Effects of Very Low Nicotine Content Cigarettes on Smoking Behavior and Biomarkers of Exposure in Menthol and Non-menthol Smokers

Experience with reduced-nicotine cigarettes and whether this decreases smoking and substitution for full-nicotine cigarettes

Studies suggest that reduced-nicotine cigarettes decrease nicotine intake and dependence. However, questions remain about reduced-nicotine cigarette abuse liability, whether reduced-nicotine cigarette exposure lowers reduced- and full-nicotine cigarette use, and whether reduced-nicotine cigarettes substitute for full-nicotine cigarettes. This randomized, double-blind laboratory study used operant behavioral economics to examine abuse liability of cigarettes with varying nicotine content. Non-treatment-seeking smokers (N = 43) self-administered reduced- (5.2, 2.4, or 1.3 mg/g) and full-nicotine (15.8 mg/g) cigarettes before and after 3 weeks of at-home exposure. Participants were randomized to full-nicotine or one of the reduced-nicotine cigarettes to determine the effect of exposure on abuse liability and substitutability. Abuse liability was assessed in single-commodity sessions, and substitutability was measured in concurrent-commodity sessions. In the self-administration sessions, concurrently available reduced-nicotine cigarettes attenuated full-nicotine cigarette demand and rendered reduced-nicotine cigarettes partial substitutes for full-nicotine cigarettes. Exposure to study cigarettes for 3 weeks marginally reduced demand for reduced- and full-nicotine cigarettes irrespective of nicotine content. Results suggest a limited influence of nicotine content on smoking behavior in established smokers and highlight the role of nonpharmacological factors (e.g., taste/smell) on the maintenance of smoking. These results should be considered in determining whether a nicotine-reduction standard is a feasible path for reducing cigarette demand.

Perceptions and Interest in Lung Cancer Screening by Smoking Status: A Cross-Sectional Study of HINTS 6 (2022)

BACKGROUND

Lung cancer screening guidelines prioritize individuals with a history of smoking due to their higher risk of the disease.

METHODS

Our study examines the awareness and interest in low-dose computed tomography (LDCT) lung cancer screening among different smoking statuses using data from the National Cancer Institute's Health Information National Trends Survey (HINTS) 6 (2022). We analyzed data from HINTS 6, including 3915 participants on smoking status, LDCT screening, and telehealth use. Participants were categorized as current smokers, former smokers, and non-smokers.

RESULTS

Current smokers had the highest likelihood of being recommended for LDCT screening (OR: 7.1, aOR: 10.4) compared with non-smokers. Former smokers also had increased odds of screening recommendations (OR: 3.1, aOR: 3.4) than non-smokers. Despite higher screening recommendations, current smokers exhibited significantly lower interest in cancer screening (interest rating score: 2.1) compared with non-smokers (interest rating score: 2.4) and former smokers (interest rating score: 2.5). Current smokers rated their telehealth care experiences more positively in terms of care quality compared with non-smokers.

CONCLUSIONS

Our findings underscore a gap in cancer screening interest among current smokers despite their higher likelihood of being recommended for LDCT screening. The favorable perception of telehealth among current smokers provides an opportunity to enhance engagement and promote LDCT scan through telehealth care.

Associations between compliance with very low nicotine content (VLNC) cigarettes, abstinence self-efficacy, and quit outcomes in a pilot smoking cessation trial

BACKGROUND

Switching to Very Low Nicotine Content (VLNC) cigarettes reduces toxicant exposure and nicotine dependence, and may improve smoking cessation. However, non-compliance with VLNCs is often high, which may reduce their effectiveness. Here, we conducted secondary analyses of a pilot smoking cessation trial utilizing VLNCs to examine associations between pre-cessation VLNC compliance and changes in smoking rate, dependence, and abstinence self-efficacy, as well as quit outcomes.

METHODS

People who smoke daily (n=35) engaged in a 4-week pre-cessation intervention including VLNCs, transdermal nicotine patch, and behavioral counseling. After quit date, participants received 8 weeks of nicotine replacement therapy and 4 additional behavioral sessions, and were followed for 10 weeks to assess abstinence. Compliance with VLNCs was assessed biweekly during pre-cessation using timeline follow-back. Statistical analyses examined associations between VLNC compliance and a) changes in smoking rate, dependence and abstinence self-efficacy over the course of study cigarette use; and b) time to relapse, controlling for other smoking variables.

