Qualitative reactions to a low nicotine product standard for cigarettes from adolescents and young adults living in the United States who smoke

Abstract

The Biden Administration is considering a low nicotine product standard for cigarettes. This qualitative study examined reactions to a nicotine reduction policy among adolescents and young adults (AYA) who smoke cigarettes. After completing a lab study involving masked exposure either to low nicotine or normal nicotine research cigarettes and unmasked exposure to e-cigarettes varying in nicotine concentration and flavor, we conducted follow-up semi-structured interviews (N = 25) to explore participants’ knowledge, attitudes, and perceptions of a low nicotine product standard and their anticipated tobacco use behavior after policy implementation. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. Nearly half of participants supported the policy because they thought it would prevent young people from starting smoking and/or would help people quit. Reasons some participants opposed the policy included beliefs that adults should have the choice to smoke or that a nicotine reduction policy is counterintuitive because the government benefits from cigarette sales. Others believed the policy would be ineffective because youth could circumvent the policy (e.g., illicit market) or would increase their smoking to maintain the same nicotine level. Almost half of participants said they would quit smoking while the other half said they would continue smoking, although potentially reduce their smoking. Overall, our qualitative findings point to the need for pre-policy media campaigns targeting AYA who smoke to minimize negative reactions, dispel fears, and correct misperceptions as well as encourage quitting and provide information on accessing cessation resources.

1. Introduction

Adolescents and young adults (AYA) who smoke cigarettes may be at particular risk for lifelong addiction. (Gentzke et al., 2022, Cornelius et al., 2020) AYA tend to underestimate the health risks of smoking and overestimate their likelihood of quitting in the future. (Lipkus and Shepperd, 2009, Weinstein et al., 2004, Mantler, 2013) Therefore, regardless of the low smoking prevalence estimates, (Park-Lee et al., 2022, Cornelius et al., 2022) AYA who smoke should still be considered a priority population. Importantly, one approach for further reducing smoking across all ages is for the Food and Drug Administration (FDA) to implement a low nicotine product standard for cigarettes, which would require all commercially-available cigarettes to contain nicotine levels that can minimize addiction. (Park-Lee et al., 2022) This policy is currently under consideration by the Biden Administration. (Gottlieb and Zeller, 2017, Announces Plans, 2022) The policy benefits for young people are two-fold: those currently experimenting with cigarettes may be much less likely to transition to regular smoking, and those currently smoking may be more successful during quit attempts. (Colby et al., 2019, Benowitz and Henningfield, 1994).

In adult trials, people assigned to smoke very low nicotine content cigarettes (VLNCs), i.e., cigarettes with ≤0.4 mg nicotine/g tobacco or approximately 95% less nicotine than conventional cigarettes, for extended periods have significant reductions in the number of cigarettes smoked per day, biomarkers of exposure, and increased quit attempts compared to those assigned normal nicotine content cigarettes (NNCs). (Donny et al., 2015, Hatsukami et al., 2018, Mercincavage et al., 2016, Shiffman et al., 2018, Tidey et al., 2019, Higgins et al., 2020, Smith et al., 2019, Krebs et al., 2021) Further, secondary analyses find that young adults (18–24 years old) report lower positive subjective responses to VLNCs than adults 25+ years old, suggesting a nicotine reduction policy could decrease cigarette reinforcement in this population. (Cassidy et al., 2019, Cassidy et al., 2021) Initial evidence suggests a low nicotine product standard may also benefit adolescents who smoke. In a lab study, AYA aged 15–21 who smoke similarly reported lower positive subjective responses for VLNCs than for higher nicotine cigarettes. (Cassidy et al., 2018) In a clinical trial, daily-smoking adolescents assigned to VLNCs for 3 weeks experienced significant reductions in smoking behavior relative to those assigned to NNCs. (Cassidy et al., 2022) Together, data suggest that a low nicotine product standard could reduce the abuse liability of cigarettes and reduce smoking in AYA.

