2nd June 2017, Volume 130 Number 1456

Trish Fraser, Anette Kira

One strategy among many proposed for accelerating reductions in smoking prevalence is reducing nicotine content of tobacco.1 This would expose new smokers to less nicotine, ensuring that they would be less likely to become addicted smokers,2 and current smokers would increase quitting behaviour.1

Very low nicotine content (VLNC) cigarettes with a non-addictive nicotine level are defined as <2mg nicotine content and <0.05mg nicotine yield per stick.1 This compares to cigarettes sold in New Zealand, which fall within a range of 5.6–12.4mg nicotine content.3

A policy that only allows VLNC cigarettes to be sold was first proposed in 19944 and then advocated by the American Medical Association.5 Initially, it was proposed that a VLNC cigarette-only strategy should be gradually implemented,5 but the WHO is now recommending that an immediate reduction of nicotine would be a better approach for practical reasons.6

Despite the potential of a VLNC cigarette-only policy, it has not been implemented by any government, indicating it may not be achievable7 and there may be some challenges. The WHO warns that a VLNC cigarette-only policy should not be implemented without capacity for market surveillance and product testing, and sufficient resources to implement it.6 It is a controversial policy with critics arguing it is ‘de facto prohibition’ of high nicotine content (HNC) cigarettes without acceptable alternatives,8,9 such as electronic cigarettes (e-cigarettes). Worldwide e-cigarettes are increasing in popularity among smokers10 and have recently been suggested as a viable alternative to tobacco that could be part of a more comprehensive and integrated nicotine policy.2 Concern has been raised about smokers increasing the intensity of smoking (‘compensatory smoking’),11 thereby increasing their intake of toxins, but recently this has largely been discredited.2,12,13 New Zealand has a comprehensive tobacco control programme and could potentially be the first country to implement a VLNC cigarette-only strategy. This is supported by a call from public health experts2 but countered by the argument that there is not enough evidence for any government to implement such a policy, even with an advanced tobacco control programme.8

To understand if a VLNC cigarette-only policy would be acceptable to key stakeholders (stakeholders) and smokers in New Zealand, and would be feasible to implement, it is necessary to understand their viewpoints. Stakeholder views, whether supported by evidence or not, can assist or hinder public health policies. Other controversial areas, such as genetic studies, have argued the importance of understanding stakeholder views.14 No study, except an unpublished thesis in 2002, has investigated smokers’ or stakeholders’ opinions relating to a VLNC cigarette-only policy.15 The qualitative study found there was not enough scientific evidence to support the introduction of a VLNC cigarette-only policy or political and public acceptability.15

The aims of this study were to investigate views held by stakeholders and smokers on VLNC cigarettes and a VLNC cigarette-only policy. As part of the investigation we repeated an in-depth examination of stakeholders’ and smokers’ views on a VLNC cigarette-only policy, conducted originally in 2002.15

Methods

This qualitative study was conducted between January and September 2015.

Selection criteria

Selection criteria were guided by the method described in the Fraser 2002 study.15 Participants taking part in that research were politicians, government health officials, health reporters and tobacco control experts, smokers and ex-smokers.15 Each participant group was analysed for their contribution to the study outcomes. For this study, we included non-health experts and political commentators but excluded ex-smokers. Inclusion criteria were smokers (over 16 years and smoked daily) and stakeholders (politicians associated with health or party leaders, government health officials with a responsibility for tobacco control, treasury advisers with regulatory experience, tobacco control and smoking cessation experts and tobacco or nicotine industry scientists with tobacco and/or nicotine manufacturing experience). Exclusion criteria were: pregnant smokers. Māori smokers were identified as a priority audience due to high rates of smoking.16

Recruitment

A purposive sampling strategy was used to recruit at least 16 stakeholders, with snowball sampling used when necessary. Focus groups were used to recruit at least 16 smokers.

