The effects of reduced nicotine content cigarettes on biomarkers of nicotine and toxicant exposure, smoking behavior and psychiatric symptoms in smokers with mood or anxiety disorders: A double-blind randomized trial

Evaluating the human abuse potential of concurrent use of electronic cigarettes and low nicotine cigarettes among adults who smoke

The U.S. Food and Drug Administration has stated its intention to reduce the nicotine content of combustible cigarettes to render them less addictive. This study evaluated the impact of providing adults who smoke with both very low nicotine content cigarettes (VLNCCs) and electronic cigarettes (ECs) of varying nicotine content on measures of human abuse potential. Participants (n = 213) were adult combustible cigarette users. They smoked their usual brand cigarettes (UBCs) during Phase 1 (baseline; week 1) and were provided with and encouraged to exclusively use VLNCCs during Phase 2 (weeks 2-4). During dual-product Phases 3 (weeks 5-7) and 4 (weeks 8-10), participants received both VLNCCs and ECs (assigned to one of two EC devices in higher or lower nicotine concentrations and choice of flavor), with instructions to use them freely in Phases 3 and 4. Assessments included product use, exposure, acceptability, risk perception, and withdrawal-related measures. Results indicated that participants used significantly fewer UBCs during the VLNCC and dual-product phases and smoked fewer VLNCCs during the dual-product phases than the VLNCC-only phase. Neither EC liquid nicotine concentration nor flavor influenced product use. The three study product phases resulted in less product liking and more withdrawal symptoms than the UBC phase. These results suggest that adults who smoke are able to switch much of their tobacco product use from UBCs to VLNCCs and will substitute combustible UBCs and VLNCCs with noncombustible nicotine-containing ECs, but most remain dual users, at least in the short term. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

What to Expect From a Low-Nicotine Product Standard for Cigarettes: A Response to "Denicotinized" Tobacco

This Viewpoint discusses the public health benefits that could be gained if the US Food and Drug Administration (FDA) were to mandate very low-nicotine-content cigarettes (VLNCs).

Likely Response to a Hypothetical Menthol Cigarette Ban Among Adults with Mood Disorders Who Smoke Menthol Cigarettes and Have No Current Plans to Quit Smoking

BACKGROUND

There is limited evidence on how the United States Food and Drug Administration's (FDA) proposed ban on menthol cigarettes and flavored cigars will impact individuals with mood disorders who smoke menthol cigarettes. This study aimed to evaluate how individuals with mood disorders who smoke menthol cigarettes might respond to a hypothetical ban on menthol cigarettes, explore the reasons for their current use, and examine how these reasons are associated with participants' characteristics.

METHODS

Study data were collected at baseline from adults (18+ years) with mood disorders who participated in a randomized controlled trial evaluating the impact of gradual nicotine reduction. Participants were individuals who smoked and had no plan to quit in the next six months. They reported demographics and tobacco consumption patterns, interest in quitting, and responded to a hypothetical question on a potential ban on menthol cigarettes. The question asked participants which actions they would most likely take if menthol-flavored cigarettes were banned. Means and frequencies were used to describe the sample. Logistic regression was used to determine factors associated with each reason for menthol use (less harmful, better flavor, less harsh on the throat, and less harsh on the chest).

RESULTS

Participants (n = 77) were an average age of 42.5 (SD 12.5) years, 61% (n = 47) were female, 68.8% (n = 53) identified as White, and 5.2% (n = 4) identified as Hispanic. On average, participants reported currently smoking 18.1 (SD 9.9) cigarettes per day and had smoked for 23.9 (SD 13.6) years. About 58.4% of participants (n = 45) expressed their intention to switch to non-menthol cigarettes, 19.5% (n = 15) intended to transition to a different type of tobacco product, and 22.1% (n = 17) intended to quit smoking entirely without substitution. The most endorsed reason for using menthol cigarettes was better flavor (89.6%, n = 69/77), followed by less harshness on the throat (41.3%, n = 31/75) and chest (40%, n = 30/75), and the belief that they were less harmful than non-menthol cigarettes (24%, n = 18/75). Older age was associated with the belief that menthol cigarettes were less harmful (OR = 1.06; p = 0.02).

