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Perceived nicotine content of reduced nicotine content cigarettes is a correlate of perceived health risks
  1. Lauren R Pacek1,
  2. F Joseph McClernon1,
  3. Rachel L Denlinger-Apte2,
  4. Melissa Mercincavage3,
  5. Andrew A Strasser3,
  6. Sarah S Dermody4,
  7. Ryan Vandrey5,
  8. Tracy T Smith6,7,
  9. Natalie Nardone8,
  10. Dorothy K Hatsukami9,
  11. Joseph S Koopmeiners10,
  12. Rachel V Kozink1,
  13. Eric C Donny11
  1. 1Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
  2. 2Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, USA
  3. 3Department of Psychiatry, University of Pennsylvania, Philadelphia, USA
  4. 4Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
  5. 5Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, USA
  6. 6University of Pittsburgh Cancer Center, Pittsburgh, USA
  7. 7Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, USA
  8. 8Department of Medicine, University of California San Francisco, San Francisco, USA
  9. 9Department of Psychiatry, University of Minnesota, Minneapolis, USA
  10. 10Division of Biostatistics, School of Public Health,University of Minnesota, Minneapolis, USA
  11. 11Department of Psychology, University of Pittsburgh, Pittsburgh, USA
  1. Correspondence to Lauren R Pacek; lauren.pacek{at}


Background Reducing cigarette nicotine content may reduce smoking. Studies suggest that smokers believe that nicotine plays a role in smoking-related morbidity. This may lead smokers to assume that reduced nicotine means reduced risk, and attenuate potential positive effects on smoking behaviour.

Methods Data came from a multisite randomised trial in which smokers were assigned to use cigarettes varying in nicotine content for 6 weeks. We evaluated associations between perceived and actual nicotine content with perceived health risks using linear regression, and associations between perceived nicotine content and perceived health risks with smoking outcomes using linear and logistic regression.

Findings Perceived—not actual—nicotine content was associated with perceived health risks; compared with those perceiving very low nicotine, individuals who perceived low (β=0.72, 95% CI 0.26 to 1.17), moderate (β=1.02, 95% CI 0.51 to 1.53) or high/very high nicotine (β=1.66, 95% CI 0.87 to 2.44) perceived greater health risks. Nevertheless, individuals perceiving low (OR=0.48, 95% CI 0.32 to 0.71) or moderate nicotine (OR=0.42, 95% CI 0.27 to 0.66) were less likely than those perceiving very low nicotine to report that they would quit within 1 year if only investigational cigarettes were available. Lower perceived risk of developing other cancers and heart disease was also associated with fewer cigarettes/day at week 6.

Conclusions Although the perception of reduced nicotine is associated with a reduction in perceived harm, it may not attenuate the anticipated beneficial effects on smoking behaviour. These findings have implications for potential product standards targeting nicotine and highlight the need to clarify the persistent harms of reduced nicotine combusted tobacco products.

  • Nicotine
  • Public policy
  • Harm Reduction

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  • Contributors LRP and FJM conceptualised the research question and LRP and JSK conducted the statistical analyses. LRP wrote the first draft of the manuscript. All authors contributed to, have critically reviewed and revised, and have approved of the final manuscript.

  • Funding Research reported in this publication was supported by the National Institute on Drug Abuse and FDA Center for Tobacco Products (U54 DA031659). Salary support for LRP during the preparation of this paper was provided by T32 AI007329. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

  • Competing interests None declared

  • Patient consent N/A.

  • Ethics approval The study was approved by the institutional review board at each study site and was reviewed by the FDA Center for Tobacco Products. It was monitored by an independent data and safety monitoring board.

  • Provenance and peer review Not commissioned; externally peer reviewed.