Stakeholders

We contacted potential participants by email and invited them to be interviewed by telephone. We selected this method of interviewing for convenience and due to budgetary constraints. Stakeholders interested in participating were emailed participant information sheets and consent forms, which they signed and returned to the lead researcher.

Smokers

We recruited smokers for two focus groups through community newspapers and referrals from a Māori community organisation in Christchurch and a marae in Wellington. Focus groups were subsequently held on the marae and on the premises of the community organisation.

Interviews and focus groups

Stakeholders

An interview schedule was developed to guide the interview process with stakeholders. (See Table 1).

Table 1: Interview schedule—key stakeholders.

Open-ended semi-structured questions about VLNC cigarettes and a VLNC cigarette-only policy

1.    Can you give me a bit of background information on the work you do and how it relates to tobacco control?

2.     What do you think of the present tobacco control programme in New Zealand?

3.     Have you ever heard of VLNC cigarettes? If yes, what do you know about them? Do you know what they are?

4.     Do you think that VLNC cigarettes should be available in New Zealand? If yes, why? If no, why not?

5.     If VLNC cigarettes were available in New Zealand do you think that smokers would be interested in smoking them? If yes, why and do you think they should be available? If no, why not?

        Lead researcher informed participant of the potential benefits of low-nicotine cigarettes and a mandated VLNC cigarette-only policy, such as prevention of addiction to nicotine, reduction of tobacco dependence leading to increased quitting smoking and that a VLNC cigarette-only policy might be the best policy option for VLNC cigarettes as it reduces the risk of smokers smoking both low and HNC cigarettes.

6.     Should there be a VLNC cigarette-only policy in New Zealand? If yes, why? If no, why not?

7.     What do you think a VLNC cigarette-only policy should include/restrict?

8.     What are the potential benefits or risks of introducing a VLNC cigarette-only policy in New Zealand?

9.     How acceptable do you think a VLNC cigarette-only policy would be to: Policymakers? Health workers? Politicians? The general public? Smokers?

10.   What do you think of such a policy, which would restrict the sale of cigarettes to only VLNC cigarettes?

11.   What practicalities would need to be considered as part of implementing the policy?

12.   Should implementation of a VLNC cigarette-only policy be sudden or gradual? Why?

13.   Should the government promote the introduction of such a VLNC cigarette-only policy to the public to gain support? If yes, why and how? If no, why not?

14.   What might the costs of implementation be?

15.   What extra support should be made available to smokers to help them manage their withdrawal from nicotine?

16.   What sort of unintended consequences might there be if a VLNC cigarette-only policy was to be implemented?

17.   What would the impact be on socioeconomic and ethnic inequalities?

18.   How would a VLNC cigarette-only cigarette policy ‘fit’ with international tobacco control strategies?

19.   Any further comments?

The range of duration of the interviews was 20 minutes to one hour.

Smokers

A focus group schedule was developed to guide the groups (see Table 2). Participant information sheets, consent forms and self-completing questionnaires were distributed to participants at the focus groups to complete. Consent forms were signed and returned with completed questionnaires to the lead researcher, who facilitated the focus groups.

Table 2: Focus group and interview schedules—smokers.

Semi-structured open-ended questions on VLNC cigarettes and a VLNC cigarette-only policy

1.     Have you ever heard of VLNC cigarettes? If yes, what do you know about them? If not, have you heard of them as reduced nicotine cigarettes, nicotine-free cigarettes, denicotinised cigarettes, denics or non-addictive cigarettes?

2.     Do you think that VLNC cigarettes should be available in New Zealand? Why/why not?

3.     If they were to be available, how should they be available in New Zealand? Would you be interested in smoking them?

        Lead researcher informed the participants of the potential benefits of VLNC cigarettes and a mandated VLNC cigarette-only policy, such as prevention of addiction to nicotine, reduction of tobacco dependence leading to increased quitting smoking and that a VLNC cigarette-only policy might be the best policy option for VLNC cigarettes as it reduces the risk of smokers smoking both low and HNC cigarettes.