However, a few challenges exist that could diminish the potential impact of a low nicotine product standard. First, youth may misperceive VLNCs as safer, potentially offsetting the reduced abuse liability of the modified cigarettes. Several studies, including one with AYA, have found that people who smoke misperceive VLNCs and reduced nicotine cigarettes as less harmful than their usual brand cigarettes, with particular confusion regarding nicotine’s contribution to cancer development (i.e., the belief that smoking VLNCs would be safer because nicotine causes cancer). (Denlinger-Apte et al., 2017, Pacek et al., 2018, Byron et al., 2018, Denlinger-Apte et al., 2019b, Denlinger-Apte et al., 2021b, Snell et al., 2021, O'Brien et al., 2016) Among adults, the misperception that VLNCs are safer cigarettes was associated with decreased intentions to quit (Byron et al., 2018) or lower odds of successful cessation. (Snell et al., 2021) Second, and relatedly, correcting this misperception may lead to further confusion about the intent of a nicotine reduction policy. A qualitative study found that some people who smoke correctly understood that VLNCs, in terms of toxicity, are likely as harmful as conventional cigarettes; however, they did not necessarily understand why the FDA would target nicotine for regulation rather than other harmful constituents. (Denlinger-Apte et al., 2021a) Third, overall support for such a policy may be reduced if it is perceived as government overreach or a Prohibition-like ban. Across several prior studies, support for a nicotine reduction policy was generally greater than opposition to the policy, even among people who smoke; (Bolcic-Jankovic and Biener, 2015, Denlinger-Apte et al., 2019a, Fix et al., 2011, O'Brien et al., 2016, Pearson et al., 2013, Schmidt et al., 2018) yet, it is plausible that policy opposition or misunderstanding could impede positive behavior change like quitting or reducing smoking. This could be especially applicable to younger people as smoking can be conceptualized as an act of ‘rebellion’ against prevailing societal norms. (Poole et al., 2022, Youatt et al., 2015).

To our knowledge, no studies have interviewed adolescents who smoke to assess their understanding of a nicotine reduction policy. This type of qualitative data is useful for identifying potential misperceptions or barriers to behavior change, like those outlined above, that could minimize the potential public health benefits of the policy. The current study examined several policy-relevant topics: (1) knowledge and beliefs about why the FDA would mandate a low nicotine product standard, (2) opinions regarding a low nicotine product standard, (3) anticipated tobacco use behavior after implementation of a low nicotine product standard, and (4) VLNC risk perceptions.

2. Materials and methods

2.1. Participants

We invited participants who had completed a nicotine reduction lab study (details below; U54DA031659; Project MPIs Colby and Tidey) to complete follow-up interviews. The parent study, which began enrollment in September 2018, recruited adolescents from Providence, RI, USA and the surrounding area. To be eligible, participants had to meet all of the following criteria: (1) being aged 15–20, (2) self-report daily or near daily cigarette smoking (response options: daily, near daily, some days, or not at all), (3) using an e-cigarette at least twice in their lifetime to avoid ethical concerns about introducing a participant to a novel product, (4) providing exhaled breath carbon monoxide (CO) levels >5 ppm (or urinary cotinine level >100 ng/ml), and (5) speaking and comprehending English. We excluded participants (1) unwilling to use the study cigarettes or e-cigarettes, (2) planning to quit smoking in the next 30 days, (3) using other tobacco products more than 15 days in the past 30, (4) reporting illicit drug use (excluding cannabis) or binge drinking alcohol more than 10 days in the past 30, (5) experiencing unstable medical or psychiatric conditions, including out of range heart rate and/or blood pressure readings, pregnancy and breastfeeding, and suicidal ideation or recent suicide attempts, (6) completing prior research cigarette studies in the past year, and (7) experiencing prior adverse reactions when using e-cigarettes. For the follow-up interviews, participants needed to have access to a device capable of installing the Zoom conferencing app.

2.2. Parent study design

The parent study examined the impact of nicotine content in cigarettes, nicotine concentration in e-cigarettes, and e-cigarette flavor availability on cigarette vs. e-cigarette choice among AYA. Participants completed five lab sessions according to a mixed between- (random assignment to one of two research cigarettes differing in nicotine content for all five visits) and within- (e-cigarette nicotine concentration and flavor availability differing across visits) subjects design. In each session, participants had the opportunity between taking two puffs of their assigned study cigarette (either Spectrum research cigarettes with 0.4 mg/g nicotine [VLNC] or 15.5 mg/g nicotine [NNC]), a study e-cigarette that varied in flavor and nicotine concentration across the sessions, or abstaining. We used masking procedures to ensure neither participants nor staff were aware of the nicotine content of the study cigarettes and e-cigarettes. However, the e-cigarette flavors were open-label. For the parent study, participants under 18 provided assent, and parental consent was obtained. Participants over 18 provided their own consent. The consent/assent documents outlined the overall study objectives and included the following information about FDA regulation of tobacco products and the purpose of a proposed nicotine reduction policy:

“You will be trying cigarettes that contain a different amount of nicotine than what is found in most brands. If you are assigned to the other condition, you will be trying cigarettes that have levels of nicotine that are similar to cigarettes available in stores. You will not be told the nicotine content of your study cigarettes until after the study has been completed.”

