https://orcid.org/0000-0001-9147-3716
Abstract
US FDA issued an advance notice of proposed rulemaking to reduce nicotine in cigarettes. To maximize the benefits of this potential standard, very low nicotine content (VLNC) cigarettes must be communicated in a way that does not result in misperceptions.
Adults (n = 567 who smoke; n = 610 non-smokers) from an online platform were randomized to a control message previously associated with accurate addictiveness perceptions of VLNC cigarettes but health misperceptions or to one of five messages that also included messaging on nicotine morbidity effects or VLNC cigarettes morbidity or mortality effects. p value <.01 was significant.
In participants who smoke, perceived lung cancer risk (responses: 1, very little risk to 10, very high risk) if smoked VLNC cigarettes regularly was higher in conditions that communicated mortality effects of VLNC cigarettes compared to the control (7.12–7.18 vs. 5.97, p values < .01). In non-smokers, perceived lung cancer risk was higher in all five message conditions when compared with the control (7.58–8.22 vs. 6.35, p values < .01). Proportion who responded accurately (ie, False) to the statement Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels was higher in conditions describing VLNC morbidity or mortality effects when compared with the control in both participants who smoke (52.04–67.37% vs. 30.85%, p values < .01) and do not smoke (62.50–72.38% vs. 32.00%, p values < .01).
Messaging on mortality effects of VLNC cigarettes (ie, cigarettes with 95% less nicotine are as deadly as current cigarettes) was associated with more accurate perceptions of the health risks of VLNC cigarettes than the control; however, misperceptions remained in one-third of participants.
One approach to communicating a VLNC cigarette standard to the public is to include messaging on the mortality effects of VLNC cigarettes. However, further study and possible refinement of this message condition are recommended since approximately one-third of participants exposed to this message still perceived VLNC cigarettes to be safer than normal nicotine content cigarettes.
Introduction
Given the central role nicotine reinforcement plays in sustaining cigarette use, the United States Food and Drug Administration (US FDA) has issued an advance notice of proposed rulemaking (ANPRM) to reduce the level of nicotine in cigarettes, and possibly other combusted tobacco products, to minimally or non-addictive levels.1 Results from randomized, double-blind clinical trials show that very low nicotine content (VLNC) cigarettes (ie, cigarettes that contain 0.4 mg nicotine per gram of tobacco compared to normal nicotine content [NNC] cigarettes which contain ~15.5 mg nicotine per gram of tobacco) are associated with reductions in cravings and nicotine dependence, increased quit attempts, and lower levels of toxicant exposure because of reduced use of cigarettes.2–6 However, a challenge to this approach is that harm misperceptions about VLNC cigarettes exist. Studies show that as many as one-half of people who smoke incorrectly believe that VLNC cigarettes are less likely to cause cancer than NNC cigarettes.7–9 Misunderstanding the harm profile of VLNC cigarettes relative to NNC cigarettes likely stems from public confusion surrounding the health harms of nicotine, as many people inaccurately believe that nicotine itself causes smoking-related cancers.9,10
It is essential to test how to best communicate a nicotine product standard to the public so that the public health benefits of this potential standard can be maximized. For example, if people falsely believe VLNC cigarettes are safer than NNC cigarettes, people who smoke may have less interest in quitting, people who have never smoked may become more interested in experimentation with cigarettes, and people who used to smoke may be interested in reinstating use. These potential scenarios work against the intended effects of cigarette nicotine reduction policy. Effective educational campaigns can aid the FDA and public health organizations in averting public confusion. Prior research has examined ways to educate the public on VLNC cigarettes.11–14 Byron et al examined the effects of different descriptions of VLNC cigarettes through text and/or visuals.11 This work found that exposure to the statement “95% of nicotine would be removed from cigarettes” increased accurate perceptions of the addictiveness of VLNC cigarettes (compared to the phrase “minimally or non-addictive”). However, exposure to this description was also associated with an increased likelihood of misperceiving that VLNC cigarettes had a lower cancer risk than NNC cigarettes, with nearly 50% of participants in this condition inaccurately believing this.
Villanti et al tested brief educational messaging on nicotine, exposing participants to two statements: “nicotine is addictive” and “nicotine itself does not cause cancer. It is the chemicals other than nicotine in cigarette smoke that can cause cancer, heart disease, and other health problems.” 12 Participants who were exposed to the educational messaging reported fewer false beliefs on VLNC cigarettes compared to a control condition that provided education on sun safety.12
To our knowledge, no study has built upon this work to identify messages that communicate to the public both what the product standard means (ie, VLNC cigarettes are less addictive than NNC cigarettes) and what the product standard does not mean (ie, VLNC cigarettes are less likely to harm one’s health than NNC cigarettes if smoked similarly). Thus, the goal of the present study is to contribute to the science base that can inform public health stakeholders on how to educate the public should a nicotine standard in cigarettes be implemented. To accomplish this goal, we leveraged the findings from Byron et al11 and Villanti et al12 to develop message conditions on both the addictiveness and health risks of VLNC cigarettes and examined associations with the following main outcomes of interest: (1) perceived risk for lung cancer if smoked VLNC cigarettes regularly and (2) perception of VLNC cigarettes being safer than NNC cigarettes. We also assessed how the message conditions related to perceptions of addictiveness of VLNC cigarettes, interest in using VLNC cigarettes, and support for a nicotine product standard and whether there were differential responses to the message conditions by smoking status. Lastly, because confusion surrounding the health harms of nicotine likely contributes to misperceptions on VLNC cigarettes, we explored associations between message conditions and perceptions of cancer risks of nicotine.
