Abstract
Introduction:
The Food and Drug Administration is considering a policy to drastically reduce the allowable nicotine content of cigarettes. The current study examined whether the policy implementation approach, i.e., either immediately reducing nicotine content to very low levels or gradually reducing nicotine content over an extended period, influences policy support among people who smoke cigarettes.
Methods:
Adults who smoked daily were randomly assigned (double-blind) to an immediate nicotine reduction condition (0.4 mg/g nicotine cigarettes), a gradual nicotine reduction condition (15.5 to 0.4 mg/g), or a control condition (15.5 mg/g) for 20 weeks. Participants were asked if they would “support or oppose a law that reduced the amount of nicotine in cigarettes, to make cigarettes less addictive.” Logistic regression analyses assessed if policy support was affected by treatment condition, demographic covariates, interest in quitting, and subjective cigarette effects.
Results:
At Week 20 (N=957 completers), 60.4% of participants supported the policy, 17.4% opposed, and 22.2% responded “Don’t know.” Policy support did not differ by treatment condition. Support was greater among those interested in quitting (OR=3.37, 95% CI=2.49, 4.55). Support was lower among males (OR=0.49, 95% CI=0.37, 0.67), those with greater dependence scores (OR=0.92, 95% CI=0.86, 0.99) and participants aged 18–24 (OR=0.53, 95% CI=0.28, 0.99). No other covariates were associated with policy support.
Conclusions:
The majority of participants supported a nicotine reduction policy. The implementation approach, immediate or gradual reduction, did not affect policy support. Participants interested in quitting smoking were more likely to support a nicotine reduction policy.
Keywords: Nicotine reduction, tobacco control policy
1.0. Introduction
Although the US smoking prevalence has reached an all-time low, an estimated 34 million people continue to smoke cigarettes.1 One approach for addressing the smoking epidemic is for the Food and Drug Administration (FDA) to implement a product standard reducing nicotine in cigarettes. The FDA can mandate that all commercially-available cigarettes have nicotine levels that are minimally-addictive, which is expected to increase cessation and reduce the progression to cigarette dependence.2,3 In prior surveys, support for a nicotine reduction policy was generally high with estimates ranging between 47–77% of the samples.4–10 These findings suggest that an FDA-mandated nicotine reduction policy would be viewed favorably by the public; but, survey respondents likely had limited exposure to very low nicotine content (VLNC) cigarettes.
In a previous VLNC cigarette clinical trial, over half of participants who used usual brand or research cigarettes varying in nicotine content for a 6-week period under double-blind conditions supported a nicotine reduction policy, and support did not differ across the different cigarette nicotine conditions.11 Participants interested in quitting smoking were three times more likely to support a nicotine reduction policy while male participants were less likely to support the policy. Understanding policy support may help regulators or public health officials develop health communication campaigns emphasizing the potential policy benefits (i.e., increased cessation) to the general public as well as create tailored messages for non-supportive groups (e.g. men who smoke) in order to maximize the public health impact of the policy. One unknown regarding support for a nicotine reduction policy is whether the implementation approach, either immediately reducing the nicotine content in cigarettes to very low levels or gradually reducing the nicotine content in cigarettes over time, will affect policy support among people who smoke.
Recently, a double-blind clinical trial was conducted to explore the optimal implementation approach for cigarette nicotine reduction by assigning participants to either an immediate reduction condition, gradual reduction condition, or a control condition.12 Participants in the immediate reduction condition, who received VLNC cigarettes for all 20 weeks of the intervention, had greater reductions in the number of cigarettes smoked per day relative to those in the gradual reduction and control conditions. However, the immediate reduction condition also had greater attrition and lower cigarette satisfaction ratings, which may indicate greater dissatisfaction with a nicotine reduction policy.12,13 Determining if policy support differed across treatment conditions may be informative to public health officials on how to communicate the policy implementation plan to the public. Therefore, the purpose of the current study was (1) to determine if the nicotine reduction approach affected policy support at the end of the trial and (2) to assess covariates associated with support during the 20-week trial. We hypothesized that participants in the immediate reduction condition would be less supportive of the policy at Week 20 based on their lower cigarette satisfaction ratings and extended exposure to VLNC cigarettes compared to those in the other two conditions.