“This research may help the Food and Drug Administration (FDA) figure out how to regulate tobacco products in the future, to improve public health. This is not a treatment program for smoking. If you would like to quit smoking, we can provide you with information about where to get help quitting smoking.

Tobacco use causes many diseases and can also cause death. One way to reduce harm from cigarettes is to lower the amount of nicotine in them. This could make cigarettes less addictive. And it could help people cut down on their smoking. It could even help people quit smoking completely.”

All procedures, including the follow-up interview, were approved by the Brown University Institutional Review Board (IRB). The minimum legal age to purchase tobacco was 18 years of age when study enrollment started in 2018 and then increased to 21 years of age in 2020. Study investigators received waivers of prosecution from the Rhode Island Attorney General in 2018 and again in 2020 for portions of the study that involved provision of tobacco products to participants younger than the legal age to purchase to tobacco.

Additional protocol details are available on https://www.clinicaltrials.gov (NCT03194256).

2.3. Interview procedures

We invited all participants who completed the parent study prior to March 2020 when enrollment paused due to the COVID-19 pandemic to complete the follow-up interview. RDA developed the semi-structured interview guide in collaboration with RNC, SMC and JWT. Together, they have extensive experience in tobacco regulatory science, adolescent research, and qualitative methods. JG, with help from a study intern, conducted the interviews virtually via Zoom. Participants received $25 Amazon e-gift cards for completing the interview. For the follow-up interviews, participants provided verbal consent since all were 18+ at the time. The Wake Forest University School of Medicine IRB approved the qualitative data analysis plan.

2.4. Data analysis

JG completed interview transcription and data cleaning prior to sharing the data with research staff (AES and KDW) at Wake Forest University School of Medicine, who imported the cleaned transcripts into Atlas.ti Version 9.0 for data management. AES and KDW conducted reflexive thematic analysis following the principles outlined by Braun and Clark. (Braun and Clark, 2022) They developed a codebook inductively by identifying relevant codes based on an iterative review of the transcripts, as well as deductively based on the project aims and interview questions. AES and KDW independently coded the transcripts in sets of four, and resolved coding discrepancies together and revised the codebook, as needed, after each set of transcripts. Once they completed coding, they generated reports for each code and reviewed data within single codes or combination of codes to identify patterns. Together, they derived themes inductively from the data. All co-authors contributed to the interpretation and finalization of themes.

3. Results

Of the 45 participants who had completed the parent study, 25 participants completed interviews in August and September 2020. Sixteen participants declined the interview request while another four could not be re-contacted. Interviewees were, on average, 19 (SD = 0.62) years old, reported smoking 5 (SD = 3.1) cigarettes per day and had been smoking daily for 1 (SD = 1.71) year. Approximately half identified as female persons, 20.8% identified as racial/ethnic minoritized persons, and 31.3% identified as LGBTQ + persons. For assignment to study cigarette condition, n = 10 interviewees received VLNCs and n = 15 received NNCs. The audio-recorded interviews averaged 21:19 min in length (range: 12:21–33:51 min). Themes and illustrative quotes are presented in Table 1, Table 2, Table 3, Table 4.

Table 1.

Nicotine reduction policy purpose.

Theme	Illustrative Quotes
Reduce cigarette addiction	“…the less addictive it is, the less people will smoke.” (Female, 19; VLNC)
Prevent new addictions especially among youth	“…so people still have access to cigarettes and can smoke, but either get less addicted or don't get addicted if they're starting.” (Male, 19; NNC) “…it's probably geared towards trying to stop younger people from smoking.” (Male, 20; VLNC)
Encourage smoking cessation	“So that people are less addicted or it's easier to quit.” (Female, 20; NNC)
Improve health outcomes	“…less people would smoke them and then less people would get cancer…”(Female, 18; VLNC)
Control tobacco companies	“…maybe just to limit like these [tobacco] companies, because… you really don't know what they're putting into their cigs and what they're doing to people …so maybe just to control tobacco monopolies from having too much power.” (Male, 19; NNC)

Information in the parenthesis are the age, gender identity, and assigned study cigarette condition of the speaker.

