Reduced Nicotine Content Expectancies Affect Initial Responses to Smoking

Effect of nicotine expectancy and nicotine dose reduction on cigarette demand, withdrawal alleviation, and puff topography

BACKGROUND

Current FDA plans include proposed nicotine reduction mandates by the end of 2023. Most research on reduced nicotine cigarettes has been dose-blinded, while a mandate would be known to the public. Few laboratory studies have examined specifically how low nicotine content labeling impacts behavioral response. The purpose of this within-subject, balanced-placebo, human laboratory study was to evaluate the main and interactive effects of nicotine dose expectancy and dose reduction on cigarette reinforcement, withdrawal alleviation, and puff topography.

METHODS

Participants who smoke daily (N=21; 9 female) completed one practice and four experimental sessions in which expectancy (labeled "average" versus "very low" nicotine) and nicotine dose (0.80mg versus 0.03mg yield) were manipulated. Participants in acute withdrawal sampled experimental cigarettes followed by withdrawal alleviation and puff topography measures. Cigarette demand was measured using an incentivized purchase task. Analyses evaluated main and interactive effects of expectancy and nicotine dose.

RESULTS

Nicotine dose manipulation produced expected physiological effects (e.g., heart rate increases) and both reduced nicotine dose and expectation manipulations reduced perceived nicotine content. Expectation of reduced nicotine alone or in combination with reduced nicotine dose did not alter demand, withdrawal alleviation, or topography. Effective withdrawal alleviation was observed in all conditions.

CONCLUSIONS

These data inform nicotine regulation policy by suggesting limited compensatory harms caused by reduced nicotine expectations. The minimal acute effects of reduced nicotine expectancy or exposure on demand suggests that reduced nicotine standards are likely to generate their greatest public health benefit through the slowing of newly initiating cigarette smoking.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.

Early Changes in Puffing Intensity When Exclusively Using Open-Label Very Low Nicotine Content Cigarettes

INTRODUCTION

In response to reducing cigarette nicotine content, people who smoke could attempt to compensate by using more cigarettes or by puffing on individual cigarettes with greater intensity. Such behaviors may be especially likely under conditions where normal nicotine content (NNC) cigarettes are not readily accessible. The current within-subject, residential study investigated whether puffing intensity increased with very low nicotine content (VLNC) cigarette use, relative to NNC cigarette use, when no other nicotine products were available.

METHODS

Sixteen adults who smoke daily completed two 4-night hotel stays in Charleston, South Carolina (U.S.) in 2018 during which only NNC or only VLNC cigarettes were accessible. We collected the filters from all smoked cigarettes and measured the deposited solanesol to estimate mouth-level nicotine delivery per cigarette. These estimates were averaged within and across participants, per each 24-hour period. We then compared the ratio of participant-smoked VLNC and NNC cigarette mouth-level nicotine to the ratio yielded by cigarette smoking machines (when puffing intensity is constant).

RESULTS

Average mouth-level nicotine estimates from cigarettes smoked during the hotel stays indicate participants puffed VLNC cigarettes with greater intensity than NNC cigarettes in each respective 24-hour period. However, this effect diminished over time (p<0.001). Specifically, VLNC puffing intensity was 40.0% (95% CI: 29.9, 53.0) greater than NNC puffing intensity in the first period, and 16.1% (95% CI: 6.9, 26.0) greater in the fourth period.

CONCLUSION

Average puffing intensity per cigarette was elevated with exclusive VLNC cigarette use, but the extent of this effect declined across four days.

IMPLICATIONS

In an environment where no other sources of nicotine are available, people who smoke daily may initially attempt to compensate for cigarette nicotine reduction by puffing on individual cigarettes with greater intensity. Ultimately, the compensatory behavior changes required to achieve usual nicotine intake from VLNC cigarettes are drastic and unrealistic. Accordingly, people are unlikely to sustain attempts to compensate for very low cigarette nicotine content.

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 "organic" descriptor and its association with commercial cigarette health risk expectancies, subjective effects, and smoking topography: a pilot human laboratory study

INTRODUCTION

The purpose of this mixed method pilot study was to (1) examine whether the "organic" descriptor affects smokers' health risk expectancies, subjective ratings of smoking, and topography, and (2) describe how smokers interpret the "organic" descriptor and relate it to their subjective smoking experience.

METHODS

Twenty-two daily smokers (45.5% men, 81.8% non-Hispanic White, M (SD) age = 47.3 [12.7], M (SD) cigarettes/day = 14.5 [5.1]) completed a within-person laboratory study. Following a baseline session, smokers attended 2 experimental sessions where they smoked a study-provided cigarette (identical across conditions) paired with either an "organic" or conventional (e.g., no "organic") descriptor condition and completed subjective and behavioral measures. Participants completed a semi-structured interview at the last visit.

