Interest in Illicit Purchase of Cigarettes Under a Very Low Nicotine Content Product Standard

E-cigarette Price Impacts legal and Black-Market Cigarette Purchasing Under a Hypothetical Reduced-Nicotine Cigarette Standard

INTRODUCTION

The Tobacco Control Act gives the U.S. Food and Drug Administration authority to establish a reduced-nicotine content standard in combusted cigarettes. This future potential regulation may pose a significant public health benefit; however, black markets may arise to meet demand for normal-nicotine content cigarettes among smokers unwilling to transition to or use an alternative product.

AIMS AND METHODS

We determined the behavioral-economic substitutability of illicit normal-nicotine content cigarettes and e-cigarettes for reduced-nicotine content cigarettes in a hypothetical reduced-nicotine regulatory market. Adult cigarette smokers were recruited online to complete hypothetical cigarette purchasing tasks for usual-brand cigarettes, reduced-nicotine content cigarettes, and illicit normal-nicotine content cigarettes, as well as a cross-commodity task in which reduced-nicotine content cigarettes were available across multiple prices and illicit cigarettes were concurrently available for $12/pack. Participants completed two three-item cross-commodity purchasing tasks in which e-cigarettes were available for $4/pod or $12/pod alongside reduced-nicotine content cigarettes and illicit cigarettes.

RESULTS

Usual-brand cigarette purchasing was greater than illicit normal-nicotine content cigarettes and less than reduced-nicotine content cigarettes. In the cross-commodity purchasing tasks, illicit cigarettes and e-cigarettes both served as economic substitutes for reduced-nicotine content cigarettes; however, when e-cigarettes were available for $4/pod, they were purchased at greater levels than illicit cigarettes and resulted in greater reductions in reduced-nicotine content cigarettes purchasing than when available for $12/pod.

CONCLUSIONS

These data suggest that some smokers are willing to engage in illicit cigarette purchasing in a reduced-nicotine regulatory environment, but e-cigarette availability at lower prices may reduce black-market engagement and shift behavior away from combusted cigarette use.

IMPLICATIONS

E-cigarettes available at low, but not high, prices were stronger substitutes for legal, reduced-nicotine content cigarettes than illegal, normal-nicotine content cigarettes in a hypothetical reduced-nicotine tobacco market. Our findings suggest the availability of relatively inexpensive e-cigarettes may reduce illicit cigarette purchasing and combusted cigarette use under a reduced-nicotine cigarette standard.

Perceptions of Nicotine Reduction Policy in the United States: A Qualitative Study

INTRODUCTION

Several countries are considering a reduced nicotine policy that would make cigarettes minimally or nonaddictive. This qualitative study documents reactions to the policy that should be addressed by future communication efforts.

METHODS

In 2020, we recruited participants in Atlanta, GA and San Francisco, CA (27 people who exclusively smoke, 25 who dual use cigarettes and e-cigarettes, 32 who formerly smoked, and 31 young adults who do not smoke). We held 16 focus groups: 2 focus groups for each smoking status in each city. Participants viewed messages about very low nicotine content cigarettes (VLNCs) and were asked about their reactions to each message and their overall response to the reduced nicotine policy.

RESULTS

While responses to the policy were predominantly positive, focus group discussion also revealed concerns, questions, and misunderstandings (referred to here collectively as "perceptions") that may need to be addressed if a reduced nicotine policy is enacted. Participants expressed perceptions related to the policy intent, including that the FDA has ulterior motives, adoption/ implementation, including that nicotine would have to be replaced with other chemicals if removed or that the policy would be unfeasible to implement, and effectiveness, including concern that VLNCs would still be addictive or the policy would backfire.

CONCLUSIONS

Addressing perceptions about reduced nicotine policy intent, adoption/implementation, and effectiveness could be key in creating public support and political motivation to move forward with such a policy. Countries contemplating adopting such a policy should consider pairing it with communications that address these perceptions.

IMPLICATIONS

This study is one of very few to use qualitative methods to explore potentially problematic perceptions about nicotine reduction policy among US adults. Results illuminated new policy-specific concerns, questions, and misunderstandings about the reduced nicotine policy intent, adoption/implementation, and effectiveness. Identifying, studying, and addressing relevant perceptions may play a key role in generating support in countries contemplating such a policy.