4.     Do you think that the government should consider introducing a low nicotine policy in New Zealand? Why/why not? If yes, what should this policy include/restrict?

5.     What are the potential benefits or risks to this policy?

6.     What might happen if the policy were to be introduced? Would it be acceptable to you and other smokers? How would you react?

7.     If the policy were implemented, should the government promote it to the public to gain support and increase public awareness? Why/why not? If yes, how?

8.     What potential issues and obstacles could arise from such a policy?

9.     What extra support could be made available to smokers to help them manage their withdrawal from nicotine?

10.   Any further comments?

Post-focus group interview schedule (after participants had smoked VLNC cigarettes)

1.    What did you think of the experience (ie, taste, smell, feel) of smoking VLNC cigarettes?

2.     If low-nicotine cigarettes were available in New Zealand would you be interested in smoking them? If yes, how do you think they should be available?

3.     Do you think the government should consider introducing a low nicotine policy? Why/why not?

4.     What should such a policy look like?

5.     What extra support could be made available to smokers to help them manage their withdrawal from nicotine? 

A gift of $30 was given to each participant as well as a light lunch. At the end of the focus groups, participants were given approximately 15 VLNC cigarettes (MAGIC brand, 22nd Century, USA, 0.07mg nicotine content, mean 0.04mg nicotine yield) to take home and smoke. The duration of the focus groups was 24 minutes.

Smokers who attended the focus groups were contacted approximately one week later and interviewed by telephone (see Table 2). The range of duration of the interviews was from 1–8 minutes.

Analysis

Interviews and focus groups were recorded and transcribed. We utilised interpretivist and pragmatist research paradigms to gain an understanding of participants’ views on reducing nicotine content in cigarettes and gather information to assist any future policy development.17 Data were analysed using a general inductive approach. An initial analysis to form main themes and sub-themes, and select quotations was conducted by AK using NVivo software. The analysis was carefully read and criticised by TF. Disagreements were resolved through discussion between AK and TF.

Data collected on stakeholders’ and smokers’ characteristics were entered into an Excel spreadsheet and simple counts calculated.

Ethical approval

Ethics approval for this study was obtained from the Ministry of Health, Health and Disability Ethics Committee (Ethics Number 14/STH/217).

Results

Twenty-seven stakeholders were contacted, 10 refused to be interviewed or did not respond. We had some difficulty recruiting according to our criteria, so minor changes were made to ensure similar representation of stakeholders (see Table 3).

Table 3: Stakeholder characteristics (N=17).

Category

Id number

Gender

Ethnicity

Political people

Politicians x3

Political 1

F

NZ European

Political 2

M

NZ European

Political 3

F

Māori

Political commentator

Political 4

M

NZ European

Government people

Government health official

Government 1

M

NZ European

Ex-government health Official

Government 2

M

NZ European

Ex-treasury official

Government 3

M

NZ European

Commercial people

Tobacco company employee

Commercial 1

M

English

E-cigarette retailer

Commercial 2

M

Māori

Tobacco retailer

Commercial 3

F

NZ European

Nicotine expert (employed by tobacco company)

Commercial 4

M

English

Health people

Tobacco control experts x4

Health 1

M

NZ European

Health 2

M

NZ European

Health 3

F

Pacific

Health 4

F

Māori/ NZ European

Smoking cessation experts x2

Health 5

F

Māori/ NZ European

Health 6

F

Māori

We recruited 21 smokers (see Table 4).

Table 4: Smoker characteristics (N=21).

Age

16–30

4

31–45

10

46+

7

Gender

Male

5

Female

16

Ethnicity (multiple responses)

NZ European

9

Māori

14

Pacific

2

Did not answer

1

Time to first cigarette

Non-daily

1

Within five mins

7

6–30 mins

9

31–60 mins

1

After 60 mins

3

Tried to quit during last 12 months

Yes

17

No

3

Did not answer

1

Seventeen smokers were interviewed following focus groups. Four did not answer their phone, respond to messages left on their answerphone or respond to text messages. One interview had to be discarded because the participant did not smoke any of the VLNC cigarettes given to him.