RESULTS

Relative to the conventional cigarette, more participants rated the "organic" cigarette as healthier, having fewer chemicals, and having a more favorable burn rate (p's<0.05). There were no differences in total puff volume by condition (p=0.42). Stratifying by gender, men inhaled 225 ml (SE = 82.7) more in the conventional condition (p=0.02); women inhaled 408 ml (SE = 233.3) more in the organic condition (p=0.11). A common understanding of "organic" was that the product was "…less processed... like less chemicals and it's more natural." Some believed that "organic" cigarettes contained fewer chemicals, which in turn produced a "much cleaner and healthier smoking cigarette" and that they could "taste the difference."

CONCLUSIONS

Findings support that smokers associate the "organic" descriptor with health and reduced harm. This descriptor may differentially impact puffing behavior by gender.

IMPLICATIONS

This study provides qualitative and quantitative data regarding how the "organic" descriptor influences adult daily smokers' perceptions and use of cigarettes. After smoking two identical cigarettes described as "organic" and conventional (e.g., no "organic"), smokers expressed more problematic health expectancies about the "organic" cigarette condition, providing further empirical support that the "organic" descriptor is associated with expectancies of reduced harm. The source of reduced harm was understood to be fewer chemicals in the organic cigarette. Though preliminary, findings suggest that "organic" may differentially affect puffing behavior by gender.

Comparing video observation to electronic topography device as a method for measuring cigarette puffing behavior

BACKGROUND

Smoking topography, or puffing behavior, is an important measure of how consumers may use tobacco products. However, numerous issues may prevent collection of this data via in-person, electronic topography device (e.g., CReSS). This study compared cigarette topography measures collected by video observation and electronic device.

METHODS

Laboratory smoking sessions were video recorded and scored for 96 cigarettes collected from 34 daily, adult non-treatment-seeking smokers (73.5 % male, 82.4 % White). Participants smoked three of their preferred brand cigarettes using an electronic topography device, providing carbon monoxide (CO) samples before and after each cigarette. Analyses compared measures from both assessment methods and examined associations with device-obtained total puff volume and CO boost.

RESULTS

Agreement analyses indicated robust similarity between methods for measures of puff count and total interpuff interval (Intraclass Correlation Coefficient [ICC]'s > 0.96,p's < 0.001; Bland-Altman [B-A] plotted differences within a priori limit of clinical significance) but diverged on total duration (ICC's > .93, p's < .001, yet B-A plots outside a priori limits). Regardless of assessment method, total duration and puff count (but not total interpuff interval) predicted total puff volume (p's < .001). None predicted CO boost (p's = .07-.90)."

CONCLUSIONS

Although some topography outcomes (e.g., total puff volume) cannot be assessed via video observation, video-observed measures of puff count, total duration, and total interpuff interval are generally interchangeable with their topography device-obtained counterparts. Thus, video observation is likely a sufficient substitute method for assessing cigarette topography when using an electronic device is not possible.

Nicotine Reduction in Cigarettes: Literature Review and Gap Analysis

BACKGROUND

The US Food and Drug Administration (FDA) is considering reducing nicotine levels in cigarettes to "minimally or non-addictive levels." However, important research gaps remain, and the FDA must determine when the available research is sufficient to support moving forward.

METHODS

The authors conducted a systematic review of research articles in PubMed relating to nicotine reduction. Building on a review of risk assessment best practices, the authors also developed a risk assessment framework for tobacco regulation and used it to guide a gap analysis of nicotine reduction research.

RESULTS

The final sample consisted of 78 articles. The majority examined either nicotine dependence on very low nicotine cigarettes (VLNCs) or markers of potential health effects of using VLNCs. One-third of the identified articles reported results from four large randomized controlled trials (RCTs). While these studies report promising results and suggest that a nicotine reduction rule would be a powerful tool to reduce cigarette smoking, our gap analysis suggests that there is a need for studies that better reflect the use and availability of a wide range of tobacco/nicotine products and the potential for dual- or multi-product use.

CONCLUSION

The current body of research on nicotine reduction is weighted towards RCTs, which is appropriate for a policy that has not yet been implemented anywhere in the world. The FDA must consider a wide range of factors that may impact a product standard's public health impact, including those difficult to assess in RCTs, such as a nicotine reduction rule's impact on smoking initiation and relapse.

IMPLICATIONS

This systematic review presents a gap analysis based on a risk assessment framework to help identify remaining research priorities to inform FDA's potential product standard to reduce nicotine levels in cigarettes. Quickly addressing those gaps would support the FDA's effort to develop a nicotine reduction product standard that will be effective and withstand legal challenges.