2.0. Methods
2.1. Participants
We recruited adults who smoked daily from communities surrounding 10 US academic institutions between July 2014 and September 2016. Participant inclusion criteria included being aged 18 or older, smoking five or more cigarettes per day for the past year, having an expired breath carbon monoxide (CO) level >8 ppm (or urinary cotinine level >1000 ng/ml), and not planning to quit smoking in the next 30 days. Exclusion criteria included positive breath alcohol and urine toxicology tests (excluding cannabis), unstable medical or psychiatric conditions, pregnancy or breastfeeding, exclusively smoking roll-your-own cigarettes, using other tobacco products more than 9 days in the past 30 days, and smoking VLNC cigarettes during the past 3 years. Institutional Review Boards at all sites approved the trial procedures and participants provided written informed consent prior to enrollment.
2.2. Study Design
After a baseline phase, participants were randomly assigned to one of three treatment conditions: (1) an immediate nicotine reduction condition smoking only VLNC cigarettes (0.4 mg nicotine / g tobacco [mg/g] research cigarettes; n=503), (2) a gradual nicotine reduction condition smoking progressively lower nicotine cigarettes (15.5, 11.7, 5.2, 2.4, and 0.4 mg/g research cigarettes; four weeks per nicotine level; n=498), or (3) a control condition smoking normal nicotine cigarettes (15.5 mg/g tobacco research cigarettes; n=249). After randomization, participants were told for the next 20 weeks to only use the research cigarettes provided by the study when they smoked. Participants attended weekly or bi-weekly visits from baseline until Week 20. Additional study details have been previously reported.11
During the baseline and Week 20 visits, participants were asked the following question: “Would you support or oppose a law that reduced the amount of nicotine in cigarettes, to make cigarettes less addictive?” with response options of Support, Oppose, or Don’t Know. Since we were specifically interested in predictors of policy support as means of informing future health communication research, we dichotomized response options into ‘Support’ vs ‘Oppose/Don’t Know.’
2.3. Statistical Analyses
Chi-square tests of independence compared policy support by treatment condition at baseline and Week 20. Unadjusted and adjusted logistic regression analyses measured associations between policy support and variables assessed prior to or at randomization (treatment condition: immediate vs control; gradual vs control; age: 18–24 years vs 25+ years; gender: male vs female; race: non-white vs white; educational attainment: ≤12 years vs >12 years; menthol smoking status: menthol vs non-menthol) and at Week 20 (intention to quit smoking in the next six months: yes vs no; Fagerström Test for Cigarette Dependence (FTCD)14; Cigarette Evaluation Scale (CES)15 - Satisfaction, Psychological Reward and Aversion Subscales; Perceived Health Risk Scale (PHRS) average score16; Minnesota Nicotine Withdrawal Scale (MNWS)17; Questionnaire for Smoking Urges (QSU)18 - Factors 1 and 2). Covariates significant at the 0.2 level in the unadjusted analyses were included in the adjusted analysis. We conducted separate analyses among participants assigned to the immediate and gradual reduction conditions to determine the impact of VLNC cigarette adherence (yes vs no) on policy support.
3.0. Results
The study sample (N=1,250) was 44% female and, on average, 45.1(13.4 SD) years old. The majority of participants (61%) identified their race as white and 45% reported full- or part-time employment. Participants reported smoking on average, 17.1 (8.5 SD) cigarettes per day. Additional information about participant demographics and baseline smoking characteristics are reported previously.12 The majority of participants supported a nicotine reduction policy both at baseline (n=731 out of 1,250 randomized; 58%) and Week 20 (n=578 out of 957 completers; 60%). Policy support did not differ by treatment condition at baseline or Week 20 (see Table 1). When examining changes in support, 81.4% of participants who supported the policy at baseline continued to support the policy at Week 20, while only 6.6% who supported the policy at baseline switched to opposing it at Week 20. Among the participants who opposed the policy at baseline, 23% supported the policy at Week 20, while 50% continued to oppose it.
