Health, Equity, and Economic Impacts of a Nicotine Product Standard in the United States for People With and Without Major Depression

Abstract

Importance: The U.S. FDA has proposed a product standard that would reduce the nicotine content and addictiveness of cigarettes. It is unclear what impact this would have on economic outcomes or priority populations who are disproportionately harmed by tobacco use, such as people with major depression.

Objective: To evaluate the long-term health and economic impacts of a nicotine product standard for the U.S. population by depression status.

Design setting and participants: A microsimulation model was developed and calibrated to National Survey on Drug Use and Health (NSDUH) 2005-2023 data on smoking, vaping, and depressive episodes. The anticipated effects of the nicotine product standard on smoking and vaping were obtained from an FDA expert elicitation and used to simulate the policy from 2027-2100.

Exposure: Smoking and vaping.

Main outcomes and measures: Health outcomes included prevalence of smoking and vaping, deaths, and life years gained overall and by major depression status. Economic outcomes include direct costs to the healthcare system and societal costs.

Results: Under the proposed nicotine product standard, smoking is projected to decline to <1% for people with and without depression by 2100. The policy is estimated to avert 1.7 million premature deaths and lead to 74.7 million life years gained. Depression prevalence is also expected to decline, with 8.5 million fewer cases of depression estimated. Longer life expectancies under the policy are projected to increase medical costs by $296 billion, while also increasing worker productivity by $266 billion with an additional $1.2 trillion in consumer spending.

Conclusions and relevance: Timely implementation of a nicotine reduction strategy, either through a federal product standard or state-level sales restrictions, is cost-effective and could prevent millions of premature deaths and reduce smoking disparities by depression status.

Figure 1.

Overview of product use and depression status transitions in the Major Depression, Smoking, and E-cigarette Model (MDSE) Notes: N = Never smoking, C = Current smoking. F = Former smoking, O = Never vaping, E = Current vaping, Q = Former vaping = Never had major depression (Never MD), D = Depressed (Current MD), R = Recovered (Former MD), X = Dead.

Figure 2.

Actual and projected Smoking and Vaping Prevalence 2005–2100 by Major Depression (MD) Status in status quo and nicotine product standard (policy) scenarios Notes: The black solid line represents the status quo scenario, and the blue dashed line is the Nicotine Product Standard scenario. Light blue shading represents the area covered by the upper and lower bounds of optimistic and pessimistic scenarios. Dots are NSDUH data points used to calibrate the model. Vertical lines on dots are confidence intervals. Note that intervals are not visible for total and Never MD populations because large sample sizes resulted in small confidence bounds.