Methods
Participants
Participants for this study were registered users of Amazon Mechanical Turk (MTurk), an online crowdsourcing platform that has been used in tobacco research studies.15–18 Eligible individuals were required to be currently living in the United States, of the federal minimum age to purchase tobacco products (18+ years at the time of the study), able to complete the consent form, and to have completed at least 100 assignments with at least a 90% or greater approval rate in MTurk to maximize data quality. Only MTurk users who fit these inclusion criteria were able to access the Qualtrics study link provided in MTurk which was available during March 2020. Participants were required to complete a CAPTCHA to make certain they were human (not computers).
Study enrollment was stratified by smoking status (ie, people who were currently smoking at the time of the survey versus people who were not currently smoking at the time of the survey) and highest level of educational attainment (ie, report not having a bachelor or graduate degree versus reporting having a bachelor or graduate degree). Current smoking was defined as having smoked at least 100 cigarettes in one’s lifetime and now smoking some days or every day. We stratified recruitment by educational attainment to help correct for the greater proportion of participants with higher versus lower educational attainment in MTurk studies than nationally represented studies.19 For each of the six conditions, we aimed to recruit 200 participants (ie, 50 participants who were currently smoking at the time of the survey with higher educational attainment, 50 participants who were not currently smoking at the time of the survey with higher educational attainment, 50 participants who were currently smoking at the time of the survey with lower educational attainment, and 50 participants who were not currently smoking at the time of the survey with lower educational attainment). Thus, the total target sample size was 1,200 participants.
Procedures
All participants completed a tobacco use questionnaire and then read the following statement: Next you will view a message about a potential scenario. Please read the message carefully and take your time. The screen will be locked for 15 seconds after which you can choose when to proceed to the next page. The next page displayed the participants’ randomly assigned message condition (described below). With the exception of the text, all message conditions were uniform (same font type, size, and color [black], and background color [white]). Following reading their assigned message condition, participants completed several questionnaires including a battery of measures on perceptions of VLNC cigarettes and nicotine (described below), socio-demographic measures, and then read a debriefing statement. Upon completion of the study, participants were compensated $4 in their MTurk account for their time. The Institutional Review Board at the University of Minnesota approved the study.
Message Conditions
Table 1 presents the six message conditions tested. Condition 1, referred to as the control, was informed by the message condition in Byron et al that resulted in increased accurate perceptions on the addictiveness of VLNC cigarettes, but also greater misperceptions of the health risks of VLNC cigarettes.11 All message conditions included the text from the control condition. Condition 2, referred to as the “Nic addict + morbidity,” also included content on the addiction and health effects of nicotine previously developed by Villanti et al.12 Condition 3, referred to as “VLNC addict + morbidity,” tailored the statements on addiction and health effects of nicotine used in Condition 2 to address addiction and health effects of VLNC cigarettes. Condition 4, referred to as “VLNC addict + morbidity + youth,” was the same as Condition 3 with the addition of a statement on the role of VLNC cigarettes in preventing youth uptake of cigarettes. The youth statement was added in to see if it impacted perceptions of VLNC addictiveness and support for a nicotine product standard in cigarettes. Condition 5, referred to as “VLNC addict + mortality,” was the same as Condition 3 with the addition of addressing the mortality versus the morbidity effects of VLNC cigarettes. Finally, Condition 6, referred to as “VLNC addict + mortality + youth,” was the same as Condition 5 with the addition of the youth statement.