Table 1:
Support for a nicotine reduction policy
| I. Baseline Policy Support | |||||
|---|---|---|---|---|---|
| Overall | Gradual | Immediate | Control | P-value | |
| Support | 731 (58.5%) | 296 (59.4%) | 292 (58.1%) | 143 (57.4%) | |
| Oppose | 202 (16.2%) | 82 (16.5%) | 84 (16.7%) | 36 (14.5%) | |
| Don’t Know | 317 (35.2%) | 120 (24.1%) | 127 (25.2%) | 70 (28.1%) | |
| 0.779 | |||||
| II. Week 20 Policy Support | |||||
| Overall | Gradual | Immediate | Control | P-value | |
| Support | 578 (60.4%) | 241 (60%) | 208 (60.8%) | 129 (60.6%) | |
| Oppose | 167 (17.5%) | 71 (17.7%) | 64 (18.7%) | 32 (15%) | |
| Don’t Know | 212 (22.2%) | 90 (22.4%) | 70 (20.5%) | 52 (24.4%) | |
| 0.735 | |||||
| III. Changes in Policy Support | ||||
|---|---|---|---|---|
| Support - Week 20 | Oppose - Week 20 | Don’t Know - Week 20 | ||
| Support - Baseline | 467 (81.4%) | 38 (6.6%) | 69 (12%) | |
| Oppose - Baseline | 34 (23%) | 74 (50%) | 40 (27%) | |
| Don’t Know - Baseline | 77 (32.8%) | 55 (23.4%) | 103 (43.8%) | |
I – The number (%) of participants indicating support, oppose or Don’t Know for a nicotine reduction policy at Baseline (overall and by treatment condition). Chi-square tests indicate no significant differences between treatment conditions. II – The number (%) of participants indicating support, oppose or Don’t Know for a nicotine reduction policy at Week 20 (overall and by treatment condition). Chi-square tests indicate no significant differences between treatment conditions. III – Changes in the number of participants (%) indicating support, oppose, or Don’t Know for a nicotine reduction policy from Baseline to Week 20.
Table 2 reports the unadjusted and adjusted associations between demographic covariates and subjective measures and support for a nicotine reduction policy at Week 20 among (1) all participants and (2) those in the immediate and gradual reduction conditions. In the adjusted analyses including all participants, individuals interested in quitting smoking in the next six months were significantly more likely to support the policy relative to those who were not interested in quitting (OR=3.37; 95% CI=2.49, 4.55). Individuals with increased cigarette risk perception scores (OR=1.05, 95% CI=1.00, 1.10) tended to be more supportive of the policy. Males (OR=0.49; 95% CI=0.37, 0.67) and those with higher dependence scores (OR=0.92, 95% CI=0.86, 0.99) had significantly lower odds of supporting a nicotine reduction policy. Participants aged 18–24 had decreased odds of support relative to those aged 25+ (OR=0.53; 95% CI=0.28, 0.99). No other covariates were associated with policy support among all participants. In the analyses restricted to the immediate and gradual reduction conditions, adherence to smoking only the VLNC cigarettes (determined via urinary total nicotine equivalents ≤6.41 nmol/ml at Week 20)19 was not significantly associated with increased policy support (OR=1.33; 95% CI = 0.95, 1.88). Participants interested in quitting smoking had increased odds of support (OR=3.08; 95% CI = 2.19, 4.34) while males had decreased odds of support (OR=0.52; 95% CI = 0.37, 0.73).
