition in bassoon players