RESULTS

Greater compliance during the second half of study cigarette use was associated with subsequent improvement in self-efficacy (p<.05). Increased self-efficacy and VLNC compliance both predicted lower likelihood of relapse. Nicotine dependence and cigarettes per day both decreased following study cigarette use, but were unrelated to compliance or relapse.

CONCLUSIONS

Compliance with VLNCs prior to quitting increased abstinence self-efficacy and predicted better quit outcomes above and beyond baseline smoking characteristics. Although preliminary, these findings suggest that identifying strategies to promote exclusive use of VLNCs during a brief pre-cessation window may be beneficial.

Dietary Patterns among Smokers and Non-Smokers: Findings from the National Health and Nutritional Examination Survey (NHANES) 2017-2018

Diet behavior and nutrition are critical for maintaining health and improving quality of life. Cigarette smoking remains the leading cause of preventable death in the United States. Poor dietary choices, such as excessively frequenting restaurants, consuming ready-to-eat foods from grocery stores, and ingesting ultra-processed foods (like frozen meals and pizzas), can adversely impact health. Despite this, research comparing dietary behaviors between smokers and non-smokers is limited. Using data from the National Health and Nutritional Examination Survey 2017-2018, we analyzed diet behavior based on smoking status. Our findings reveal that smokers had a significant increase (90%) in the frequency of consuming frozen meals/pizzas in the past 30 days compared to non-smokers (coefficient: 1.9; 95% CI: 1.4, 2.6; p-value < 0.001). Additionally, over 70% of participants, regardless of their smoking status, were unaware of MyPlate, a nutritional guide created by the United States Department of Agriculture (USDA) to encourage Americans to make healthier food choices. There is an urgent need to increase public awareness of MyPlate and promote a better understanding of healthy dietary behaviors.

Understanding the mediation effects of cigarettes per day on time to first cigarette and carcinogen biomarkers: National Health and Nutrition Examination Survey 2015-2016

INTRODUCTION

Previous research indicates that cigarette smokers with a time to first cigarette (TTFC) of less than 30 minutes after waking up had significantly higher levels of carcinogen biomarkers compared to those with a TTFC of more than 30 minutes. The mediation (potential mediator: cigarettes smoked per day) between TTFC and carcinogen biomarkers, remains unclear and has yet to be established.

METHODS

Multivariable linear regression models were used to estimate adjusted geometric means (GMs) and ratios of GMs for urine biomarkers of VOCs by smokers' TTFC status (≤30 vs >30 min). Further, data from the NHANES 2015-2016 special sample were analyzed to assess the mediation between TTFC (exposure) and carcinogen biomarkers, including urine metabolites of polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs), and cadmium.

RESULTS

Cigarette smokers with a short TTFC (≤30 min) presented significantly higher concentrations in 8 out of 17 urine metabolites of VOCs examined compared to smokers with TTFC >30 min. The association between exposure and carcinogen biomarkers was not mediated by CPD.

CONCLUSIONS

Cigarette smokers with a short TTFC (≤30 min) had significantly higher levels in VOCs, PAHs, and cadmium, but the association was not mediated by cigarettes smoked per day.

Switching people who smoke to unfiltered cigarettes: Effects on smoking topography

Introduction

Smoking topography (ST) describes smoking behavior and patterns. Removal of the cigarette filter and subsequent impact on ST has not been investigated. This is the first clinical trial comparing ST for filtered and unfiltered cigarettes in a naturalistic experiment.

Methods

We conducted a crossover clinical trial following established people who smoke cigarettes (n = 32) for two weeks under filtered and unfiltered smoking experimental conditions. Participants (50 % female, mean age 38.3 yr.) smoked in each experimental condition followed by a 3-week post-washout period. ST (puff count, volume, duration, peak and average flow) was measured at six time-points. Statistical analysis included a linear repeated mixed-effects model of smoking experimental conditions by visit number and sex.

Results

Average flow (ml/sec) was significantly less for filtered smoking (-6.92 lower (95 % CI: -13.44 to -0.39), p < 0.05), thus demonstrating more resistance on inhalation. No significant differences were found between filtered or unfiltered experimental conditions for other ST variables. However, average volume and average peak flow were somewhat higher in unfiltered smoking, and lower mean puff counts/cigarette were observed for unfiltered compared to filtered smoking.