Table 2:
Association between demographics and subjective measures assessed at Week 20 and support for a nicotine reduction policy at Week 20
| All participants | ||||
|---|---|---|---|---|
| Covariate | Unadjusted Analyses | Adjusted Analyses# | ||
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Treatment = Gradual | 0.97 (0.69, 1.37) | 0.883 | ||
| Treatment = Immediate | 1.01 (0.71, 1.43) | 0.952 | ||
| Age = 18–24 | 0.52 (0.30, 0.91) | 0.023 | 0.53 (0.28, 0.99) | 0.048* |
| Gender = Male | 0.42 (0.32, 0.54) | < 0.001 | 0.49 (0.37, 0.67) | < 0.001* |
| Race = Non-white | 0.78 (0.59, 1.01) | 0.063 | 0.98 (0.67, 1.42) | 0.903 |
| Education = HS or less | 0.76 (0.58, 0.99) | 0.039 | 1.11 (0.81, 1.51) | 0.521 |
| Menthol = Yes | 0.74 (0.57, 0.96) | 0.025 | 0.75 (0.53, 1.06) | 0.107 |
| Intention-to-quit = Yes | 4.00 (3.01, 5.33) | < 0.001 | 3.37 (2.49, 4.55) | < 0.001* |
| FTCD | 0.91 (0.86, 0.96) | 0.001 | 0.92 (0.86, 0.99) | 0.018* |
| CES Satisfaction | 1.01 (0.94, 1.09) | 0.750 | ||
| CES Psychological reward | 0.98 (0.88, 1.09) | 0.704 | ||
| CES Aversion | 1.01 (0.86, 1.20) | 0.865 | ||
| PHRS Average | 1.08 (1.03, 1.12) | 0.001 | 1.05 (1.00, 1.10) | 0.063 |
| MNWS | 1.01 (0.99, 1.04) | 0.344 | ||
| QSU Factor 1 | 0.98 (0.96, 0.99) | 0.003 | 1.01 (0.98, 1.03) | 0.683 |
| QSU Factor 2 | 0.96 (0.94, 0.99) | 0.002 | 0.99 (0.95, 1.03) | 0.548 |
| Participants randomized to the gradual and immediate reduction conditions | ||||
| Covariate | Unadjusted Analyses | Adjusted Analyses* | ||
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Treatment = Immediate## | 1.04 (0.77, 1.39) | 0.809 | ||
| VLNC Adherence = Yes | 1.69 (1.25, 2.28) | 0.001 | 1.33 (0.95, 1.88) | 0.099 |
| Age = 18–24 | 0.66 (0.24, 0.88) | 0.021 | 0.51 (0.24, 1.06) | 0.073 |
| Gender = Male | 0.43 (0.31, 0.58) | < 0.001 | 0.52 (0.37, 0.73) | < 0.001* |
| Race = Non-white | 0.81 (0.60, 1.10) | 0.178 | 0.99 (0.65, 1.51) | 0.962 |
| Education = HS or less | 0.76 (0.56, 1.03) | 0.075 | 1.01 (0.71, 1.43) | 0.953 |
| Menthol = Yes | 0.78 (0.58, 1.05) | 0.105 | 0.85 (0.57, 1.26) | 0.411 |
| Intention-to-quit = Yes | 3.72 (2.69, 5.14) | < 0.001 | 3.08 (2.19, 4.34) | < 0.001* |
| FTCD | 0.92 (0.86, 0.97) | 0.004 | 0.94 (0.87, 1.01) | 0.091 |
| CES Satisfaction | 1.06 (0.97, 1.16) | 0.204 | ||
| CES Psychological Reward | 1.03 (0.91, 1.17) | 0.591 | ||
| CES Aversion | 1.00 (0.83, 1.22) | 0.960 | ||
| PHRS Average | 1.06 (1.01, 1.11) | 0.019 | 1.03 (0.97, 1.08) | 0.376 |
| MNWS | 1.02 (0.99, 1.04) | 0.288 | ||
| QSU Factor 1 | 0.97 (0.96, 0.99) | 0.005 | 1.00 (0.97, 1.03) | 0.859 |
| QSU Factor 2 | 0.96 (0.93, 0.99) | 0.015 | 1.00 (0.95, 1.05) | 0.998 |
Logistic regression analyses measuring associations between covariates and support for cigarette nicotine reduction after 20 weeks in the trial.
Adjusted analyses include covariates significant at the p < 0.2 level in the unadjusted analyses;
Immediate vs. gradual reduction; HS = high school; FTCD = Fagerström Test for Cigarette Dependence; CES = Cigarette Evaluation Scale; PHRS = Perceived Health Risk Scale; MNWS = Minnesota Nicotine Withdrawal Scale; QSU= Questionnaire on Smoking Urges; VLNC cigarette adherence was defined as urinary total nicotine equivalents levels ≤ 6.41 nmol/ml at Week 2020
Represents significant findings for the adjusted analyses at the p <0.05 level.