Message Conditions
| Condition 1 “Control” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. |
|---|---|
| Condition 2 “Nic addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Nicotine… • is addictive. • makes it harder for people to quit smoking • does not cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 3 “VLNC addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • are as likely to cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 4 “VLNC addict + morbidity + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking. • are as likely to cause cancer. • It is chemicals other than nicotine in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 5 “VLNC addict + mortality” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 6 “VLNC addict + mortality + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 1 “Control” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. |
|---|---|
| Condition 2 “Nic addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Nicotine… • is addictive. • makes it harder for people to quit smoking • does not cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 3 “VLNC addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • are as likely to cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 4 “VLNC addict + morbidity + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking. • are as likely to cause cancer. • It is chemicals other than nicotine in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 5 “VLNC addict + mortality” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 6 “VLNC addict + mortality + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
Message Conditions
| Condition 1 “Control” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. |
|---|---|
| Condition 2 “Nic addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Nicotine… • is addictive. • makes it harder for people to quit smoking • does not cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 3 “VLNC addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • are as likely to cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 4 “VLNC addict + morbidity + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking. • are as likely to cause cancer. • It is chemicals other than nicotine in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 5 “VLNC addict + mortality” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 6 “VLNC addict + mortality + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 1 “Control” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. |
|---|---|
| Condition 2 “Nic addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Nicotine… • is addictive. • makes it harder for people to quit smoking • does not cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 3 “VLNC addict + morbidity” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • are as likely to cause cancer. • It is other chemicals, not nicotine, in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 4 “VLNC addict + morbidity + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking. • are as likely to cause cancer. • It is chemicals other than nicotine in cigarette smoke that can cause cancer, heart disease, and the majority of other health problems. |
| Condition 5 “VLNC addict + mortality” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
| Condition 6 “VLNC addict + mortality + youth” | • Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes. • Cigarettes with 95% less nicotine… • are less addictive. • may prevent kids from getting hooked on smoking. • may make it easier for people to quit smoking • Cigarettes with 95% less nicotine are as deadly as current cigarettes. |
Measures
Socio-Demographic Factors and Smoking Behavior
We assessed socio-demographics, political affiliation (since political affiliation can broadly represent perspectives on the appropriateness of regulations in favor of public health over individual autonomy), and smoking status. As described above, current smoking was defined as having smoked at least 100 cigarettes in one’s lifetime and now smoking some days or every day. Former smoking was defined as having smoked at least 100 cigarettes in one’s lifetime and now not smoking some days or every day. Never smoking was defined as not having smoked 100 cigarettes in one’s lifetime. Participants who were currently smoking were also asked about number of cigarettes per day (CPD) on days smoked, level of dependence as assessed through the heaviness of smoking index (HSI) (ie, commonly used indicator of cigarette dependence with scores from 0 to 6 and higher scores indicating greater dependence),20,21 and whether the participant had ever used a VLNC cigarette such as the commercial brand Quest (ie, on the US market around 2005–2010)22 or the research brand Spectrum.
Comprehension
Participants were asked removing 95% of the nicotine from cigarettes means: Removing all of the nicotine, Removing almost all of the nicotine, Removing very little nicotine, or Removing none of the nicotine. The accurate response (ie, removing almost all of the nicotine) was compared to all other responses.
Perceptions of VLNC Cigarettes
The first main outcome measure was assessed by asking participants the following: Indicate what you believe your risk would be for lung cancer if you regularly smoked cigarettes with 95% less nicotine (Response options: 1, very little risk to 10, very high risk). For context, the same prompt and scale was utilized to measure perceived risk for lung cancer if regularly smoked cigarettes with normal nicotine levels. The second main outcome measure was collected by asking participants to read the following statement: Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels (Response options: True, False, I do not know). We compared the accurate perception (ie, False) to the misperception (ie, True) or the response I do not know.
Additionally, we asked participants to Indicate what you believe your risk would be for addiction if you regularly smoked/used cigarettes with 95% less nicotine (Response options: 1, very little risk to 10, very high risk). For context, the same prompt and scale was utilized to measure perceived risk for addiction if regularly smoked cigarettes with normal nicotine levels.
Interest in Using VLNC Cigarettes
Participants were asked Please assess your interest in using cigarettes with 95% less nicotine using a scale from 0 to 100 where 0 indicated no interest and 100 indicated very interested. For comparison, the same statement and scale were utilized to assess interest in cigarettes with normal nicotine levels. Among participants who were currently smoking, the following statement was asked: If cigarettes with 95% less nicotine were the only type of cigarettes available to purchase, would you … Stop smoking, Smoke less, Smoke same, or Smoke more.
Support for a Low Nicotine Standard in Cigarettes
Participants were asked Would you support or oppose a law that required cigarette manufacturers to make all cigarettes with 95% less nicotine? Response options were: Support, Oppose, and I do not know.
Perceptions of Nicotine
Participants were asked to respond to the following statement: Nicotine is a cause of cancer. We compared the accurate perception (ie, False) to the misperception (ie, True) or the response I do not know.
Statistical Analyses
Data were summarized descriptively via means and standard deviation (STD) or proportions. Least squares linear regression and chi-square/Fisher exact tests for association were conducted to test for statistically significant differences in measures between the control condition and each of the other five conditions. There were two main outcomes of interest: (1) perceived risk for lung cancer if smoked VLNC cigarettes regularly and (2) perception of VLNC cigarettes being safer than NNC cigarettes. An alpha of 0.01 (0.05/5) for statistical significance was used to account for the multiple comparisons between the control condition and each of the other message conditions. All analyses were conducted separately by current smoking status. Since all measured potential confounders were distributed similarly across the six message conditions (all p values for differences in means or proportions across conditions >.05), no adjusted analyses were performed. Statistical analyses were conducted in SAS version 9.4. Data can be made available upon request.
Results
Socio-Demographic Factors and Smoking Behavior
Of the 1,200 participants who provided informed consent and completed the study, 23 participants were removed because of reporting a smoking status at screening that did not match the smoking status they reported after consent in the survey questionnaire. Because of stratification, 49.2% of participants were currently smoking at the time of the survey, 51.8% were not currently smoking at the time of the survey, 48.8% did not have a bachelor’s degree or greater, and 51.2% had a bachelor’s degree or greater.