Conclusion

Lower average flow rates were associated with filtered cigarette smoking. No significant differences were found for other ST variables between smoking experimental conditions. ST measurements comparing cigarette smoking conditions may determine if product regulatory changes, such as removing the cigarette filter could impact smoking behavioral patterns among people who smoke. This proof-of-principle study measuring ST may be replicated in larger trials to determine potential behavioral changes in smoking unfiltered cigarettes.

Disparities in Healthcare and HBV Vaccination by Smoking Status: Findings from the National Health and Nutrition Examination Survey (NHANES) 2017-2018

Cigarette smokers face greater challenges in accessing healthcare compared with non-smokers. In the US, approximately 2.2 million individuals are chronically infected with hepatitis B virus (HBV). I used data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 to investigate the association between smoking status (current, former, and never smoker) and different health outcomes, including healthcare accessibility, HBV vaccination, general health condition, and health insurance. Multivariable logistic regressions were used to analyze healthcare disparity by smoking status. I found that current smokers had 40% higher odds (AOR = 1.4, 95% CI: 1.1, 1.8) of lacking routine healthcare access compared with non-smokers. Regardless of smoking status, I observed a high rate of HBV non-vaccination among all participants. Specifically, 64% of current smokers, 67% of former smokers, and 57% of non-smokers had not received a single dose of HBV immunization. My study sheds light on the persisting gaps in healthcare access, particularly for smokers, and the urgent need to promote awareness and vaccination against hepatitis B.

Comparison of urine heavy metals in exclusive menthol and non-menthol cigarette users by race/ethnicity: The 2015-2016 National Health and Nutrition Examination Survey Special Sample

INTRODUCTION

The objective of this study was to investigate the differences in urine concentrations of heavy metals (uranium, cadmium, and lead) between exclusive menthol and non-menthol cigarette smokers across three racial/ethnic groups using data from the National Health and Nutrition Examination Survey (NHANES) 2015-2016 Special Sample.

METHODS

Data from NHANES 2015-2016 Special Sample were analyzed to assess the association between menthol smoking and heavy metal biomarkers in urine across three racial/ethnic groups (N=351), including Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic/Other (HISPO). Multivariable linear regression models were used to estimate adjusted geometric means (GMs) and ratio of GMs (menthol/non-menthol smokers) (RGMs) for urine biomarkers of heavy metals between menthol and non-menthol smokers by race/ethnicity.

RESULTS

Among the 351 eligible participants, 34.4% (n=121) were NHW, 33.6% (n=118) were NHB, and 32.0% (n=112) were HISPO exclusive cigarette smokers. The analysis revealed significantly higher concentrations of urine uranium in NHB menthol smokers compared to NHB non-menthol smokers (RGMs=1.3; 95% CI: 1.0-1.6; p=0.04). NHW menthol smokers appeared to have higher levels of urine uranium than non-menthol smokers, but the difference was not statistically significant (9.0 vs 6.3; RGMs=1.4; 95% CI: 1.0-2.2; p=0.08). There were no significant differences in urine metals (cadmium and lead) by menthol status among NHW, NHB, or HISPO cigarette smokers (p>0.05).

CONCLUSIONS

The research findings regarding the higher levels of urine uranium among Non-Hispanic Black (NHB) menthol cigarette smokers raise questions about the claims suggesting that additives in cigarettes do not contribute to increased toxicity.

Manipulation of Menthol and Nicotine Content in Cigarettes: Effects on Smoking Behavior and Toxicant Exposure in Women Menthol Smokers

BACKGROUND

The purpose of this study was to determine the effects of smoking and other outcomes of assigning cigarettes with reduced nicotine and/or no menthol to female menthol smokers.

AIMS AND METHODS

Nontreatment-seeking female menthol smokers (N = 263) participated in a randomized controlled trial in which levels of menthol and nicotine in cigarettes were manipulated using experimental cigarettes. After a baseline period, participants were assigned to the following conditions for 6 weeks: (1) their own brand of cigarette (conventional nicotine with menthol), (2) a conventional nicotine cigarette with no menthol, (3) a cigarette with reduced nicotine (RNC) with menthol, or (4) a RNC cigarette and no menthol. Participants then returned to using their own brand and were followed for another 6 weeks. Outcomes included cigarettes smoked, biomarkers of exposure, and dependence measures.