CONCLUSION

Among individuals with mood disorders and who smoke menthol cigarettes and have no plans to quit smoking, 22.1% may try to quit smoking if a menthol ban is implemented, while the majority (58.4%) stated that they would switch to non-menthol cigarettes. As the reasons for using menthol cigarettes included perceived lower harm, there is a need for targeted public awareness campaigns to correct misconceptions about the harms of menthol cigarettes.

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.

Racial Differences in Nicotine Reduction: Pooled Results from Two Double-Blind Randomized Controlled Trials

INTRODUCTION

Tobacco regulatory policies are generally intended to apply to all segments of the population and to be equitable. Results from clinical trials on switching from commercial cigarettes to reduced nicotine cigarettes have included black populations but race-specific findings are not widely reported.

METHODS

Data were pooled from two parallel randomized controlled trials of gradually reduced nicotine in cigarettes from 11.6 mg per cigarette down to 0.2 mg nicotine (very low nicotine content; VLNC) vs. usual nicotine content (UNC) cigarettes (11.6 mg) over an 18-week period in smokers with low socioeconomic status (SES) and mental health conditions, respectively. We used linear regression to determine the potential effects of cigarettes and biomarker reductions (blood cotinine and exhaled carbon monoxide) when using VLNC study cigarettes. An intention-to-treat (ITT) analysis included all randomized participants regardless of adherence to the protocol. A secondary compliance analysis compared control subjects (11.6 mg cigarettes) only to those switched to low nicotine cigarettes who were biochemically determined to be compliant to exclusively using VLNC cigarettes.

RESULTS

Both Black and White VLNC smokers had significantly lower plasma cotinine and exhaled carbon monoxide compared to those randomized to UNC cigarettes. The treatment × race interaction term was not significant for the outcome measures in both the ITT and secondary compliance analyses, except for cotinine in the ITT analysis (Whites: - 190 ng/mL vs. Blacks: - 118 ng/mL; p = 0.05).

CONCLUSIONS

A reduced nicotine regulation for cigarettes would result in substantial reduction in exposure to nicotine and toxicants in Black and White smokers.

Reduced nicotine in cigarettes in a marketplace with alternative nicotine systems: randomized clinical trial

Background

Reducing cigarette addictiveness has the potential to avert millions of yearly tobacco-related deaths worldwide. Substantially reducing nicotine in cigarettes decreases cigarette consumption, but no large clinical trial has determined the effects of reduced-nicotine cigarettes when other nicotine-containing products are available. The aim of this study was to examine the effects of reduced-nicotine cigarettes in the context of the availability of alternative nicotine delivery systems.

Methods

In a U.S. six-site, open-label, parallel-arm study, smokers were randomized for twelve weeks to an experimental marketplace containing cigarettes with either 0.4 mg or 15.8 mg nicotine per gram of tobacco; all had access to non-combusted alternative nicotine delivery systems (e.g., e-cigarettes; medicinal nicotine). Group differences in the primary outcomes (cigarettes per day, number of smoke-free days) were examined using linear and negative binomial regression, respectively (Trial Registration: NCT03272685).

Findings

Among 438 randomized participants (mean [standard deviation (SD), range] age, 44.5 [11.9, 20-73] years, 225 [51.4%] women, 282 [64.4%] White and 339 [77.4%] trial completers), those in the 0.4 mg vs. 15.8 mg nicotine cigarette condition experienced significantly lower cigarettes per day at the end of intervention (mean [SD], 7.05 [7.88] vs. 12.95 [9.07], adjusted mean difference, -6.21 [95% CI, -7.66 to -4.75], P < 0.0001) and greater smoke-free days during intervention (mean [SD], 18.59 [27.97] vs. 5.06 [13.77], adjusted rate ratio, 4.25 [95% CI, 2.58-6.98], P < 0.0001).