Three key themes and sub-themes were identified in the data.

Negative views of VLNC cigarettes

Did not like the taste of VLNC cigarettes

Before smoking VLNC cigarettes, smokers were generally interested in them when they first heard about them. However, most did not like the cigarettes for a range of reasons, in particular the unpleasant taste and smell of them.

“At the group [focus] I thought ‘this will be interesting’ but once I tried, no, no, they were just terrible.” Smoker (after smoking VLNC cigarettes)

“It [a VLNC cigarette] didn’t really have a taste, it didn’t smell too good and yeah it just had an awful smell ...” Smoker (after smoking VLNC cigarettes)

However, a couple of smokers were slightly more positive about the cigarettes.

“I actually thought they were okay.” Smoker (after smoking VLNC cigarettes)

The taste of VLNC cigarettes is a problem.

“They don’t taste as good as ordinary cigarettes. That’s the main problem.” Health 1

VLNC cigarettes still harmful

Several stakeholders and smokers stated that VLNC cigarettes could still cause harm to smokers.

“… ban all cigarettes … cause I think they’re going to be just as harmful because they’re full of chemicals.” Smoker (prior to smoking VLNC cigarettes)

There were concerns that VLNC cigarettes might be perceived as being healthy.

“I don’t know whether you want to put those words [healthy] next to something that’s still cigarettes.” Political 3

Lack of support for a mandated VLNC cigarette-only policy

Most stakeholders and smokers did not want a VLNC cigarette-only policy to be implemented in New Zealand.

“I don’t think the case has been made yet to mandate the removal of nicotine from tobacco and I think it would be hard to make that case without better evidence.” Government 3

Lack of freedom of choice was considered an issue by a couple of participants.

“We’ll have no choice, it’ll be like North Korea.” Smoker (before smoking VLNC cigarettes)

“First and foremost there would be freedom of choice. I would say there would be a pretty big storm if they were to disallow full strength cigarettes and bring in very low-nicotine cigarettes.” Commercial 2

However, a few stakeholders (health) thought that mandating only VLNC cigarettes be available was important.

“I think if they were only selling low-nicotine cigarettes that they would work.” Health 3

Equally, a couple of smokers thought that if VLNC cigarettes were the only cigarettes on the market people might quit smoking, as they would not like the taste of them.

“If it’s going to be the only cigarettes then people are going to have to smoke them and if they don’t like them, then they won’t want to smoke them will they? Smoker (after smoking VLNC cigarettes)

Difficult to implement

Practically, it was considered that it would be quite complicated, difficult and time-consuming to introduce a VLNC cigarette-only policy.

“You have to have a mandated method of testing the nicotine content so that you can always guarantee that a reduced nicotine cigarette is in fact reduced nicotine.” Health 1

“… if we couldn’t create product [VLNC cigarettes] for the market that [pulling out of the market] would be I guess a consequence … the practicalities of creating these products [VLNC cigarettes] might be insurmountable.” Commercial 1

Negative consequences of a VLNC cigarette-only policy

Negative consequences that could result from a mandated VLNC cigarette-only policy were highlighted. The tobacco industry would be likely to make it very difficult for the government to implement such a policy, eg, not manufacturing VLNC cigarettes for New Zealand and essentially changing the policy to one of prohibition.

 “You could probably expect two consequences [from the tobacco industry] ... a very hard fight, pulling out all stops we’ve seen on things like tobacco plain packaging … you could probably conjecture that equally they might play a brinksmanship game and threaten to actually pull out of the country altogether.” Government 1

VLNC cigarette-only policy has never been implemented

Several stakeholders thought that because no other country has a VLNC cigarette-only policy, politicians would be nervous about introducing such a policy.

“That’s going to make it difficult [that no other country has a mandated VLNC cigarette-only policy]. That would make our politicians nervous I would think, especially this Government.” Health 1

On the other hand, a couple of the health stakeholders thought that New Zealand would be a good place to try implementing a VLNC cigarette-only policy.