RESULTS

Results indicated that, after an initial increase, rates of smoking of all three experimental cigarettes were at or below baseline rates of smoking of one's own brand. Levels of biomarkers also decreased during the experimental phase but rebounded somewhat after participants resumed smoking their own brand. There was evidence that the overall amount of smoking decreased similarly among women who switched to non-menthol and/or RNC cigarettes.

CONCLUSIONS

These results suggest that no detrimental effect will occur in nicotine or toxicant exposure levels with a ban on characterizing menthol and/or a product standard on nicotine content in cigarettes.

IMPLICATIONS

The implication of this work is that there would be no risk to women menthol smokers associated with regulations restricting nicotine and eliminating menthol in cigarettes.

Effects of very low nicotine content cigarettes on smoking across vulnerable populations

There has been long-standing interest in a reduced-nicotine product standard for combusted tobacco, which is within the regulatory purview of the Food and Drug Administration (FDA). In weighing whether to establish this standard, it is important to consider potential responses among people who are at elevated risk for tobacco-related health harms. In this narrative review, we summarize studies of very low nicotine content (VLNC) cigarettes conducted between 2010 and 2021 in groups that the FDA has identified as vulnerable populations. Studies conducted to date in adults with mental health conditions, adults with opioid use disorder, socioeconomically-disadvantaged adults, and youth or young adults indicate that immediate switching to VLNC cigarettes decreases smoking, with minimal or no unintended negative consequences. Few studies have investigated the effects of VLNC cigarettes in racial or ethnic minorities, people who smoke menthol cigarettes, and pregnant women, but initial findings suggest that responses of these individuals are similar to responses observed in other vulnerable populations. We are not aware of studies that have investigated VLNC cigarettes in military/veteran populations, sexual or gender minority individuals, or people living in underserved rural environments. Future research directions include understanding how to promote cessation in the context of a reduced-nicotine standard, and how to correct VLNC misperceptions in vulnerable populations. Nevertheless, the evidence to date indicates that a reduced-nicotine standard is likely to have the same beneficial effects on smoking reductions as it does in less vulnerable populations, which should provide some confidence in pursuing this regulatory approach.

Effect of menthol on nicotine reduction: Pooled results from two double-blind randomized controlled trials

BACKGROUND

Menthol upregulates nicotinic acetylcholine receptors and is associated with tobacco dependence. The effects of menthol when smoking cigarettes with varying low nicotine content up to 98 % (e.g., non-addicting) less than commercial cigarettes is not well understood. The U.S. Food and Drug Administration is considering two tobacco product standards in cigarettes including banning menthol and reducing nicotine content. These new standards have the potential to significantly reduce smoking initiation and maintenance by limiting the mechanistic effects of nicotine and menthol on the brain.

METHODS

We conducted two parallel randomized clinical trials of gradually reduced nicotine in cigarettes from 11.6 mg down to 0.2 mg nicotine/cigarette (very low nicotine content; VLNC) vs. usual nicotine content (11.6 mg; UNC) over an 18-week period in people who smoke cigarettes with low socioeconomic status (SES) and mental health conditions.

RESULTS

Compared to UNC, VLNC was associated with significant reductions in cotinine, cigarettes per day, expired carbon monoxide levels, nicotine dependence and symptomology. These associations did not differ between menthol and non-menthol cigarettes, except people who smoke menthol cigarettes had less of a cotinine reduction in the SES trial. The pooled odds ratio of being adherent with using only VLNC study cigarettes in the gradual nicotine reduction arm for people who smoke non-menthol vs. menthol cigarettes was 2.6 (95 % CI:1.0, 6.4; p-value: 0.04).

CONCLUSIONS

When nicotine is lowered to non-addicting levels, the results indicate an independent effect of menthol on the need to sustain nicotine intake in addicted people who smoke cigarettes.

Menthol preference moderates the relationship between cigarette nicotine content choice and reactions in young adults who smoke infrequently

BACKGROUND

Half of young adults who smoke use menthol cigarettes, which is associated with continued smoking and greater nicotine dependence. Additionally, early subjective reactions to cigarettes predict future use. Menthol may blunt the sensory effects of nicotine. We investigated the moderating role of menthol on subjective reactions to, and choice of varied nicotine content cigarettes in young adults who smoke infrequently.

METHODS

In three counterbalanced, double-blinded sessions, young adults who smoke ≤ 15 days/month smoked fixed doses from very low (VLNC), intermediate (INC), and normal (NNC) nicotine content cigarettes, which were menthol or non-menthol depending on preference. Participants chose their preferred cigarette in a final session. Positive and negative subjective reactions were measured in each session. ANOVA tests investigated the relationship between menthol preference, nicotine content, and subjective reactions.