Supplementary Table 1 shows the characteristics of the participants. The average age was approximately 40 years, about one-half of participants were female sex, and approximately three-fourths of participants identified as White, non-Hispanic race/ethnicity. Participants who were currently smoking: The majority were smoking daily, smoking less than a half a pack a day on days smoked, made a quit attempt in the past 12 months, and had not ever tried a VLNC cigarette. Participants who were not currently smoking: About two-thirds were participants who never smoked versus one-third who previously smoked. All Table 2 characteristics were distributed similarly across the six message conditions by smoking status (p values > .05).
Perceptions of LNC Cigarettes, Interest in LNC Cigarettes, and Support for a LNC Cigarette Standard Among Participants by Current Smoking Status
| Participants who were currently smoking (N = 567) | ||||||
|---|---|---|---|---|---|---|
| Control (n = 94) | Nic addict + morbitity (n = 92) | VLNC addict + morbitity (n = 98) | VLNC addict + morbitity + youth (n = 94) | VLNC addict + mortality (n = 95) | VLNC addict + mortality + youth (n = 94) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 87.23 | 89.13 | 92.86 | 97.87* | 92.63 | 92.55 |
| Removing all/very little/none of the nicotine | 12.77 | 10.87 | 7.14 | 2.13 | 7.37 | 7.45 |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 30.85 | 48.91 | 52.04* | 52.13* | 67.37* | 61.70* |
| True/Do not know | 69.15 | 51.09 | 47.96 | 47.87 | 32.63 | 38.30 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 47.22 (37.00) | 44.72 (34.43) | 48.72 (35.71) | 50.90 (34.99) | 48.56 (35.75) | 48.64 (34.21) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 70.95 (27.38) | 70.89 (28.76) | 72.18 (28.85) | 63.94 (28.92) | 73.28 (27.62) | 73.98 (25.13) |
| If cigarettes with 95% less nicotine were only type available, I would | ||||||
| Stop smoking | 19.15 | 20.65 | 16.33 | 18.09 | 11.58 | 11.70 |
| Smoke less | 30.85 | 26.09 | 37.76 | 30.85 | 38.95 | 31.91 |
| Smoke same | 29.79 | 35.87 | 33.67 | 31.91 | 27.37 | 37.23 |
| Smoke more | 20.21 | 17.39 | 12.24 | 19.15 | 22.11 | 19.15 |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 43.62 | 32.61 | 42.86 | 47.87 | 41.05 | 36.17 |
| Oppose | 41.19 | 48.91 | 35.71 | 30.85 | 34.74 | 36.17 |
| Do not know | 14.89 | 18.48 | 21.43 | 21.28 | 24.21 | 27.66 |
| Nicotine is a cause of cancer | ||||||
| False | 25.53 | 60.87* | 38.78 | 28.72 | 44.21* | 18.09 |
| True/Do not know | 74.47 | 39.13 | 61.22 | 71.28 | 55.79 | 81.91 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 99.00 | 97.89 | 99.04 | 99.03 | 95.15 | 97.14 |
| Removing all/very little/none of the nicotine | 1.00 | 2.11 | 0.96 | 0.97 | 4.85 | 2.86 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 32.00 | 61.05* | 62.50* | 69.90* | 66.02* | 72.38* |
| True/Do not know | 68.00 | 38.95 | 37.50 | 30.10 | 33.98 | 27.62 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 4.16 (11.88) | 4.27 (14.66) | 3.20 (12.11) | 5.12 (17.64) | 4.76 (16.47) | 4.57 (14.08) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 4.07 (13.50) | 4.36 (15.76) | 2.30 (9.10) | 4.14 (14.91) | 3.28 (11.52) | 4.14 (14.42) |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 69.00 | 72.63 | 53.73 | 70.87 | 62.14 | 64.76 |
| Oppose | 8.00 | 10.53 | 13.46 | 12.62 | 15.53 | 14.29 |
| Do not know | 23.00 | 16.84 | 29.81 | 16.50 | 22.23 | 20.95 |
| Nicotine is a cause of cancer | ||||||
| False | 31.00 | 66.32* | 52.88* | 41.75 | 26.21 | 33.33 |
| True/Do not know | 69.00 | 33.68 | 47.12 | 58.25 | 73.79 | 66.67 |
| Participants who were currently smoking (N = 567) | ||||||
|---|---|---|---|---|---|---|
| Control (n = 94) | Nic addict + morbitity (n = 92) | VLNC addict + morbitity (n = 98) | VLNC addict + morbitity + youth (n = 94) | VLNC addict + mortality (n = 95) | VLNC addict + mortality + youth (n = 94) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 87.23 | 89.13 | 92.86 | 97.87* | 92.63 | 92.55 |
| Removing all/very little/none of the nicotine | 12.77 | 10.87 | 7.14 | 2.13 | 7.37 | 7.45 |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 30.85 | 48.91 | 52.04* | 52.13* | 67.37* | 61.70* |