Very low nicotine content cigarettes; NNC: Normal nicotine content cigarettes.

Table 2.

Nicotine reduction policy opinions.

Theme	Illustrative Quotes
Support
Potential public health benefits	“…you still get the same amount of tobacco, so you're still getting the full experience of smoking a cig, but you're just not getting the same addiction…so I guess it'd make it easier to quit.” (Male, 19; NNC) “I don't think it’s a bad idea. I think it would help if the addictiveness is minimized.” (Female, 19; NNC)
Good for public health but concerned for people who smoke	“I think that would be helpful. It would be a hard transition for people that smoke obviously, but I think it would overall in the long run be helpful.” (Male, 19; NNC) “I would be more worried, I guess, about what would happen to if they started regulating more or taking, banning more things.” (Female, 19; NNC)
Oppose
Adults should be able to choose to smoke	“I think that's kind of stupid…I feel like if grown people want to be addicted to something then they should be able to…If they want to blow their money on cigarettes and be addicted to cigarettes then they should be able to.” (Female, 18; VLNC)
Will not address smoking-related stigma	“I believe it's harmful because…there is sort of a stigma of people who use different substances as a way to cope. So when we see a person smoking outside of work or something like that, people look down upon them, even though this may be their only break for the day, and then they have to go home to a toxic work environment, toxic home environment. Reducing the amount of nicotine won't decrease, the amount of smokers that exist.” (Male, 18; NNC)
Counterintuitive since the government benefits from cigarette sales	“I feel like putting things on like restriction is kind of dumb because I feel like you could eventually like benefit from like, like, not like so much you smoking them, but like the government, like it could tax on it.” (Female, 19; VLNC)
Ineffective
Will lead to increased smoking	“It sounds good on paper, but…I've read studies about like people smoking light cigarettes. And that they end up consuming the same amount of nicotine in the day and they just smoke more of them.” (Male, 18; VLNC)
Will lead to illicit markets	“It's just going to create a black market of higher nicotine products that are unregulated or unscientifically confirmed to have a certain amount of percentage.” (Male, 18; NNC)
Nicotine is not the only reason to smoke	“I feel like addiction is more broad than the nicotine itself. You know, it's also the act of going outside, sitting in our lawn for example, smoking the cigarettes for five minutes where you're doing nothing, but you're smoking that cigarette. I think…you have a very limited view of what addiction is.” (Male, 18; VLNC)
Other tobacco control policies are ineffective	“…in Rhode Island in general, they raised the smoking age from 18 to 21, not smoking but for purchasing products. I don’t know a single person who was smoking…they implemented the law, and then they stopped….just because they raised the smoking age or they’re gonna decrease [the] amount of nicotine in cigarettes…I feel like people are going to be more adamant about doing it.” (Female, 19; NNC)

Information in the parenthesis are the age, gender identity, and assigned study cigarette condition of the speaker.

Very low nicotine content cigarettes; NNC: Normal nicotine content cigarettes.

Table 3.

Anticipated behavior after implementation of a nicotine reduction policy.

Theme	Illustrative Quotes
Continue smoking cigarettes	“I think I'd keep smoking…it's kind of a habit at this point, and an addiction. And I know people around me would probably continue to smoke.” (Male, 19; NNC) “… a big part of smoking is not the actual nicotine itself, but also the act of smoking the cigarette and going outside and taking the time and everything. So I feel like I may do well with the other cigarettes because you provide these other factors, but less nicotine.” (Male, 19; VLNC)
Quit smoking cigarettes	“I would probably quit because it just wouldn't be the same.” (Female, 18; VLNC) “I think that I would probably quit because…cigarettes are already expensive as it is. If they were maintained at a similar price, but there was a lower nicotine content, then, I don't know, I really don't think it's worth it.” (Male, 20; VLNC)
Switch to other nicotine or tobacco products	“Wherever the nicotine is, I'll go there…I'd probably just do Juul again.” (Female, 18; VLNC) “I would definitely use those nicotine pack pouches that you put under your lip. I think those are called…ZYN?…also shisha, hookah.” (Female, 19; VLNC)

Information in the parenthesis are the age, gender identity, and assigned study cigarette condition of the speaker.

VLNC: Very low nicotine content cigarettes; NNC: Normal nicotine content cigarettes.

Table 4.

Perceived health risks of the research cigarettes.

