Public Attitudes Regarding Banning of Cigarettes and Regulation of Nicotine

Abstract

Knowledge of current public opinion is important as the Food and Drug Administration (FDA) applies the best scientific evidence available to tobacco product regulation. Based on a nationally representative survey of the US adult population, we report 43% support for banning of cigarettes, 65% for reducing nicotine, and 77% for reducing nicotine if such an action could cause fewer children to become addicted to cigarettes. The FDA should consider protecting children by removing all but nonaddictive cigarettes from the marketplace.

Whereas the Food and Drug Administration's (FDA) new authority to regulate tobacco products under the Family Smoking Prevention and Tobacco Control Act¹ (FSPTCA) precludes the outright banning of cigarettes, the law does allow the FDA to ban ingredients in cigarettes that encourage youth initiation for the protection of public health. Flavored cigarettes have been banned, and the FDA is considering banning menthol. Furthermore, the FSPTCA allows the FDA to reduce nicotine in cigarettes, the primary substance that leads to addiction. Reduction of nicotine in cigarettes to nonaddictive levels could directly improve public health by preventing initiation and increasing cessation and is a feasible strategy according to Benowitz and Henningfield.² The Act assigns responsibility to the Tobacco Product Scientific Advisory Committee (TPSAC) to make recommendations to the Secretary regarding the effects of altering nicotine yields of cigarettes, and whether a biological threshold level exists below which a tobacco product does not produce dependence.

Knowledge of public opinion is essential in policymaking as demonstrated by wide variation in responses to prior bans, such as prohibition. We report the current public opinion of smokers and nonsmokers regarding the possibilities of banning cigarettes or reducing nicotine to nonaddictive levels. This information is valuable to the FDA as it applies the best scientific evidence available to tobacco product regulation within a highly politicized environment.

METHODS

A nationally representative public opinion survey of the US adult population aged 18 years and older, excluding Hawaii and Alaska, was conducted from May 18 through June 5, 2011 by Social Science Research Solutions under contract with Harvard School of Public Health. The sample was obtained by bilingual random-digit-dialing of landline telephones in households and of cell phone numbers, and with random selection of a single respondent within each household. This survey over-sampled smokers, and a minimum of 30 interviews was conducted weekly in Spanish for representation of the Hispanic population. Of 2,913 respondents contacted, 1,021 completed the smoking component of the survey until reaching quotas of both nonsmokers and smokers. The final weighting stage involved poststratification adjustment by raking so that the weighted sample reflects the US adult population along several population parameters. Respondents were asked how strongly they agreed or disagreed with the statement that cigarettes should be banned in the United States, and which if any actions by the FDA regarding nicotine in cigarettes they would support. Potential relationships between age, gender, and racial characteristics of respondents and responses to each of the survey questions were explored with multiple logistic regression analysis including all covariates in each model.

RESULTS

A total of 511 nonsmokers and 510 smokers were interviewed. Approximately 2 in 5 persons (43%) supported the banning of cigarettes, including 55% of nonsmokers and 33% of smokers. Nearly 2 in 3 (65%) persons supported reducing nicotine in cigarettes to nonaddictive levels, including 73% of nonsmokers and 58% of smokers; and more than 3 in 4 persons (77%), including 81% of nonsmokers and 74% of smokers, supported the reduction of nicotine if it could cause fewer children to become addicted to cigarettes (Table 1). Nonsmokers were more likely than smokers to support the banning of cigarettes (odds ratio [OR] 2.70; 95% confidence interval [CI] 1.90, 3.83), as were African American non-Hispanics (OR 4.60; 95% CI 2.49, 8.49), and Hispanics (OR 2.71; 95% CI 1.57, 4.69) compared with White non-Hispanics. Nonsmokers were more likely than smokers to support reducing nicotine in cigarettes (OR 1.94; 95% CI 1.35, 2.79). Nonsmokers were also more likely than were smokers to support reducing nicotine in cigarettes if it could cause fewer children to become addicted (OR 1.55; 95% CI 1.02, 2.35). No statistically significant differences in responses were observed between genders or age groups.