| True/Do not know | 69.15 | 51.09 | 47.96 | 47.87 | 32.63 | 38.30 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 47.22 (37.00) | 44.72 (34.43) | 48.72 (35.71) | 50.90 (34.99) | 48.56 (35.75) | 48.64 (34.21) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 70.95 (27.38) | 70.89 (28.76) | 72.18 (28.85) | 63.94 (28.92) | 73.28 (27.62) | 73.98 (25.13) |
| If cigarettes with 95% less nicotine were only type available, I would | ||||||
| Stop smoking | 19.15 | 20.65 | 16.33 | 18.09 | 11.58 | 11.70 |
| Smoke less | 30.85 | 26.09 | 37.76 | 30.85 | 38.95 | 31.91 |
| Smoke same | 29.79 | 35.87 | 33.67 | 31.91 | 27.37 | 37.23 |
| Smoke more | 20.21 | 17.39 | 12.24 | 19.15 | 22.11 | 19.15 |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 43.62 | 32.61 | 42.86 | 47.87 | 41.05 | 36.17 |
| Oppose | 41.19 | 48.91 | 35.71 | 30.85 | 34.74 | 36.17 |
| Do not know | 14.89 | 18.48 | 21.43 | 21.28 | 24.21 | 27.66 |
| Nicotine is a cause of cancer | ||||||
| False | 25.53 | 60.87* | 38.78 | 28.72 | 44.21* | 18.09 |
| True/Do not know | 74.47 | 39.13 | 61.22 | 71.28 | 55.79 | 81.91 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 99.00 | 97.89 | 99.04 | 99.03 | 95.15 | 97.14 |
| Removing all/very little/none of the nicotine | 1.00 | 2.11 | 0.96 | 0.97 | 4.85 | 2.86 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 32.00 | 61.05* | 62.50* | 69.90* | 66.02* | 72.38* |
| True/Do not know | 68.00 | 38.95 | 37.50 | 30.10 | 33.98 | 27.62 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 4.16 (11.88) | 4.27 (14.66) | 3.20 (12.11) | 5.12 (17.64) | 4.76 (16.47) | 4.57 (14.08) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 4.07 (13.50) | 4.36 (15.76) | 2.30 (9.10) | 4.14 (14.91) | 3.28 (11.52) | 4.14 (14.42) |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 69.00 | 72.63 | 53.73 | 70.87 | 62.14 | 64.76 |
| Oppose | 8.00 | 10.53 | 13.46 | 12.62 | 15.53 | 14.29 |
| Do not know | 23.00 | 16.84 | 29.81 | 16.50 | 22.23 | 20.95 |
| Nicotine is a cause of cancer | ||||||
| False | 31.00 | 66.32* | 52.88* | 41.75 | 26.21 | 33.33 |
| True/Do not know | 69.00 | 33.68 | 47.12 | 58.25 | 73.79 | 66.67 |
An asterisk (*) indicates that the given message condition differed significantly (p < .01) from the control condition.
Perceptions of LNC Cigarettes, Interest in LNC Cigarettes, and Support for a LNC Cigarette Standard Among Participants by Current Smoking Status
| Participants who were currently smoking (N = 567) | ||||||
|---|---|---|---|---|---|---|
| Control (n = 94) | Nic addict + morbitity (n = 92) | VLNC addict + morbitity (n = 98) | VLNC addict + morbitity + youth (n = 94) | VLNC addict + mortality (n = 95) | VLNC addict + mortality + youth (n = 94) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 87.23 | 89.13 | 92.86 | 97.87* | 92.63 | 92.55 |
| Removing all/very little/none of the nicotine | 12.77 | 10.87 | 7.14 | 2.13 | 7.37 | 7.45 |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 30.85 | 48.91 | 52.04* | 52.13* | 67.37* | 61.70* |
| True/Do not know | 69.15 | 51.09 | 47.96 | 47.87 | 32.63 | 38.30 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 47.22 (37.00) | 44.72 (34.43) | 48.72 (35.71) | 50.90 (34.99) | 48.56 (35.75) | 48.64 (34.21) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 70.95 (27.38) | 70.89 (28.76) | 72.18 (28.85) | 63.94 (28.92) | 73.28 (27.62) | 73.98 (25.13) |
| If cigarettes with 95% less nicotine were only type available, I would | ||||||
| Stop smoking | 19.15 | 20.65 | 16.33 | 18.09 | 11.58 | 11.70 |
| Smoke less | 30.85 | 26.09 | 37.76 | 30.85 | 38.95 | 31.91 |
| Smoke same | 29.79 | 35.87 | 33.67 | 31.91 | 27.37 | 37.23 |
| Smoke more | 20.21 | 17.39 | 12.24 | 19.15 | 22.11 | 19.15 |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 43.62 | 32.61 | 42.86 | 47.87 | 41.05 | 36.17 |
| Oppose | 41.19 | 48.91 | 35.71 | 30.85 | 34.74 | 36.17 |
| Do not know | 14.89 | 18.48 | 21.43 | 21.28 | 24.21 | 27.66 |
| Nicotine is a cause of cancer | ||||||
| False | 25.53 | 60.87* | 38.78 | 28.72 | 44.21* | 18.09 |
| True/Do not know | 74.47 | 39.13 | 61.22 | 71.28 | 55.79 | 81.91 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 99.00 | 97.89 | 99.04 | 99.03 | 95.15 | 97.14 |
| Removing all/very little/none of the nicotine | 1.00 | 2.11 | 0.96 | 0.97 | 4.85 | 2.86 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 32.00 | 61.05* | 62.50* | 69.90* | 66.02* | 72.38* |