RESULTS

Participants (N = 87) were 18-25 years old and reported smoking 15.2 cigarettes per month over 8 days (35 % menthol). Non-menthol preferring participants had increased negative reactions with greater nicotine content (F(1, 55)= 10.76, p < .001); menthol preferring participants did not. Choice of higher nicotine cigarettes was associated with having reported a greater difference in positive reactions to NNC and VLNC for non-menthol preferring participants (F(1, 55)= 12.72, p < .001) but not for menthol preferring participants.

CONCLUSIONS

Young adults who smoke infrequently are a priority tobacco control population given their high risk of transitioning to daily smoking. Results from this study in the form of subjective reactions indicate that a menthol ban is required for a nicotine reduction standard to be maximally effective in this vulnerable group.

Effects of Very Low Nicotine Content Cigarette use on Cigarette Reinforcement among Smokers with Serious Mental Illness

BACKGROUND

Among people without psychiatric disorders who smoke, very low nicotine content (VLNC) cigarette use reduces cigarette reinforcement. Whether this is true of people with serious mental illness (SMI) who smoke is unknown. Using a hypothetical purchase task, we compared the effects of 6-week use of VLNC versus normal nicotine content (NNC) cigarettes on study cigarette and usual brand (UB) cigarette reinforcement among people with SMI who smoke.

METHODS

After a baseline period of UB cigarette use, participants with SMI (n = 58) were randomized to use NNC cigarettes (15.8 mg nicotine/g tobacco) or VLNC cigarettes (0.4 mg/g) for 6 weeks. At Week 6, they completed the CPT for both their assigned study cigarette and UB. The groups were compared on demand intensity (number of cigarettes purchased at no cost) and elasticity (rate of decline in demand as price increases) using extra sum-of-squares F-tests. The effects of treatment on demand indices while controlling for covariates were assessed using hierarchical regression.

RESULTS

At Week 6, intensity of demand for study cigarettes was lower and elasticity was higher for the VLNC group relative to the NNC group (p < 0.0001). Furthermore, intensity of demand for UB cigarettes was lower for participants in the VLNC group relative to participants in the NNC group (p < 0.01). When controlling for baseline cigarettes per day, intensity remained significantly different for study cigarettes and usual brand cigarettes at Week 6.

CONCLUSION

A nicotine reduction policy may reduce cigarette reinforcement in this vulnerable population.

A review of the evidence on cigarettes with reduced addictiveness potential

BACKGROUND

In May 2018, the Secretariat for the World Health Organization Framework Convention on Tobacco Control convened a meeting to discuss the potential for reducing the addictiveness of tobacco products. A central focus was to review research findings on the behavioral effects of reducing the addictiveness of cigarettes.

METHODS

This manuscript reports the results of a review of the behavioral science literature, updated through April 2021, with special attention to both the potential benefits and unintended consequences of reducing nicotine in cigarettes.

RESULTS

Available evidence suggests that reducing nicotine content in cigarettes to very low levels could benefit public health in three primary ways, by 1) decreasing uptake of regular smoking, 2) decreasing the amount people smoke, and 3) increasing the likelihood of smoking cessation. Current evidence also suggests that reducing nicotine in cigarettes may produce similar benefits across many important subpopulations of people who smoke, including those with psychiatric comorbidities, those who use other substances, those with low socioeconomic status, young people, people who smoke infrequently and people who prefer menthol cigarettes. Cigarette nicotine reduction could also lead to some undesirable outcomes, such as experiencing withdrawal, product manipulation, an illicit market, and harm misperceptions; strategies that may mitigate each are discussed.

CONCLUSION

Overall, behavioral research suggests product standards that limit the nicotine content of combusted tobacco products could render cigarettes and similar products less addictive. The availability of legal, non-combusted products that effectively substitute for cigarettes and the dissemination of public health campaigns that clarify misperceptions about the relationship between nicotine, tobacco and disease may facilitate the extent to which a nicotine reduction policy reduces smoking.

Reactions to reduced nicotine content cigarettes in a sample of young adult, low-frequency smokers

RATIONALE

Reducing nicotine content in cigarettes to ≤ 2.4 mg per g of tobacco [mg/g] reduces smoking behavior and toxicant exposure among adult daily smokers. However, cigarettes with similar nicotine content could support continued experimentation and smoking progression among young adults who smoke infrequently.