Interpretation

A reduced-nicotine cigarette standard in the context of access to other non-combusted nicotine products has the potential to benefit public health.

Funding

U.S. NIH/FDA U54DA03165.

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.

Underreporting of non-study cigarette use by study participants confounds the interpretation of results from ambulatory clinical trial of reduced nicotine cigarettes

BACKGROUND

As part of its comprehensive plan to significantly reduce the harm from tobacco products, the US Food and Drug Administration is establishing a product standard to lower nicotine in conventional cigarettes to make them "minimally addictive or non-addictive". Many clinical studies have investigated the potential impact of such a standard on smoking behavior and exposure to cigarette constituents. These ambulatory studies required participants who smoke to switch to reduced nicotine study cigarettes. In contrast to clinical trials on pharmaceuticals or medical devices, participants had ready access to non-study conventional nicotine cigarettes and high rates of non-study cigarette use were consistently reported. The magnitude of non-compliance, which could impact the interpretation of the study results, was not adequately assessed in these trials.

METHODS

We conducted a secondary analysis of data from a large, randomized trial of reduced nicotine cigarettes with 840 participants to estimate the magnitude of non-compliance, i.e., the average number of non-study cigarettes smoked per day by study participants assigned to reduced nicotine cigarettes. Individual participants' non-study cigarette use was estimated based on his/her urinary total nicotine equivalent level, the nicotine content of the study cigarette assigned and the self-reported number of cigarettes smoked, using a previously published method.

RESULTS

Our analysis showed that (1) there is a large variation in the number of non-study cigarettes smoked by participants within each group (coefficient of variation 90-232%); (2) participants in reduced nicotine cigarette groups underreported their mean number of non-study cigarettes smoked per day by 85-91%; and (3) the biochemical-based estimates indicate no reduction in the mean number of total cigarettes smoked per day for any group assigned to reduced nicotine cigarettes after accounting for non-study cigarettes.

CONCLUSIONS

High levels of non-compliance, in both the rate and magnitude of non-study cigarette use, are common in ambulatory reduced nicotine cigarette trials where participants have access to conventional nicotine non-study cigarettes. The potential impact of high non-compliance on study outcomes should be considered when interpreting the results from such ambulatory studies.

Nicotine beliefs and perceptions of low nicotine labels and mitigating statements among people who do and do not smoke: a cross-sectional study from Aotearoa New Zealand

BACKGROUND

Aotearoa New Zealand proposed a new maximum nicotine content of 0.8 mg/g for smoked tobacco products, although the new government plans to repeal this legislation. Requiring 'Very low nicotine' (VLN) messages on cigarettes meeting this standard may reinforce misperceptions that they are less harmful than cigarettes currently sold.

METHODS

To explore knowledge of nicotine and very low nicotine cigarettes (VLNCs), and perceptions of cigarette packs featuring different low nicotine messages (eg, 'Very low nicotine') and mitigating statements (eg, 'No cigarettes are safe'), we surveyed 354 people who smoked, 142 who formerly smoked, and 214 people who had never smoked regularly.

RESULTS

Around half of all respondents believed VLNCs were less harmful than regular cigarettes and around two-thirds incorrectly thought nicotine causes most of the related health problems resulting from smoking. Nearly a third thought VLNCs would be less harmful than regular cigarettes; 34% believed they would be just as harmful. Mitigating statements did not affect perceptions of people who smoked, although people who formerly, or who had never smoked regularly, perceived mitigating statements referring to poisons and cancer as significantly more likely than the VLN message to discourage smoking.

CONCLUSIONS

Misunderstanding of VLNCs as less harmful than regular cigarettes is widespread; VLN messages may reinforce this misperception, which mitigating statements did not correct among people who smoke. As an alternative to VLN messages, policy makers could consider introducing VLNCs on a specified date and developing public information campaigns; these measures would avoid phase-in confusion and obviate the need for VLN messaging.