How to “Nudge” Smokers to Reduce Tobacco Use?

Published - Written by James Yeh, M.D. M.P.H.

Reduced-Nicotine Standards Insight Post 9-30-15Health problems due to smoking account for 6 million deaths annually and are the leading cause of death worldwide. Despite the dramatic reduction of smoking rates in the past 50 years in the U.S., nearly 18% of adults are current smokers. Each day 2100 youth and young adults become regular daily smokers. As nicotine sustains tobacco use, several interventions are used to reduce nicotine dependence. Clinicians often can prescribe nicotine replacement treatments or other pharmacologic interventions for patients who are interested in quitting. On a regulatory level, the taxing of tobacco products helped reduce smoking uptake and increase smoking cessation world-wide.

What about other forms of intervention? There is some evidence that low nicotine content cigarettes containing less than 0.7 mg/g of tobacco (different than the so-called “light cigarettes”) can reduce nicotine dependence and increase smoking cessation.

In this week’s issue of NEJM, Donny and colleagues conducted a 6-week multi-site double-blinded clinical trial randomizing over 800 adult daily smokers (self-reported > 5 cigarettes daily) with laboratory evidence of active smoking who are not interested in quitting to either placebo (their usual brand of cigarettes) or to one of 6 investigational cigarettes that contained varying amount of nicotine content or tar level. The primary outcome was the average number of self-reported cigarettes smoked per day during week 6 of the intervention. Additional outcomes included laboratory markers of nicotine product use and subjective assessment of withdrawal.

In the study, those assigned to the low nicotine content cigarettes containing 0.4, 1.3, and 2.4 mg of nicotine per gram of tobacco smoked less than the placebo or the 15.8 mg/g control cigarettes (14.9, 16.3, and 16.5 versus 22 and 21.3 cigarettes daily; p<0.001). Individuals assigned the cigarettes containing 5.2 mg or less of nicotine per gram of tobacco had lower urinary nicotine equivalents than those assigned the control 15.8 mg/g cigarettes (p <0.01). There were no differences in individuals with self-reported withdrawal symptoms among those assigned the low nicotine content cigarettes compared to the placebo and the control nicotine content cigarettes during week 1 or week 6 of the intervention. Individuals assigned 0.4 mg/g nicotine level cigarettes had relatively lower dependence score (p=0.001).

From this 6-week study we learned that cigarettes with 2.4 mg/g or less nicotine helped individuals smoke up to 40% fewer cigarettes per day. The lowest nicotine content cigarettes (0.4 mg/g) reduced nicotine dependence. This suggests that if nicotine content is reduced adequately, smokers may smoke less and be less dependent. The study findings would need to be validated by a longer follow-up period.

In a NEJM Perspective, Fiore and Baker from the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine believe “these data support exploration of a national nicotine-reduction policy, and we recommend that additional attention be paid to low-nicotine cigarettes as a potential clinical smoking-cessation resource”. However, the success of such a policy would be dependent on the application and enforcement of the rules to all nicotine containing tobacco products.

What is your view on the use of such policies to “nudge” people towards healthier lifestyles choices?

How effective are smoking cessation interventions that you implement for your patients?

The authors of these studies are available through October 9th to answer your questions on the NEJM Group Open Forum