TABLE 1—

Current US Public Opinion Regarding Cigarette and Nicotine Regulation: May 18–June 5, 2011

	Nonsmokers (n = 511), Proportion (SE)	Smokers (n = 510), Proportion (SE)	White Non-Hispanic (n = 750), Proportion (SE)	African American Non-Hispanic (n = 87), Proportion (SE)	Hispanic (n = 93), Proportion (SE)	Other/Unknown (n = 91), Proportion (SE)	Total (n = 1021), Proportion (SE)
How strongly do you agree or disagree with the statement, by the next decade, cigarettes should be banned in the United States?
Strongly agree	0.246 (0.023)	0.177 (0.022)	0.178 (0.017)	0.343 (0.065)	0.190 (0.048)	0.249 (0.052)	0.207 (0.016)
Agree	0.285 (0.027)	0.150 (0.021)	0.163 (0.018)	0.306 (0.061)	0.407 (0.061)	0.117 (0.037)	0.210 (0.017)
Disagree	0.250 (0.024)	0.221 (0.023)	0.256 (0.020)	0.166 (0.044)	0.157 (0.044)	0.286 (0.059)	0.234 (0.017)
Strongly disagree	0.179 (0.021)	0.446 (0.028)	0.380 (0.023)	0.168 (0.053)	0.234 (0.050)	0.306 (0.056)	0.327 (0.019)
Don't know	0.041 (0.010)	0.007 (0.004)	0.023 (0.007)	0.018 (0.011)	0.012 (0.012)	0.41 (0.024)	0.022 (0.005)
Which of the following actions by the FDA would you support?
FDA should immediately decrease nicotine in all cigarettes sold in the US	0.507 (0.029)	0.371 (0.027)	0.402 (0.023)	0.513 (0.067)	0.534 (0.062)	0.383 (0.072)	0.433 (0.020)
FDA should gradually over the next fifteen years decrease nicotine in all cigarettes sold in the US	0.222 (0.025)	0.210 (0.023)	0.222 (0.020)	0.230 (0.060)	0.170 (0.045)	0.231 (0.075)	0.215 (0.017)
FDA should conduct more research before deciding whether to decrease nicotine in cigarettes	0.106 (0.018)	0.156 (0.021)	0.127 (0.016)	0.099 (0.042)	0.158 (0.046)	0.210 (0.067)	0.133 (0.014)
FDA should take no action regarding nicotine in cigarettes	0.164 (0.021)	0.263 (0.025)	0.249 (0.021)	0.158 (0.048)	0.137 (0.045)	0.176 (0.055)	0.219 (0.017)
Do you think that the FDA should reduce nicotine in cigarettes if it would cause fewer kids to become addicted or hooked on smoking?: Yes	0.810 (0.023)	0.740 (0.026)	0.742 (0.022)	0.908 (0.042)	0.844 (0.045)	0.664 (0.075)	0.771 (0.017)

Note. FDA = Food and Drug Administration

DISCUSSION

The public opinion survey found substantial support for the banning of cigarettes, which is currently outside of the FDA's authority. A large majority of the US population supports reducing nicotine in cigarettes to nonaddictive levels, especially if this could play a role in protecting children. Society's readiness for change is often ahead of policy change because policy issues may be unduly influenced by opposition from powerful special interests. The strong support among African Americans for FDA action on nicotine is of particular note because the community has been a unique target of the tobacco industry for decades.³

In light of the potential public health benefit from reducing nicotine in cigarettes to nonaddictive levels, the FDA and its advisory committee, TPSAC, should move promptly to investigate this course as mandated by the US Congress. Opinions vary regarding the better of 2 alternative approaches, immediate or gradual reduction over time.⁵ Large-scale surveillance is needed in either case to understand the population-level effects, including unintended consequences such as illicit cigarette marketing, smuggling, and possibly differential consumption patterns.⁴

Nevertheless considering the scientific understanding of nicotine dependence documented in US Surgeon General Reports^5–7 and the goal of the FSPTCA to reduce tobacco use in the United States, the FDA should initiate a process that could at least better protect children by removing all but nonaddictive cigarettes from the marketplace. The present findings support immediate action by the FDA to address the extremely important issue of nicotine in cigarettes in response to both broad public support and to protect the public health of this nation from a product that results in the premature deaths of more than 400 000 Americans each year and the recruitment of more than 3800 new youth smokers daily.⁸