Theme	Illustrative Quotes
Less harmful due to the lower nicotine levels	“…they told me that the levels of nicotine could vary in them [the research cigarettes]. So I think if it was lower, it’d probably be less [risk].” (Female, 19; VLNC) “I mean, if the research cigarettes I got were lower in nicotine, then that’s obviously better for me.” (Female, 19; VLNC)
Usual brand cigarettes contain more tar and/or chemicals	“I would like to think that since the research ones were less strong, they were healthier. Less tobacco and tar going inside, but I’m not too sure about the science behind it.” (Male, 19; NNC)
Designed for science	“I assume that they were a little bit lower because they weren't designed for pleasure. They were designed for science and they wouldn't want it to be like too nasty.” (Male, 18; NNC)

Information in the parenthesis are the age, gender identity, and assigned study cigarette condition of the speaker.

VLNC: Very low nicotine content cigarettes; NNC: Normal nicotine content cigarettes.

3.1. Purpose of a nicotine reduction policy

We asked participants for their perceptions about why the FDA would enact a nicotine reduction policy (Table 1). Some participants specified the FDA would want to prevent youth from becoming addicted and limit the number of young people that smoke. Others stated the FDA would want to encourage people who currently smoke to quit. About a third of participants thought the FDA would want to limit the amount of nicotine in cigarettes in order to improve health and/or reduce the adverse health effects of cigarette smoking. A few participants mentioned financial reasons, though they had differing opinions: One participant thought the FDA would limit nicotine in cigarettes “to enforce customers to buy more cigarettes and collect more taxes”. Another participant thought a nicotine reduction policy would be an experiment to determine if and how the policy affected cigarette sales, “just to see what happens.” Finally, a couple of participants thought the FDA would limit the amount of nicotine in cigarettes to control tobacco companies and decrease their sales/profits.

3.2. Opinions regarding a nicotine reduction policy

When asked their opinions regarding a nicotine reduction policy, participants reported mixed viewpoints (Table 2). Nearly half of participants, including 30% in the VLNC condition, supported a nicotine reduction policy to some extent and did so because they thought the policy would help prevent people from becoming addicted to cigarettes or help people who currently smoke quit. Many participants indicated support for the policy overall even while acknowledging the policy could be worrisome for people who smoke, because the transition to VLNC might be difficult for them or the policy could invoke fear of additional tobacco regulation. Among the participants who opposed the policy, reasons for opposition included the belief that adults should have the choice to smoke, the belief that a nicotine reduction policy would reinforce smoking stigma for those who continued smoking, or the belief that the policy is counterintuitive because the government benefits from cigarette sales.

Nearly half of participants thought a nicotine reduction policy would be ineffective at reducing cigarette smoking, with the majority believing people would find ways to circumvent the policy (e.g., illicit market) or switch to other nicotine and tobacco products. About one-third of participants believed the policy would be ineffective because people would increase the number of cigarettes they smoke in order to maintain the same nicotine level. A few participants felt nicotine is only one aspect of the appeal of smoking, and expressed uncertainty that reducing the nicotine content in cigarettes would change smoking behavior. A couple of participants mentioned their perception that Tobacco 21 laws have been ineffective as evidence that a nicotine reduction policy would potentially also be ineffective. One participant cautioned if the FDA wants to reduce the number of young people using nicotine and tobacco products, then a nicotine reduction policy would be ineffective because younger people use e-cigarettes more than regular cigarettes.

3.3. Anticipated behavior after implementation of a nicotine reduction policy

We asked participants to describe whether or how their tobacco use would change if the FDA were to implement a nicotine reduction policy (Table 3). Participants frequently endorsed multiple behavioral outcomes. Nearly half of participants said they would continue smoking. Several participants said they would likely reduce the amount they smoked but would not attempt to quit. Participants shared multiple reasons why they would continue smoking, including addiction, habit, stress relief, and social reasons. Alternatively, nearly half of participants said they would attempt to quit smoking. This included some participants who had quit smoking after their participation in the parent study had ended. Participants said they would attempt to quit smoking because the experience of smoking would not be the same and the lower nicotine content would curb their addiction. However, several participants also expressed being motivated by factors external to the nicotine reduction policy (e.g. were already thinking about quitting, concern about health risks, minimum age policy). Finally, approximately one-third of participants said they would switch to another tobacco or nicotine product at least some of the time. Most said they would switch to e-cigarettes, but other products mentioned included smokeless tobacco, oral nicotine pouches, and hookah.