| True/Do not know | 68.00 | 38.95 | 37.50 | 30.10 | 33.98 | 27.62 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 4.16 (11.88) | 4.27 (14.66) | 3.20 (12.11) | 5.12 (17.64) | 4.76 (16.47) | 4.57 (14.08) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 4.07 (13.50) | 4.36 (15.76) | 2.30 (9.10) | 4.14 (14.91) | 3.28 (11.52) | 4.14 (14.42) |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 69.00 | 72.63 | 53.73 | 70.87 | 62.14 | 64.76 |
| Oppose | 8.00 | 10.53 | 13.46 | 12.62 | 15.53 | 14.29 |
| Do not know | 23.00 | 16.84 | 29.81 | 16.50 | 22.23 | 20.95 |
| Nicotine is a cause of cancer | ||||||
| False | 31.00 | 66.32* | 52.88* | 41.75 | 26.21 | 33.33 |
| True/Do not know | 69.00 | 33.68 | 47.12 | 58.25 | 73.79 | 66.67 |
| Participants who were currently smoking (N = 567) | ||||||
|---|---|---|---|---|---|---|
| Control (n = 94) | Nic addict + morbitity (n = 92) | VLNC addict + morbitity (n = 98) | VLNC addict + morbitity + youth (n = 94) | VLNC addict + mortality (n = 95) | VLNC addict + mortality + youth (n = 94) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 87.23 | 89.13 | 92.86 | 97.87* | 92.63 | 92.55 |
| Removing all/very little/none of the nicotine | 12.77 | 10.87 | 7.14 | 2.13 | 7.37 | 7.45 |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 30.85 | 48.91 | 52.04* | 52.13* | 67.37* | 61.70* |
| True/Do not know | 69.15 | 51.09 | 47.96 | 47.87 | 32.63 | 38.30 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 47.22 (37.00) | 44.72 (34.43) | 48.72 (35.71) | 50.90 (34.99) | 48.56 (35.75) | 48.64 (34.21) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 70.95 (27.38) | 70.89 (28.76) | 72.18 (28.85) | 63.94 (28.92) | 73.28 (27.62) | 73.98 (25.13) |
| If cigarettes with 95% less nicotine were only type available, I would | ||||||
| Stop smoking | 19.15 | 20.65 | 16.33 | 18.09 | 11.58 | 11.70 |
| Smoke less | 30.85 | 26.09 | 37.76 | 30.85 | 38.95 | 31.91 |
| Smoke same | 29.79 | 35.87 | 33.67 | 31.91 | 27.37 | 37.23 |
| Smoke more | 20.21 | 17.39 | 12.24 | 19.15 | 22.11 | 19.15 |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 43.62 | 32.61 | 42.86 | 47.87 | 41.05 | 36.17 |
| Oppose | 41.19 | 48.91 | 35.71 | 30.85 | 34.74 | 36.17 |
| Do not know | 14.89 | 18.48 | 21.43 | 21.28 | 24.21 | 27.66 |
| Nicotine is a cause of cancer | ||||||
| False | 25.53 | 60.87* | 38.78 | 28.72 | 44.21* | 18.09 |
| True/Do not know | 74.47 | 39.13 | 61.22 | 71.28 | 55.79 | 81.91 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Removing 95% of the nicotine from cigarettes means, % | ||||||
| Removing almost all of the nicotine | 99.00 | 97.89 | 99.04 | 99.03 | 95.15 | 97.14 |
| Removing all/very little/none of the nicotine | 1.00 | 2.11 | 0.96 | 0.97 | 4.85 | 2.86 |
| Participants who were not currently smoking (N = 610) | ||||||
| Control (n = 100) | Nic addict + morbitity (n = 95) | VLNC addict + morbitity (n = 104) | VLNC addict + morbitity + youth (n = 103) | VLNC addict + mortality (n = 103) | VLNC addict + mortality + youth (n = 105) | |
| Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels, % | ||||||
| False | 32.00 | 61.05* | 62.50* | 69.90* | 66.02* | 72.38* |
| True/Do not know | 68.00 | 38.95 | 37.50 | 30.10 | 33.98 | 27.62 |
| Interest in using cigarettes with 95% less nicotine (0–100), mean (STD) | 4.16 (11.88) | 4.27 (14.66) | 3.20 (12.11) | 5.12 (17.64) | 4.76 (16.47) | 4.57 (14.08) |
| Interest in using cigarettes with normal nicotine levels (0–100), mean (STD) | 4.07 (13.50) | 4.36 (15.76) | 2.30 (9.10) | 4.14 (14.91) | 3.28 (11.52) | 4.14 (14.42) |
| Would you support or oppose a law that required all cigarette manufacturers to make all cigarettes with 95% less nicotine? % | ||||||
| Support | 69.00 | 72.63 | 53.73 | 70.87 | 62.14 | 64.76 |
| Oppose | 8.00 | 10.53 | 13.46 | 12.62 | 15.53 | 14.29 |
| Do not know | 23.00 | 16.84 | 29.81 | 16.50 | 22.23 | 20.95 |
| Nicotine is a cause of cancer | ||||||
| False | 31.00 | 66.32* | 52.88* | 41.75 | 26.21 | 33.33 |
| True/Do not know | 69.00 | 33.68 | 47.12 | 58.25 | 73.79 | 66.67 |
An asterisk (*) indicates that the given message condition differed significantly (p < .01) from the control condition.