4.0. Discussion
Among study completers, policy support did not differ by treatment condition suggesting that the implementation approach may not affect public support if the FDA moves forward with a low nicotine product standard for cigarettes. The most notable finding was that participants interested in quitting smoking in the next six months were three times more likely to support a nicotine reduction policy. Interest in quitting and policy support appears to be a robust association since the current findings replicate our previous report from a 6-week VLNC cigarette trial.11. Since nearly 70% of people who smoke cigarettes report wanting to quit,1 regulators may want to consider framing a nicotine reduction policy as a means of potentially facilitating cessation. Health communication campaigns informing people that a nicotine reduction policy may help them quit or reduce their smoking may be beneficial for maximizing the public health impact of the policy.
Males, younger adults, and those with higher dependence scores had lower odds of policy support at Week 20. These participants could represent smoking subpopulations that may require additional resources or tailored policy messages to increase support for the policy. Participants who were adherent to smoking only the VLNC cigarettes responded in the direction of increased support. Our previous 6-week trial also found that VLNC adherence was significantly associated with increased policy support.11 Intuitively, it makes sense that participants who were better able to tolerate smoking VLNC cigarettes would be more supportive of the policy. Thus, strategies to increase VLNC tolerability (e.g., co-use of non-combusted nicotine), might also be expected to increase policy support.
Participants with increased risk perceptions also tended to have increased odds of support, which may be another effective health communication message. Individuals who are concerned about the health consequences of smoking may be more open to cigarette regulation, possibly because they believe the policy will result in positive health outcomes, like facilitating cessation. Alternatively, if these individuals incorrectly believe that VLNC cigarettes are less harmful, as previously reported,20 enabling them to continue smoking with fewer health risks, then their policy support is misguided. More research is needed to determine why individuals with increased cigarette risk perceptions support a nicotine reduction policy to ensure that misperceptions do not diminish the public health impact of the policy.
Policy support was generally stable over time with more than 80% of participants reporting support at baseline continuing to support the policy at Week 20. However, we conducted follow-up analyses to examine changes in support during the trial. Among the subset of participants who opposed the policy at baseline, intentions to quit smoking were associated with increased odds of support at Week 20. These individuals may have perceived some benefit from study participation, like increased motivation to quit, which may have led to changes in policy support. Conversely, among the subset of participants who supported the policy at baseline, lower cigarette satisfaction ratings were associated with decreased odds of policy support at Week 20, suggesting that using VLNC cigarettes may reduce support for those individuals who find them unsatisfying.
There are a couple of limitations to consider. First, attrition was higher in the immediate reduction condition (32%) relative to the gradual (19%) and control (14%) conditions,12 so excluding non-responses from the analyses may have led to an overestimation of support. It is plausible that individuals who withdrew do not support a nicotine reduction policy, especially an immediate reduction approach. Second, we only measured support using a single-item assessment with phrasing that is inconsistent with the FDA’s current policy language (i.e., “minimally-addictive or non-addictive”), so this may have led to an overestimation of support. Future studies should revise questions to align with the language used by regulators to ensure researchers accurately capture support for a nicotine reduction policy. Additional policy support questions should emphasize the substantial reduction in nicotine content (i.e., 95–97% less) and clarify that such a policy would apply to all commercially available cigarettes. Finally, participants self-selected to participate in the trial, so they may represent people who smoke with higher baseline support for cigarette nicotine reduction.
4.1. Conclusions
This study provides important information regarding support for a nicotine reduction policy among people who smoke in the US. 60% of participants completing the study indicated support for a nicotine reduction policy, including those with 20 weeks of exposure to VLNC cigarettes. The fact that support was similar across treatment conditions and after 20 weeks of exposure to VLNC cigarettes is encouraging in that it suggests that policy support may not erode during implementation of a low nicotine standard. Participants interested in quitting were much more likely to support the policy, suggesting a possible health communication strategy to employ if the FDA moves forward with implementing a nicotine reduction policy.