3.4. Perceived health risks of the research cigarettes

We also examined participants’ risk perceptions of the research cigarettes (Table 4). More than two-thirds of all participants, including 60% assigned to VLNCs, thought the research cigarettes had lower health risks compared to their usual brand cigarettes, though several participants shared they still thought the research cigarettes were harmful to health. Not all participants elaborated on the reasons why they believed the research cigarettes had lower health risks, but those who did described two primary reasons: (1) they believed that the research cigarettes had a lower nicotine content and/or (2) they believed their usual brand cigarettes contain more tar and/or chemicals. Other risk perceptions were that the research cigarettes had lower risks because they were “designed for science” and not “designed for pleasure,” or that they trusted the research cigarettes more because they were not produced by a large tobacco company. A third of participants felt the research cigarettes and their usual brand cigarettes had comparable risks, although most did not elaborate on the reasons why they believed this.

4. Discussion

As the FDA weighs a low nicotine mandate for cigarettes and other combusted tobacco, it is important to understand the knowledge, attitudes, and perceptions of a nicotine reduction policy among adolescents who smoke. Qualitative data are particularly useful for identifying potential barriers to behavior change, such as misperceptions about the intentions of this policy. AYA who had completed a laboratory study in which they sampled VLNCs or NNCs, along with study e-cigarettes, expressed: (1) mostly correct understandings that the goal of the policy was to prevent and reduce smoking, especially among youth, (2) mixed support for the policy, and (3) some misperceptions that research cigarettes were less harmful to health.

Consistent with other qualitative and quantitative VLNC smoking studies, (Denlinger-Apte et al, 2021a, Denlinger-Apte et al., 2019a, Denlinger-Apte et al., 2021c) about half of participants, including those with exposure to VLNCs, supported a low nicotine product standard for cigarettes and attributed their support to the potential benefits of the policy. However, some participants voiced concerns for individuals who smoke. One participant worried a policy intended to reduce smoking would not address existing stigmatization of those who continued to smoke. Given the low prevalence of smoking among young people, it is not surprising that stigma may be a concern for some. Importantly, although some studies have found that internalized stigma about smoking was associated with increased quit intentions, (O'Connor et al., 2017, Lozano et al., 2020) experiencing stigma is often a barrier to behavior change and/or obtaining support. (Stangl et al., 2019) Other participants expressed concerns that switching to VLNCs could be challenging for some. Thus, incorporating support strategies, like providing free, easily accessible nicotine replacement therapies, into the implementation plan may help to increase support for the policy and facilitate quitting. Another participant mentioned the possibility of a nicotine reduction policy leading to other tobacco regulations, although was not explicit about what other potential regulations concerned them. However, prior research among young adults has reported low policy support for banning menthol as a characterizing flavor in cigarettes, (Wackowski et al., 2018) another regulation being pursued by the FDA. (Proposes Rules Prohibiting Menthol Cigarettes and Cigars, 2022).

Among participants expressing policy opposition, a few tapped into constructs like limiting freedom or individual autonomy if the government were to mandate low nicotine levels. One participant who opposed the policy thought adults should have the choice to smoke and regulations targeting cigarettes would diminish this freedom of choice. Participants in another qualitative study expressed similar viewpoints about nicotine regulation (Henderson et al., 2022) and the topic of smoking “choice” has been discussed at length elsewhere. (Palmer et al., 2022) Alternatively, another participant said the policy would maintain cigarette availability for people who smoke but that people may become less dependent on cigarettes. Although cessation is the primary goal of nicotine reduction, messages about feeling less dependent and having more freedom when smoking may resonate with people who smoke but feel a nicotine reduction policy is governmental over-reach. Such messages could be explored in future studies focused on increasing policy acceptability prior to implementation.