“New Zealand’s a great place to try [a VLNC cigarette-only policy] because of our border and our current tobacco framework … countries can see how it could be done.” Health 6

While the policy has not been implemented anywhere in the world, some stakeholders were aware of discussions happening internationally about implementing a VLNC cigarette-only policy, particularly in the US.

“… the FDA was saying that they can regulate nicotine containing products. They can regulate it down, they just can’t regulate it out.” Government 1

Not a priority

A couple of politicians thought that other tobacco control policies were a higher priority.

“We need to take the steps to making plain packaging part of our legislation and then we also need to go to the smokefree cars where children are present. That would be the next move and then the low nicotine.” Political 3

E-cigarettes

E-cigarettes were suggested by several stakeholders as an effective alternative product or addition to a VLNC cigarette-only policy to reduce smoking.

 “I don’t think e-cigarettes are the sole answer. I don’t think there’s any magic bullet out there, but I think there’s a strong case as part of a spectrum of alternatives for smokers.” Commercial 4

“I certainly think that the e-cigarettes present a much better way of dealing with those health issues. Political 4

“… so it would be a staged reduction … and doing it that way I think would be quite good, quite acceptable and the e-cigarettes would provide a bit of a backdrop, like they would provide nicotine in other ways.” Health 1

VLNC cigarettes should be available for sale as an option

While most stakeholders and smokers were not in favour of a VLNC cigarette-only policy, they were in favour of VLNC cigarettes being available for sale in New Zealand as an option for smokers.

“I think that it [VLNC cigarettes] could help a lot of people, maybe not myself but others, or give them the option anyway.” Smoker (after smoking VLNC cigarettes)

“Absolutely I’ve got no doubt at all that they [VLNC cigarettes] should be available as one option.” Political 4

VLNC cigarettes would need to be cheaper than HNC cigarettes

Despite generally not liking the taste of VLNC cigarettes, most smokers stayed with the opinion that they should be available on the market provided they were much cheaper price than HNC cigarettes.

“Cost would need to be around $3 a pack.” Smoker (after smoking VLNC cigarettes)

A differentiated tax on tobacco was thought to be a good way to encourage smokers to smoke VLNC cigarettes rather than their usual HNC cigarettes.

“Some people have suggested a differentiated tobacco excise tax levied on nicotine content rather than tobacco content … have a graduated taxation base or tax the hell out of HNC cigarettes to the exclusion of low-nicotine cigarettes and e-cigarettes for a period.” Government 1

“I have no problem with them being clearly labelled high nicotine or even the potential for different prices for the different levels of nicotine, but as a blanket ban on high nicotine, I personally disagree with that.” Political 4

Regulations would be needed

There was agreement that VLNC cigarettes should have to comply with the same regulations and legislation as HNC cigarettes.

“They [VLNC cigarettes] cause the same harm so they should be subject to the same requirements in terms of age restrictions, product displays, sale in whole packets, advertising controls.” Government 3

One suggestion was that all tobacco brands should be required to have a VLNC cigarette option in addition to their HNC cigarettes.

“We would support the availability of these products [VLNC cigarettes] and probably a requirement that said every cigarette brand had to have this variant.” Commercial 3

Discussion

Despite the potential of VLNC cigarettes to assist a reduction in smoking prevalence, a VLNC cigarette-only policy was not popular with many of the stakeholders and smokers in this study. Reasons are complex and varied. For stakeholders, while they are interested in such a policy, there is a belief that there is not enough evidence for it yet, it would be politically difficult to implement and it is not a priority for policy makers. For smokers, most did not like the taste of the cigarettes and they were concerned that the most harmful components remained in the cigarettes.