OBJECTIVES

This study evaluated the threshold for nicotine in cigarettes that produces reactions associated with smoking progression in a sample of young adults who smoke infrequently.

METHODS

Young adults (n = 87, 18-25 years, 49% female) using tobacco products ≤ 15 days per month completed three counterbalanced, double-blinded sessions, each measuring positive and negative subjective reactions to fixed doses of smoke from investigational cigarettes containing one of three different nicotine contents: normal (NNC; 15.8 mg/g); very low (VLNC; 0.4 mg/g); and intermediate (INC; 2.4 mg/g). In a final session, participants chose one of the cigarettes to self-administer.

RESULTS

Post-cigarette breath carbon monoxide was greater for VLNC than for NNC (p < 0.001). Positive reactions were greater for NNC than INC (p < 0.001) and for INC than VLNC (p = 0.001). Negative reactions were greater for NNC than INC and VLNC (both p < 0.001); INC and VLNC did not differ. Cigarette choices did not differ from an even distribution (43% NNC, 25% INC, 32% VLNC), but choice for NNC or INC was associated with higher ratio of positive to negative reactions during the NNC and INC fixed dose sessions, respectively (p < 0.001).

CONCLUSIONS

Reducing nicotine content will likely lower the abuse liability of cigarettes for most young, low-frequency smokers. Additional work is needed to determine if compensatory smoking may lead to increased toxicant exposure, and if a subset of individuals choosing lower nicotine cigarettes may continue to smoke regardless of nicotine content.

Regulatory approaches and implementation of minimally addictive combusted products

INTRODUCTION

A joint meeting was held by the World Health Organization (WHO) and the Convention Secretariat of the WHO Framework Convention on Tobacco Control to examine the potential effects of a regulatory policy to reduce nicotine in cigarettes to minimally addictive levels. This paper reviews the feasibility of and approaches to implementing a nicotine product standard.

METHODS

Prior WHO reports on this topic were consulted and a systematic review of the scientific literature was conducted. The paper was reviewed by the participants at the aforementioned meeting and their feedback was incorporated.

RESULTS

The nicotine dose most likely to consistently reduce smoking behavior and dependence is < 0.4 mg nicotine/g tobacco. An immediate rather than a gradual nicotine reduction approach appears to be more beneficial. Smokers are likely to seek nicotine from alternate sources (e.g., nicotine replacement therapies, e-cigarettes) or potentially, the illegal market. As such, the availability of alternative products, as well as strong policies against illegal markets, can potentially mitigate unintended consequences. An effective reduced nicotine regulation must be imbedded in a comprehensive and strong tobacco control program that includes public education and surveillance. Barriers and challenges to implementing a nicotine product standard exist, particularly in low-capacity countries.

CONCLUSION

Not all countries will have the capacity to implement a regulation to reduce nicotine in cigarettes (and preferably other combusted tobacco products) to minimally addictive levels. However, for the countries that choose to implement it, such a policy could potentially dramatically reduce the burden of tobacco use.

Risk Perceptions of Low Nicotine Cigarettes and Alternative Nicotine Products across Priority Smoking Populations

BACKGROUND

As the U.S. Food and Drug Administration considers a low nicotine product standard for cigarettes, it is important to examine how people who smoke, especially individuals from priority populations disproportionately affected by smoking, perceive low nicotine content (LNC) cigarettes and their relative risk perceptions of alternative nicotine delivery system (ANDS) products, including e-cigarettes and snus, and medicinal nicotine.

METHODS

Data are from Wave 4 (2016-2017) of the adult Population Assessment of Tobacco Use and Health (PATH) Study. We examined respondents' absolute risk perceptions about nicotine, LNC cigarettes, ANDS products and medicinal nicotine; their relative risk perceptions of LNC cigarettes and ANDS products compared to conventional cigarettes; and their relative risk perceptions of medicinal nicotine compared to ANDS products.

RESULTS

The majority of respondents across priority smoking populations indicated snus, e-cigarettes, and LNC cigarettes were 'about the same' level of harmfulness or addictiveness as conventional cigarettes. The majority of respondents indicated e-cigarettes to be 'about the same' harmfulness as medicinal nicotine.

CONCLUSIONS

Our study indicates that adults who smoke cigarettes generally have misperceptions about the harms of nicotine and the relative risks of ANDS products and such misperceptions exist regardless of their racial/ethnic identity, sexual orientation, and gender identity.