Verbal suggestions of nicotine content modulate ventral tegmental neural activity during the presentation of a nicotine-free odor in cigarette smokers

Expectancies of nicotine content have been shown to impact smokers' subjective responses and smoking behaviors. However, little is known about the neural substrates modulated by verbally induced expectancies in smokers. In this study we used functional magnetic resonance imaging (fMRI) to investigate how verbally induced expectations, regarding the presence or absence of nicotine, modulated smokers' neural response to a nicotine-free odor. While laying in the scanner, all participants (N = 24) were given a nicotine-free odor, but whereas one group was correctly informed about the absence of nicotine (control group n = 12), the other group was led to believe that the presented odor contained nicotine (expectancy group n = 12). Smokers in the expectancy group had significantly increased blood-oxygen-level-dependent (BOLD) responses during the presentation of the nicotine-free odor in the left ventral tegmental area (VTA), and in the right insula, as compared to smokers in the control group (Regions of interest analysis with pFWE-corrected p ≤ 0.05). At a more liberal uncorrected statistical level (p-unc ≤ 0.001), increased bilateral reactivity in the dorsolateral prefrontal cortex (dlPFC) was also observed in the expectancy group as compared with the control group. Our findings suggest that nicotine-expectancies induced through verbal instructions can modulate nicotine relevant brain regions, without nicotine administration, and provide further neural support for the key role that cognitive expectancies play in the cause and treatment of nicotine dependence.

Effect of Cigarette Rod Length on Smokers Switching to SPECTRUM Cigarettes

Objectives: Cigarettes vary in rod length but are generally thought of as a constant unit. In this study, we evaluated whether the rod length of participants' usual brand cigarettes affected their perceptions and smoking habits when switching to SPECTRUMs. Methods: Data were analyzed for 341 participants smoking their own brand cigarettes for one week and after switching to normal nicotine content (11.6 mg) SPECTRUMs for 2 weeks. Changes in perceptions of cigarette attributes and biomarkers of smoke exposure were evaluated using linear mixed models among 3 groups: usual length short (ULS, 72 mm); medium/king (ULM, ~84 mm); and long (ULL ≥ 100 mm). Results: Among the 3 cigarette length groups, only ULL smokers' rated SPECTRUMs significantly less strong, harder to draw, lower in taste, and lower in enjoyment (p < .03) compared to usual brand. Among all groups, satisfaction was significantly lower for SPECTRUMs (p < .02). Cigarettes per day (CPD) increased significantly more for ULL (+4.75 CPD) as compared to ULM (+1.38 CPD) (p < .001). When switching to SPECTRUMs, cotinine-per-cigarette decreased among all groups, and exhaled carbon monoxide increased significantly in ULL and ULM smokers (p < .001). Conclusion: People who smoked long cigarettes had the largest changes in perceptions and use when switching to SPECTRUM research cigarettes.

Acceptability of SPECTRUM Research Cigarettes among Participants in Trials of Reduced Nicotine Content Cigarettes

Objectives

SPECTRUM research cigarettes (SPECTRUMs) are being used in trials evaluating the effects of switching to reduced nicotine content (RNC) cigarettes. Because smokers have a high brand affinity, we evaluated if they were willing to switch and continue smoking normal nicotine content (NNC) SPECTRUMs.

Methods

We asked smokers (N = 341) to rate their own brand of cigarettes and NNC SPECTRUMs (after 2 weeks of use) using subjective measures including satisfaction, reward, taste, and craving reduction. We measured plasma cotinine, exhaled carbon monoxide (CO), and cigarettes per day (CPD), and recorded reasons for dropping out.

Results

After 2 weeks, 95% of participants chose to continue using SPECTRUMs for an additional 18 weeks. Moreover, 67% said SPECTRUMs were as good as or better than their own brand, and 65% said they would consider purchasing them. Ratings of satisfaction, reward, and craving reduction were 10%-15% lower on SPECTRUMs than on their own brand (p < .01). There were no differences in these ratings between menthol and non-menthol smokers.

Conclusions

Menthol and non-menthol SPECTRUMs are acceptable to smokers. Lower SPECTRUM ratings were likely due to brand switching and did not hinder study retention.

Low Nicotine Content Descriptors Reduce Perceived Health Risks and Positive Cigarette Ratings in Participants Using Very Low Nicotine Content Cigarettes

INTRODUCTION

Understanding how smokers perceive reduced nicotine content cigarettes will be important if the FDA and global regulatory agencies implement reduced nicotine product standards for cigarettes. Prior research has shown that some smokers incorrectly believe "light" cigarettes are less harmful than regular cigarettes. Similar misunderstandings of health risk could also apply to reduced nicotine cigarettes. To date, most studies of reduced nicotine cigarettes have blinded subjects to the nicotine content. Therefore, little is known about how smokers experience reduced nicotine content cigarettes when they are aware of the reduced content, and how use may be impacted.