Many of the stakeholders and smokers expressed a preference for VLNC cigarettes to be available on the market in addition to HNC cigarettes. However, cigarettes with low nicotine content have been available for sale previously with very little success due to a lack of smoker interest.18 While smokers do not generally like VLNC cigarettes1,18 some thought there was a place for them on the market if they were much cheaper than HNC cigarettes and particularly for smokers wishing to quit. Smokers in New Zealand would be reluctant to purchase VLNC cigarettes unless there was a significant price differential, such as $15–$16.1 Differential taxation on VLNC and HNC cigarettes was suggested by several stakeholders, and while it may not necessarily be the best policy option for VLNC cigarettes, it could still be an effective option for the New Zealand government to reduce smoking prevalence.1

A limitation of the study was that it was a small qualitative study, and while the results represent the breadth of participants’ views, they do not represent the views of all key stakeholders and smokers in New Zealand. Participants were informed of the benefits of VLNC cigarettes but not the potential harms, drawbacks and alternative approaches. However, many of the questions initiated discussion on the potentially negative effects of the cigarettes. The study does have some strengths. It is the first time that smokers have been asked for their views on a VLNC cigarette-only policy before and after smoking VLNC cigarettes. Smokers in New Zealand are very supportive of reducing the addictiveness of cigarettes even if smoking would be less pleasurable,19 but this study has given smokers the opportunity to experience the actual taste of VLNC cigarettes and then comment. Another strength is the high percentage of Māori smokers (68%) who participated in this study, which is important because of high rates of smoking among Māori.16

If the New Zealand government were to implement a significant differential taxation on very low and HNC cigarettes in combination with better access to nicotine containing e-cigarettes, smokers may shift away from HNC cigarettes. This variation on a VLNC cigarette-only policy would be a world first, have the potential to help New Zealand achieve its Smokefree 2025 goal (<5% smoking)20 and be relatively easy for the government to implement.

Summary

Very low-nicotine cigarettes are cigarettes that are not addictive. If they were the only cigarettes on the market they could help smokers to quit and young people taking up smoking would not become addicted. However, the cigarettes have very little appeal to smokers, who would generally only be interested in them if they were wanting to quit. Most policy makers, politicians and participants with a commercial interest in cigarettes did not believe any government would be interested in reducing nicotine levels significantly in all cigarettes. Most of the participants thought very low-nicotine cigarettes should be available for sale at a much cheaper price, and policy makers and health people in particular thought alternative nicotine products should also be available to help smokers make the switch from high-nicotine cigarettes.

Abstract

Aim

To investigate views of New Zealand key stakeholders (stakeholders) and smokers on very low nicotine content (VLNC) cigarettes, and a policy mandating that only VLNC cigarettes are available for sale.

Method

Using a semi-structured interview schedule, we interviewed 17 stakeholders and held focus groups with 21 smokers. Questions were asked about VLNC cigarettes and a VLNC cigarette-only policy. Smokers were given approximately 15 VLNC cigarettes to take home and smoke. One week after the focus groups, 17 smokers were interviewed. Data were analysed using a general inductive approach.

Results

Stakeholders and smokers were largely unconvinced of the value of a mandated reduction in nicotine in cigarettes. After smoking VLNC cigarettes, smokers had less interest in them but would support them being sold alongside high nicotine content (HNC) cigarettes at a much cheaper price.

Conclusion

The government is not likely to mandate nicotine reduction in cigarettes if there is a perceived lack of support from stakeholders or smokers. However, they could make VLNC cigarettes available as an option for smokers utilising a differential tax favouring VLNC cigarettes. If this were combined with better access to nicotine containing e-cigarettes, smokers may shift away from HNC cigarettes.

Author Information

Trish Fraser, Director, Global Public Health, Glenorchy; Anette Kira, Independent Researcher, Manawatu.

Acknowledgements

We thank all the participants in this study. We are grateful to Associate Professor Marewa Glover and Professor Chris Bullen for comments on the draft paper.

Correspondence

Trish Fraser, Director, Global Public Health, PO Box 82, Glenorchy 9350.

Correspondence Email

trish@tukuwahaglenorchy.com

Competing Interests

Nil.

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