Comprehension
In both participants who were currently smoking and participants who were not currently smoking, the proportion of participants who correctly perceived that removing 95% of the nicotine from cigarettes means removing almost all of the nicotine did not differ in any of the five message conditions when compared with the control condition with the following exception: In participants who were currently smoking the “VLNC addict + morbidity + youth” condition resulted in a greater proportion of participants reporting removing almost all of the nicotine than the control condition (97.87% vs. 87.23%, p value = .0055; see Table 2).
Main Outcome Measures
Perceived risk for lung cancer if regularly smoked cigarettes with 95% less nicotine (see Figure 1; Supplementary Tables 2 and 3).
In participants who were currently smoking: Mean perceived risk for lung cancer was higher in the “VLNC addict + mortality” condition compared to the control condition (7.18 vs. 5.97, p value = .0011) and in the “VLNC addict + mortality + youth” condition compared to the control condition (7.12 vs. 5.97, p value = .0021). In participants who were not currently smoking: Mean perceived risk for lung cancer was higher in all five message conditions when compared with the control condition (7.58–8.22 vs. 6.35, all p values < .01).
Proportion who responded False to the statement Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels (see Figure 2; Table 2; Supplementary Table 3).
In participants who were currently smoking: The proportion who responded False to the statement Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels was higher in all four of the message conditions tailored to VLNC when compared with the control condition (52.04–67.37% vs. 30.85%, all p values < .01). In participants who were not currently smoking: The proportion who responded False was higher in all five message conditions when compared with the control condition (61.05–72.38% vs. 32.00%, all p values < .01).
Perceived risk for lung cancer if smoked cigarettes with 95% less nicotine regularly and perceived risk for lung cancer if smoked cigarettes with normal nicotine levels regularly where 1 indicates very little risk and 10 indicates very high risk.
An asterisk (*) indicates that the given message condition differed significantly (p < .01) from the control condition.
Proportion of participants who reported the following statement was false (versus true/I do not know): Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels.
An asterisk (*) indicates that the given message condition differed significantly (p < .01) from the control condition.
Perceptions of Nicotine
In participants who were currently smoking: As shown in Table 2, the proportion who responded False to the statement Nicotine is a cause of cancer was higher in the “Nic addict + morbidity” condition compared to the control (60.87% vs. 25.53%, p value < .0001) and the “VLNC addict + mortality” (44.21% vs. 25.53%, p value = .0071). In participants who were not currently smoking: The proportion who responded False was higher in the “Nic addict + morbidity” condition compared to the control (66.32% vs. 31.00%, p value < .0001) and the “VLNC addict + morbidity” (52.88% vs. 31.00%, p value = .0016).
Interest in Using VLNC Cigarettes
As shown in Table 2, mean interest in using VLNC cigarettes did not differ in any of the message conditions when compared with the control condition in both participants who were smoking and participants who were not currently smoking. Additionally, the proportion of participants who were currently smoking who reported they would stop smoking if VLNC cigarettes were the only type available did not differ in any of the five message conditions when compared with the control condition.
Support for VLNC Cigarette Policy
Regarding support for VLNC cigarette policy, the proportion who supported the policy did not differ in any of the message conditions when compared with the control condition in both participants who were smoking and participants who were not currently smoking.
Discussion
Prior research has shown that many people who smoke misperceive the health risks associated with VLNC cigarettes, thinking that they are safer to one’s health than conventional cigarettes with normal nicotine levels.14 This misperception could minimize the public health benefit of a low nicotine standard in cigarettes. Therefore, it is important to reflect on the results in this study and prior work that seeks to understand how to educate the public on both the addictiveness and health risks associated with VLNC cigarettes. In this study, a control message that stated Cigarette manufacturers will be required to remove 95% of the nicotine from cigarettes was compared to five message alternatives that included the control message plus various additional statements on the addictiveness and health risks of VLNC cigarettes and/or nicotine. Across all message conditions and in both participants who were currently smoking and participants who were not currently smoking the vast majority of participants accurately comprehended the product standard correctly by stating that removing 95% of the nicotine from cigarettes means removing almost all of the nicotine. These results provide further support for the previous research by Byron et al that was used to generate the control condition in the present study.11
Adding information on the mortality effects of VLNC cigarettes reduced health risk misperceptions of VLNC cigarettes. The “VLNC addict + mortality” and “VLNC addict + mortality + youth” conditions were associated with significantly higher perceived risk for lung cancer risk than the control condition in both participants who were currently smoking and participants who were not currently smoking. Regarding the other main outcome measure (ie, response to the statement Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels), the proportion of participants who stated the accurate response (ie, False) was higher for all alternative message conditions tailored to VLNC cigarettes (ie, “VLNC addict + morbidity,” “VLNC addict + morbidity + youth,” “VLNC addict + mortality,” and “VLNC addict + mortality + youth”) than the control condition regardless of smoking status. Considering the results from both of the outcome measures, the “VLNC addict + mortality” condition may provide a helpful starting point for educating the public on the potential health risks of VLNC cigarettes. One plausible reason for this finding beyond the content of the message is that of the five alternative message conditions this message condition was the most concise—a message quality that has been shown to be beneficial for health communication.23
Misperceptions associated with nicotine have been documented, with many people, and even physicians, falsely believing that nicotine directly causes cancer and the many diseases associated with smoking.9,10,24 In the present study, multiple message conditions appeared to mitigate nicotine misperceptions. For example, among both participants who were currently smoking and participants who were not currently smoking, the “nic addict + morbidity” condition more than doubled the proportion of participants who reported the accurate response (ie, False) to the statement Nicotine is a cause of cancer than the control condition. Interestingly, the “VLNC addict + mortality” condition which performed well in terms of the main outcome measures also resulted in a greater proportion of participants who reported the accurate response to Nicotine is a cause of cancer when compared with the control condition, but this relationship was only observed among participants who were currently smoking. Among participants who were not currently smoking, the “VLNC addict + mortality” condition did not differ from the control condition in terms of the proportion of participants who reported the accurate response to Nicotine is a cause of cancer. These results may be interpreted to suggest that the “VLNC addict + mortality” condition is helpful in correcting misperceptions of nicotine among people who currently smoke but not among people who currently do not smoke. Alternatively, this differential relationship may reflect a spurious finding. More research is recommended that examines the impact of these messages on a broader array of nicotine beliefs.