METHODS

The present study was a within-subjects experiment with 68 adult daily smokers who smoked two identical very low nicotine content Quest 3 (0.05 mg nicotine yield) cigarettes. Subjects were told that one cigarette contained "average" nicotine content, and the other contained "very low" nicotine content. After smoking each cigarette, subjects completed subjective measures about their smoking experience.

RESULTS

Subjects rated the "very low" nicotine cigarette as less harmful to their health overall compared to the "average" nicotine cigarette; this effect held true for specific smoking-related diseases. Additionally, they rated the "very low" nicotine cigarette as having less desirable subjective effects than the "average" nicotine cigarette and predicted having greater interest in quitting smoking in the future if only the "very low" nicotine cigarette was available.

CONCLUSIONS

Explicit knowledge of very low nicotine content changes smokers' perceptions of very low nicotine content cigarettes, resulting in reduced predicted harm, subjective ratings and predicted future use.

IMPLICATIONS

Before a reduced nicotine product standard for cigarettes can be implemented, it is important to understand how product information impacts how smokers think about and experience very low nicotine content cigarettes. Prior research has shown that smokers incorrectly believed light cigarettes were less harmful products. As such, smokers may also misunderstand the health risks associated with smoking very low nicotine content cigarettes. This study highlights the importance of smokers' perceptions of nicotine content in cigarettes on the perceived health risks and the subjective effects of smoking very low nicotine content cigarettes.

Attrition during a randomized controlled trial of reduced nicotine content cigarettes as a proxy for understanding acceptability of nicotine product standards

AIMS

To determine (1) if nicotine content affects study attrition-a potential behavioral measure of acceptability-in a trial that required compliance with three levels of reduced nicotine content (RNC) cigarettes, and (2) if attrition is associated with subjective and behavioral responses to RNC cigarettes.

DESIGN

Secondary analysis of a 35-day, parallel-design, open-label, randomized controlled trial. After a 5-day baseline period, participants were randomized to smoke for three 10-day periods: their preferred brand (control group) or RNC cigarettes with three nicotine levels in a within-subject stepdown (one group: high-moderate-low) or non-stepdown (five groups: high-low-moderate, low-moderate-high, low-high-moderate, moderate-low-high, moderate-high-low) fashion.

SETTING

A single site in Philadelphia, PA, USA.

PARTICIPANTS

A total of 246 non-treatment-seeking daily smokers [mean age = 39.52, cigarettes per day (CPD) = 20.95, 68.3% white] were recruited from October 2007 to June 2013.

MEASUREMENTS

The primary outcome was attrition. Key predictors were nicotine content transition and study period. Exploratory predictors were taste and strength subjective ratings, total puff volume and carbon monoxide (CO) boost. Covariates included: age, gender, race, education and nicotine dependence.

FINDINGS

Overall attrition was 31.3% (n = 77): 24.1% of the control and 25.0% of the stepdown RNC cigarette groups dropped out versus 44.6% of non-stepdown groups (P = 0.006). Compared with controls, attrition odds were 4.5 and 4.7 times greater among smokers transitioning from preferred and the highest RNC cigarettes to the lowest RNC cigarettes, respectively (P = 0.001 and 0.003). Providing more favorable initial taste ratings of study cigarettes decreased attrition odds by 2% (P = 0.012).

CONCLUSIONS

The majority of participants completed a 35-day trial of varying levels of reduced nicotine content cigarettes. Participant dropout was greater for cigarettes with lower nicotine content and less in smokers reporting more favorable subjective ratings of the cigarettes.

Advances in Behavioral Laboratory Methods that Inform Tobacco Regulatory Science: A TCORS Working Group Special Issue

Objective

The 2009 Family Smoking Prevention and Tobacco Control Act (TCA) created unprecented enabling conditions for establishing national regulatory policy that reduces the burden of public health and societal problems associated with tobacco product use. The Center for Tobacco Products (CTP), created by the FDA to implement the TCA, developed a first-of-its-kind FDA/National Institutes of Health (NIH) collaborative program to fund Tobacco Centers of Regulatory Science (TCORS).

Methods

To assist the TCORS with addressing research priorites, working groups (WGs) comprised of FDA-CTP liasions and TCORS investigators were formed. Under the direction of the Center for Evaluation and Coordination of Trainin and Research (CECTR), the TCORS WGs seek to develop tangible work products in their respective areas of focus.

Results

The focus of the behavioral pharmacology WG evolved from publishing a narrow paper on behavioral methods in electronic cigarette research to a collection of papers on advances in behavioral laboratory methods that may inform tobacco regulatory science.

Conclusion

This Special Issue contains articles that address all of the CTP research priorities and demonstrates how advances in behavioral laboratory methods made by TCORS investigators can inform FDA efforst to regulate tobacco products.