"I actually finally feel like the cigarettes aren't controlling me." - Interviews with participants smoking very low nicotine content cigarettes during a residential study

BACKGROUND

The U.S. Food and Drug Administration (FDA) is considering a low-nicotine product standard for cigarettes. The purpose of this qualitative study was to explore participants' experiences after 72 hours of exclusively smoking very low nicotine content (VLNC) cigarettes.

METHODS

We conducted a residential study during which participants who smoked cigarettes (N = 16) stayed in a smoking-friendly hotel for 5 days/4 nights. Participants only had access to VLNC cigarettes and were told the cigarettes had 97% less nicotine compared to conventional cigarettes. We conducted individual interviews with participants to assess their initial expectations about VLNC cigarettes, subjective experiences when smoking VLNC cigarettes, opinions regarding a low-nicotine product standard, and predicted use behavior if only VLNC cigarettes were available. Interviews were transcribed verbatim and analyzed using thematic analysis methods.

RESULTS

Several participants expected, prior to trying VLNC cigarettes, to compensate for the reduced nicotine levels by smoking more cigarettes but were surprised when they did not increase their smoking. A subset of participants reported experiencing minor withdrawal symptoms, such as irritability and fatigue. Several participants reported feeling less dependent after exclusively smoking VLNC cigarettes. Most participants said they would smoke VLNC cigarettes if they were the only cigarettes available to purchase. Some also said that smoking VLNC cigarettes could help people taper down or quit smoking.

CONCLUSIONS

Health communication strategies are needed to inform people who smoke about what to expect from a low-nicotine product standard for cigarettes in order to maximize the public health impact of the policy and increase support.

Tobacco harm reduction: Past history, current controversies and a proposed approach for the future

Tobacco harm reduction remains a controversial topic in tobacco control. Tobacco harm reduction involves providing tobacco users who are unwilling or unable to quit using nicotine products with less harmful nicotine-containing products for continued use. The skepticism towards harm reduction is based in part on the experience with low-yield tar/nicotine cigarettes, which were presumed to be associated with lower health risks than higher yield cigarettes and marketed as such by cigarette manufacturers. Only later did the field learn that these cigarettes were a deceptive way for cigarette manufacturers to allay the health concerns over cigarette smoking. Since this experience, there has been a proliferation of tobacco products that might potentially serve as a means to reduce tobacco harm. Some members of the tobacco control community believe that these products have great potential to reduce mortality and morbidity among smokers who completely switch to them. Others believe that we will be addicting another generation to tobacco products. This paper reviews the past history, the current tobacco landscape and controversies, and an approach that might rapidly reduce the yearly half-million deaths associated with cigarette smoking in the U.S.

Reducing the relative value of cigarettes: Considerations for nicotine and non-nicotine factors

Despite notable progress in recent decades, cigarette smoke persists as a leading cause of premature death and preventable disease. To weaken the link between nicotine reinforcement and the toxicity associated with combusted tobacco, the United States Food and Drug Administration is considering a product standard targeting cigarette nicotine content. In this review, we summarize research assessing the potential impacts of reducing nicotine in cigarettes. Evidence to date suggests cigarette smoking, toxicant exposure and dependence would decline following substantial reductions in nicotine content. However, reduced nicotine content may not eliminate smoking entirely. Regulatory efforts that shape the nicotine and tobacco marketplace should consider that non-nicotine reinforcing factors and decision-making biases can contribute to the value of smoking. The impact of reducing nicotine in cigarettes will likely depend on the alternative nicotine products available to current smokers. This article is part of the special issue on 'Contemporary Advances in Nicotine Neuropharmacology'.

Nicotine Standards in the United States

This Special Issue on nicotine standards in the United States will address many of the questions raised in the Advance Notice of Proposed Rulemaking (ANPRM) through a series of policy commentaries and timely empirical studies across a variety of topic areas within the proposed comprehensive nicotine standards plan. The questions addressed in this issue include: (1) the threshold dose of nicotine (and other constituents) that would lead to minimally addictive cigarettes; (2) the effects of a nicotine product standard in smokers with co-morbidity, youth and young adult smokers, and menthol smokers; (3) a step-down or targeted data approach to reducing nicotine in cigarettes; (4) perceptions and communications about product standards; and (5) requirements associated with the implementation of a nicotine product standard.