It is important to clarify some key limitations of this study. First, this study used an online convenience sample through MTurk, which limits the generalizability of the findings. However, by stratifying participant recruitment on highest level of educational attainment, we were able to capture a more representative sample of the US population than what is typical for this platform. Inclusion criteria (ie, requiring participants to have completed at least 100 assignments with at least a 90% or greater approval rate in MTurk) and timing minimums on the messages were used to address some of the typical concerns associated with online data collection. On the other hand, the online nature of the study may be more reflective of the real world where news and public health campaigns are increasingly being disseminated online. Another limitation of the study is the lack of considering the nuance that VLNC cigarettes may actually reduce the risk of lung cancer and/or esophageal cancer because of having lower levels of the tobacco-specific nitrosamines 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) and N-nitrosonornicotine (NNN) in their smoke than NNC cigarettes.2,3,25 Reduced levels of tobacco-specific nitrosamines appear to be a manufacturing by-product of reducing nicotine in VLNC cigarettes. However, there is a wide range of other smoke constituents at similar to or slightly lower levels than found in NNC cigarettes; 26,27 which, suggests the toxicity of VLNC cigarettes is likely to be comparable to that of NNC cigarettes if smoked similarly. Another limitation is that unlike the first main outcome (ie, Perceived risk for lung cancer if regularly smoked cigarettes with 95% less nicotine) the second main outcome (ie, Cigarettes with 95% less nicotine are safer than cigarettes with normal nicotine levels) did not include a statement quantifying the frequency of use and therefore allows for possible misinterpretation. Some participants may have stated True (ie, the inaccurate response) if they believed that since fewer people would smoke them cigarettes with 95% less nicotine are safer. To address this concern, we examined mean responses to the first main outcome based on response to the second main outcome and observed a higher mean perceived risk for lung cancer among participants who stated False (7.58 for smokers; 8.50 for non-smokers) versus those who stated True or Don’t Know across all conditions (5.78 for smokers; 6.23 for non-smokers). Thus, the concordance between the two main outcome measures provides confidence that misinterpretation of the second main outcome is likely not of great concern. Finally, the wording used in the VLNC cigarette policy support measure was likely biased in favor of supporting the product standard, and therefore future research should consider an approach recommended in recently published work.28
Conclusions
The “VLNC addict + mortality” condition, which communicated that cigarettes with 95% less nicotine are as deadly as current cigarettes, performed well in terms of the main outcome measures and may provide a helpful starting point for educating the public on the potential health risks of VLNC cigarettes. Further study and possible refinement of this message condition are recommended since approximately 1/3 of participants exposed to the “VLNC addict + mortality” condition still perceived VLNC cigarettes to be safer than NNC cigarettes. Also, misperceptions about nicotine’s cancer effects remained at large. Future work could entail investigations on the impact of the “VLNC addict + mortality” condition on perceptions when participants are exposed multiple times to the condition and how this message condition impacts tobacco use behavior. Additionally, given that the vast majority of participants in the present study identified as white, non-Hispanic race/ethnicity, future study should consider the performance of this message condition in other race/ethnicity groups who bear a disproportionate health burden from cigarettes.
Supplementary Material
A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.
Funding
This study was funded by internal funds from the Masonic Cancer Center, University of Minnesota to Dr. DMC as part of the Center for Evaluation of Nicotine in Cigarettes (CENIC) Pilot Project Program. Research reported in this publication was also supported by the National Institute on Drug Abuse of the NIH under award number U54 DA031659 (to DKH and ECD) and the National Institute On Minority Health And Health Disparities of the NIH under award number K01MD014795 (to DMC). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Declaration of Interests
The authors declare no conflicts of interest.
References
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