Footnotes
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REFERENCES
- 1.U.S. Department of Health and Human Services. Smoking Cessation A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020. [Google Scholar]
- 2.Gottlieb S, Zeller M. A nicotine-focused framework for public health. N Engl J Med. 2017;377(12):1111–1114. [DOI] [PubMed] [Google Scholar]
- 3.Apelberg BJ, Feirman SP, Salazar E, et al. Potential public health effects of reducing nicotine levels in cigarettes in the United States. N Engl J Med. 2018;378(18):1725–1733 [DOI] [PubMed] [Google Scholar]
- 4.Fix BV, O’Connor RJ, Fong GT, Borland R, Cummings KM, Hyland A. Smokers’ reactions to FDA regulation of tobacco products: Findings from the 2009 ITC United States survey. BMC Public Health. 2011;11:941. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Connolly GN, Behm I, Healton CG, Alpert HR. Public attitudes regarding banning of cigarettes and regulation of nicotine. Am J Public Health. 2012;102(4):e1–2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Pearson JL, Abrams DB, Niaura RS, Richardson A, Vallone DM. Public support for mandated nicotine reduction in cigarettes. Am J Public Health. 2013;103(3):562–567. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Bolcic-Jankovic D Public opinion about FDA regulation of menthol and nicotine. Tob Control. 2015;24(e4):e241–e245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Schmidt AM, Kowitt SD, Myers AE, Goldstein AO. Attitudes towards potential new tobacco control regulations among U.S. adults. Int J Environ Res Public Health. 2018;15(1):72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Patel M, Cuccia AF, Zhou Y, et al. Nicotine perceptions and response to proposed low-nicotine cigarette policy. Tob Reg Sci. 2019;5(6):480–490. [Google Scholar]
- 10.O’Brien EK, Nguyen AB, Persoskie A, Hoffman AC. U.S. adults’ addiction and harm beliefs about nicotine and low nicotine cigarettes. Prev Med. 2016;96:94–100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Denlinger-Apte RL, Tidey JW, Koopmeiners JS, et al. Correlates of support for a nicotine-reduction policy in smokers with 6-week exposure to very low nicotine cigarettes. Tob Control. 2019;28(3):352–355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Hatsukami DK, Luo X, Jensen JA, et al. Effect of immediate vs gradual reduction in nicotine content of cigarettes on biomarkers of smoke exposure: A randomized clinical trial. J Am Med Assoc. 2018;320(9):880–891. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Smith TT, Donny EC, Luo X, et al. The impact of gradual and immediate nicotine reduction on subjective cigarette ratings. Nicotine TobRes. 2019;21(Suppl 1):S73–s80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: A revision of the Fagerstrom Tolerance Questionnaire. Br J Add. 1991;86(9):1119–1127. [DOI] [PubMed] [Google Scholar]
- 15.Cappelleri JC, Bushmakin AG, Baker CL, Merikle E, Olufade AO, Gilbert DG. Confirmatory factor analyses and reliability of the modified Cigarette Evaluation Questionnaire. Addict Behav. 2007;32(5):912–923. [DOI] [PubMed] [Google Scholar]
- 16.Hatsukami DK, Vogel RI, Severson HH, Jensen JA, O’Connor RJ. Perceived health risks of snus and medicinal nicotine products. Nicotine Tob Res. 2016;18(5):794–800. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hughes JR, Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen Psychiatry. 1986;43(3):289–294. [DOI] [PubMed] [Google Scholar]
- 18.Cox LS, Tiffany ST, Christen AG. Evaluation of the Brief Questionnaire of Smoking Urges (QSU-brief) in laboratory and clinical settings. Nicotine Tob Res. 2001;3(1):7–16. [DOI] [PubMed] [Google Scholar]
- 19.Denlinger RL, Smith TT, Murphy SE, Koopmeiners J, Benowitz NL, Hatsukami DK, Pacek LR, Colino C, Cwalina SN, & Donny EC (2016). Nicotine and anatabine exposure from very low nicotine content cigarettes. Tobacco Regulatory Science, 2(2), 186–203. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Byron MJ, Jeong M, Abrams DB, Brewer NT. Public misperception that very low nicotine cigarettes are less carcinogenic. Tob Control. 2018;27(6):712–714. [DOI] [PMC free article] [PubMed] [Google Scholar]