Commentary on Nardone et al . (2016): Satisfaction, dissatisfaction and complicating the nicotine‐reduction strategy with more nicotine
Year: 2016
Type: editorial
Abstract: Additional ways of assessing and reporting satisfaction/dissatisfaction and compliance with very low nicotine cigarettes are needed. Mixing more satisfying nicotine products with fully toxic, less satisfying low nicotine cigarettes will probably influence net satisfaction, longevity of their use and health effects. Nardone et al. 1 extend a previous publication 2 by reporting that lower ‘satisfaction’ from very low nicotine cigarettes (VLNC) predicts non-compliance with VLNC. While only 39% of participants reported non-compliance, a new objective measure indicates that 78% were probably smoking other cigarettes. Smokers lacked something in VLNC. Mandatory VLNC have been advanced as a tobacco control strategy 3, 4, but not without criticism 5-7. Compliance with VLNC by healthy, well-paid volunteers sheds light upon challenges smokers might face, even if greater challenges could befall mentally ill, alcohol-abusing smokers 6, 8. The three-item cigarette evaluation scale (CES) satisfaction scale was used: ‘Was smoking satisfying?’, ‘Did the cigarettes taste good?’ and ‘Did you enjoy the sensations in your throat and chest?’. This measure employs seven-point scales often with descriptors: 1, not at all; 2, very little; 3, a little; 4, moderately; 5, a lot; 6, quite a lot; and 7, extremely 9. Nardone et al. report ratios of geometric means and 95% confidence intervals (CI) = 0.70 (0.58–0.85). It would be valuable to know what participants answered on average. Were VLNC only ‘very little’ or ‘a little’ satisfying? Another VLNC report 10 used a 0–100 scale for ‘satisfaction.’ Usual brand was 83.6 ± 1.4, a regular nicotine test cigarette was 61.4 ± 4.1 and the VLNC was 36.8 ± 4.1. These scores suggest frank dissatisfaction with VLNC. Future research would benefit from adding direct, natural-language comparisons of satisfaction from usual and test brands (cf. 11, 12). Even within reliable, multi-item scales, looking at individual questions can be valuable 13. Do differences in satisfaction represent VLNC being only less satisfying than usual brands, but still substantially satisfying, or are they significantly dissatisfying? The two decades of history of the strategy can be characterized as moving from ‘deprivation’ towards ‘satisfaction’. In the beginning 3, they hoped that their cigarettes ‘may provide enough nicotine for taste and sensory stimulation’ but, quite logically, they offered no supplemental nicotine at all. Acknowledging undiminished toxins in VLNC, they hoped that the ‘…risk may be offset by the long-term benefit of a greater likelihood that they will stop smoking (as cigarettes become less satisfying)’ and by the prevention of addiction in non-smokers. Four years later 14, unsatisfying, nicotine-replacement medicines were welcomed into the strategy as short-term smoking-cessation aids. In an enormous further step, proponents have now embraced nicotine for long-term harm reduction 4: ‘The key to successful cigarette nicotine reduction is likely to lie with providing readily available, consumer-acceptable non-combusted forms of nicotine to support shifting the source of nicotine from cigarettes to a non-combusted product’ 15. They acknowledged that e-cigarettes were more satisfying than patches and wrote: ‘Dual use would be less of a problem because [VLNC] cigarettes would be less desirable, and e-cigarettes more satisfying in comparison’ 15. This represents a sea change in the original nicotine-deprivation model that hypothesized that mandatory VLNC would prevent dependence in youth and cause dependence to wither in adults. A nicotine-deprivation therapy, after all, is compromised directly by adding higher, more satisfying levels of nicotine to the mix of daily use. Might nicotine products be used to give mandatory VLNC a boost? What complex patterns of multi-product use might develop with VLNC and more satisfying forms of nicotine use? In a trial in which VLNC were made much cheaper than regular cigarettes, overall smoking did not decrease—because the participants used both products and saved money by using VLNC alongside conventional cigarettes 16. Could combining VLNC with vaping or other nicotine products make for a satisfying experience that would actually undermine cessation of VLNC? Concerns about health consequences of dual use of vaping and cigarettes 17 apply equally to dual use of vape and VLNC. Patterns of use of other nicotine products with VLNC in an open market, including by individuals abusing other substances 8 or challenged by mental illness, could help to assess what might be wrought by a mandatory VLNC policy 18. Applying simplified models of what will happen in complex systems often goes wrong 19. How an inventive public might actually use VLNC alongside other nicotine/tobacco products, possibly to achieve continued satisfaction, will probably influence how long they will use VLNC and any resultant therapeutic and individual or public health effects. The author has previously written critically of the mandatory low-nicotine strategy.
Source: Addiction
DOI: 10.1111/add.13598
Author: Lynn T. Kozlowski
Institution: University at Buffalo, State University of New York
Language: English
Subfield: Physiology (medical)
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2552604486