Responses to reduced nicotine cigarette marketing features: a systematic review

OBJECTIVE

To systematically review the literature regarding responses to commercial and public health marketing features for reduced nicotine cigarettes (RNCs) to anticipate potential industry and regulatory actions should an RNC product standard be issued.

DATA SOURCES

We searched PubMed for English-language articles using several keywords for reduced nicotine products, cigarettes and marketing features published through 2020.

STUDY SELECTION

Of 4092 records, 26 studies were retained for review that met criteria focusing on responses to RNC marketing features.

DATA EXTRACTION

Search terms created by the research team were used for review and included independent extraction and coding by two reviewers. Coding was categorised using study design terminology, commercial and public health features in tobacco regulatory science, and their association with individual responses outlined by several message processing outcomes.

DATA SYNTHESIS

Most studies focused on current cigarette smokers and were cross-sectional. Reactions to RNCs and attitudes and beliefs were the most common outcomes measured. For commercial features, articles generally studied RNC advertisements, products and/or descriptors. For public health features, articles studied counter-messaging (eg, warning labels) or general descriptors about nicotine or a reduced nicotine product standard. Commercial features were generally associated with favourable responses. Public health features offset favourable responses across most outcomes, though their efficacy was mixed. Contrasts in results by smoking status are discussed.

CONCLUSIONS

Commercial marketing of RNCs is appealing and may need stronger regulations or communication campaigns to accurately convey risks. Opportunities exist for future research within tobacco regulatory science.

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.

The Illegal Experimental Tobacco Marketplace I: Effects of Vaping Product Bans

OBJECTIVES

Banning vaping products may have unintended outcomes, such as increased demand for illegal products. This study experimentally examined the effects of a vaping ban and a flavored vaping ban on the probability of purchasing illicit vaping products, and factors affecting purchasing from a hypothetical illegal marketplace.

METHODS

A crowdsourced sample of exclusive cigarette smokers, exclusive e-cigarette users, and frequent dual users (n = 150) completed hypothetical purchasing trials in an Experimental Tobacco Marketplace under three conditions (no ban, vaping ban, and flavored vaping ban). Participants chose to purchase in a hypothetical legal experimental tobacco marketplace (LETM) or illegal experimental tobacco marketplace (IETM). Vaping products were available in each marketplace depending on the condition. Other tobacco products were always available in the LETM. A hypothetical illicit purchase task with five fine amounts assessed the effect of monetary penalties.

RESULTS

Participants from all groups were more likely to purchase from the IETM when product availability in the LETM was more restricted, with e-cigarette users being most affected. The likelihood of purchasing illegal products was systematically decreased as monetary penalties associated with the IETM increased, with e-cigarette users showing greater persistence in defending their illicit purchases.

CONCLUSIONS

Restricting vaping products from the marketplace may shift preference towards purchasing vaping products in the illegal marketplace. Nevertheless, penalties imposed on consumer's behavior might be effective in preventing illicit trade. The IETM is a methodological extension that supports the utility and flexibility of the ETM as a framework for understanding the impact of different tobacco regulatory policies.

IMPLICATIONS

This study suggests that limiting or banning vaping products as a possible strategy to reduce the adverse effects of vaping products could result in some tobacco-users seeking banned products from illegal sources. Monetary fines were shown to reduce illegal purchases. Therefore, policymakers should consider implementing strategies that may mitigate illegal purchases.

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.

Effects of education methods on self-efficacy of smoking cessation counseling among medical students

Background

Medical students need to receive training in providing smoking cessation counseling to provide effective smoking cessation interventions to smokers when they become doctors. This study examined the smoking cessation education curricula and factors affecting counseling self-efficacy (CSE) in smoking cessation treatment among medical students.

Methods

In a multicenter cross-sectional study, we obtained demographic information, personal history of tobacco use and intention to quit smoking, exposure to secondhand smoke in the school premises during the past week, the experience of learning about tobacco in each medical school, tobacco-related medical knowledge, and self-efficacy in smoking cessation counseling on medical students of four Korean medical schools.

Results

Among 1,416 medical students eligible, 313 (22.1%) students completed a self-administered questionnaire. Only 20.3% of the students reported positive CSE on smoking cessation. The factors affecting positive CSE were scores of ≥ 60 on tobacco-related medical knowledge, smoking experience, and blended learning (p = 0.014, 0.005, and 0.015, respectively).

Conclusion

This study shows that high scores in tobacco-related medical knowledge and blended learning are correlated with positive CSE for smoking cessation counseling.

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.