Most participants seemed to understand why the FDA would implement a low nicotine product standard for cigarettes, which differs from previous qualitative studies of nicotine reduction among adults who smoke. Several participants said the purpose of the policy is to make it easier for people to quit smoking or prevent initiation. (Denlinger-Apte et al, 2021a, Henderson et al., 2022) Indeed, about half of participants said they would attempt to quit smoking if a low nicotine product standard were implemented. However, despite correctly identifying the policy’s purpose and/or holding positive intentions, most felt the policy would be ineffective, which is consistent with adult reactions. (Denlinger-Apte et al, 2021a, Denlinger-Apte et al., 2022) These dismissive perspectives point to the importance of communicating to the public about the science of nicotine reduction. First, messages correcting concerns about compensatory smoking due to reduced nicotine levels, which has not been observed in VLNC clinical trials including one among adolescents, (Cassidy et al., 2022, Donny et al., 2015, Hatsukami et al., 2018, Higgins et al., 2020, Krebs et al., 2021, Smith et al., 2019, Smith et al., 2020, Tidey et al., 2019) would likely be very beneficial. Second, promoting potential policy benefits such as increased cessation, along with providing linkage to cessation resources, may help reduce perceptions that the policy will be ineffective. Third, it may also be important to explain nicotine reduction within the context of the tobacco continuum of harm. (Abrams et al., 2018) One participant voiced confusion about why the FDA would target cigarettes rather than e-cigarettes for nicotine reduction, if the goal is to reduce adolescent tobacco use. Messages emphasizing the harms of combusted tobacco may help clarify the policy’s intent. However, such nicotine reduction messaging must also ensure that nicotine-naïve AYA do not initiate use of less harmful products.

Consistent with our prior quantitative assessment of adolescent VLNC risk perceptions, (Denlinger-Apte et al., 2019b) some participants perceived that lower nicotine meant lower risk. Different sensory experiences when smoking VLNCs may partially contribute to perceptions of reduced harm. Several participants described the research cigarettes as being mild or less harsh than their regular brands. One interesting theme was the perception that research cigarettes were less harmful because they were “designed for science.” This implicit association equating science and safety could also occur if the FDA implements a low nicotine product standard. Adolescents could reasonably conflate FDA’s regulatory approach for tobacco (i.e., population public health standard) and FDA’s regulatory approach for pharmaceuticals, vaccines, etc. (i.e., individual safety and efficacy standard). Thus, it is critical for information to be conveyed to the public that VLNCs are only less harmful products to the extent they help people quit or reduce their dependence on cigarettes. Otherwise, long-term use of VLNCs may confer the same health risks as conventional cigarettes. Worth noting, Spectrum cigarettes are specifically for research purposes and are not commercially available. Thus, novelty of the cigarettes combined with use in an academic research setting likely also contributed to misperceptions.

However, interpretations of VLNC misperceptions require nuance. It is possible the adolescents who said lower nicotine cigarettes were lower risk accurately understood the connection between reducing nicotine and increasing cessation. Therefore, they may have perceived a product intended to help people quit smoking would be less harmful than a product that maintains smoking behavior. This critical distinction was not adequately disentangled during our interviews. Future qualitative studies examining VLNC risk perceptions should include explicit probing questions to clearly examine knowledge about a nicotine reduction policy.

There are a few study limitations to consider. The parent study enrolled adolescents who smoke daily; so, themes reported here may not reflect the larger proportion of adolescents who smoke non-daily. Therefore, the results may not generalize to all adolescents who smoke. However, adolescents who smoke daily are at highest risk of persistent tobacco use. The sample size is relatively small, albeit, reasonable for the goals of qualitative research. Finally, the interviewers were conducted several months after participants completed the trial, so the results are subject to recall biases.

Despite the limitations, this qualitative study contributes important and timely data to the nicotine reduction literature. Although many adolescents supported the policy, correctly understood the purpose and indicated quit intentions, skepticism about the potential effectiveness was common and several expressed concerns about infringement on personal liberties, increased stigma, and compensatory smoking. Such findings point to the importance of educational media campaigns targeting AYA who smoke to minimize negative reactions, dispel fears, and correct misperceptions about the policy as well as encourage AYA to use a nicotine reduction policy as an opportunity to quit smoking and provide information on accessing cessation resources.

CRediT authorship contribution statement

Rachel L. Denlinger-Apte: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft. Rachel N. Cassidy: Conceptualization, Writing – review & editing, Writing – review & editing. Eric C. Donny: Conceptualization, Funding acquisition, Writing – review & editing, Writing – review & editing. Julissa Godin: Data curation, Investigation, Writing – review & editing, Writing – review & editing. Dorothy K. Hatsukami: Conceptualization, Funding acquisition, Writing – review & editing, Writing – review & editing. Ashley E. Strahley: Data curation, Formal analysis, Software, Writing – review & editing. Kimberly D. Wiseman: Data curation, Formal analysis, Software, Writing – review & editing. Suzanne M. Colby: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing. Jennifer W. Tidey: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.