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There has been long-standing interest in a reduced-nicotine product standard for combusted tobacco, which is within the regulatory purview of the Food and Drug Administration (FDA). In weighing whether to establish this standard, it is important to consider potential responses among people who are at elevated risk for tobacco-related health harms. In this narrative review, we summarize studies of very low nicotine content (VLNC) cigarettes conducted between 2010 and 2021 in groups that the FDA has identified as vulnerable populations. Studies conducted to date in adults with mental health conditions, adults with opioid use disorder, socioeconomically-disadvantaged adults, and youth or young adults indicate that immediate switching to VLNC cigarettes decreases smoking, with minimal or no unintended negative consequences. Few studies have investigated the effects of VLNC cigarettes in racial or ethnic minorities, people who smoke menthol cigarettes, and pregnant women, but initial findings suggest that responses of these individuals are similar to responses observed in other vulnerable populations. We are not aware of studies that have investigated VLNC cigarettes in military/veteran populations, sexual or gender minority individuals, or people living in underserved rural environments. Future research directions include understanding how to promote cessation in the context of a reduced-nicotine standard, and how to correct VLNC misperceptions in vulnerable populations. Nevertheless, the evidence to date indicates that a reduced-nicotine standard is likely to have the same beneficial effects on smoking reductions as it does in less vulnerable populations, which should provide some confidence in pursuing this regulatory approach.

Smokers unwilling to make a quit attempt can still benefit from smoking intervention. However, it is unclear what proportion of smokers will enter such a Motivation phase intervention, and whether such an intervention attracts different types of smokers than does abstinence oriented treatment. We conducted a study from June 2010 to October 2013 based on a chronic care model of tobacco treatment among study eligible primary care patients (N=1579; 58% women, 89% White) presenting for regular health care visits in southern Wisconsin, U.S. Medical assistants, prompted via the electronic health record (EHR), invited smokers (n=10,242) to learn more about treatment options to help them either reduce their smoking or quit. Of those invited to learn more who were then reached by study staff, 10.2% (n = 1046) reported interest in reduction treatment and 24% (n = 2465) reported interest in cessation treatment. Patients who selected and ultimately entered reduction (n=492) versus cessation (n=1087) were more likely to report: older age; a history of anxiety; lower motivation to quit; lower primary dependence motives; more close friends or family who smoke; and a greater interval since their last quit attempt (ps

Smokefree environment created by smokefree policies is associated with smoking reduction; however, there is paucity of literature on the relationship between smokefree home rules and smoking intensity in low-and-middle income countries (LMICs), and how smokefree policy affects smoking behavior of smokers at different stages of smoking cessation. This study examined the relationship between smokefree home rules and average number of cigarettes smoked per day (CPD) among daily smokers at different stages of the transtheoretical model (TTM) of change. Data from 18,718 current daily cigarette smokers from the Global Adult Tobacco Survey (GATS) conducted from 2011 to 2017 in 20 LMICs were analyzed. Weighted multivariable linear regression analyses were conducted using the log of CPD as the outcome variable with smokefree home rules as the exposure variable, controlling for selected covariates. Approximately 15% of the participants were in precontemplation, 5% were in preparation, 15% lived in partial smokefree homes, and 30% lived in complete smokefree homes. The average number of CPD was 12.3, 12.0, and 10.6 among participants living in homes where smoking was allowed, partial smokefree homes, and complete smokefree homes, respectively. Compared to living in homes where smoking was allowed, living in complete smokefree homes were associated with 22.5% (95%CI = 18.4%–26.5%), 17.9% (95%CI = 8.4%–27.3%), and 29.3% (95% CI = 17.1%–41.5%) fewer CPD among participants in precontemplation, contemplation, and preparation stages, respectively. These findings suggest that complete smokefree home policy will benefit smokers in LMICs irrespective of their intention to quit smoking in addition to protecting non-smokers from secondhand smoke exposure.

INTRODUCTION. U.S. reductions in smoking have not been experienced equally. Smoking prevalence is greater among persons of lower education, lower income, and unemployed. We evaluated whether a cessation intervention for job-seekers would result in significantly fewer cigarettes smoked per day and a greater likelihood of tobacco abstinence and re-employment, compared to the control condition at 6-months follow-up. METHODS. Unemployed, job-seekers who smoked daily were recruited from five employment development departments in the San Francisco Bay Area, October 2015 to February 2018. Intention to quit smoking was not required. Participants were randomized to a brief motivationally-tailored, computer-assisted counseling intervention or referred to a toll-free quitline. Midstudy, 8-weeks of combination nicotine replacement was added to the intervention. Expired carbon monoxide and cotinine testing verified abstinence. Data were analyzed fall 2019. RESULTS. Participants (N=360; 70% men; 43% African American, 27% non-Hispanic Caucasian; 19% unhoused) averaged 12 cigarettes/day (SD=6), 67% smoked within 30 minutes of wakening; 27% were in preparation stage to quit. During the 6-month study period, intervention participants were more likely to make a quit attempt (71% vs. 58%, p=.021) and reported significantly greater reduction in cigarettes/day than control participants (median reduction: 6.9 vs. 5.0, p=.038); however, bioconfirmed abstinence (3%) and re-employment (36%) did not differ by treatment group. CONCLUSIONS. In a diverse sample with economic hardships, quit attempts and smoking reduction were greater in the intervention group; however, few achieved abstinence, and neither abstinence nor re-employment differed by condition. A priority group, further research is needed on smoking and re-employment. CLINICAL TRIALS REGISTRATION: NCT02478697, https://clinicaltrials.gov/ct2/show/NCT02478697

Objective To assess whether smoking ban policies are associated with smoking reduction and quit attempts among California smokers. Methods Data were examined for 1718 current smokers from follow-up telephone interviews conducted in 2011 of persons previously identified as smokers in a representative sample of the adult population of California. Population weighted logistic regressions controlling for demographic and other variables were used to evaluate the association between smoking ban policies (home, work, and town) and changes in tobacco use (past year quit attempt or reduction in smoking rate). Results Living in a home with a total ban was significantly associated with smoking reduction (adjusted odds ratio, AOR: 2.4, 95% CI: 1.4–4.2) and making a quit attempt (AOR: 2.3, 95% CI: 1.3–3.9) compared to living in a home with no home ban. Self-reported perception of an outdoor ban in one's city/town was associated with smoking reduction (AOR: 1.7, 95% CI: 1.02–2.7) and making a quit attempt (AOR: 1.8, 95% CI: 1.05–2.9). Conclusion These results indicate that smoking bans not only protect nonsmokers from the harms of secondhand smoke, but are also associated with smoking reduction and cessation.

Objective To describe the factors associated with smoking reduction in a population-based cohort study in Cornella de Llobregat (Barcelona, Spain). Material and methods We used data from the Cornella Health Interview Survey Follow-up Study ( n = 2,500). We included for the analysis those subjects who declared to be daily smokers at baseline (1994) and continued smoking after eight years of follow-up ( n = 234). We considered as operational definition of reduction to reduce ≥10 cigarettes/day. We calculated the relative risk (RR) of smoking reduction vs. maintain or increase tobacco consumption and 95% confidence intervals (CI) by means of a Breslow–Cox regression model. Results The average reduction on number of cigarettes among subjects who reduced their tobacco consumption was similar in men and women (13 cigarettes/day). The consumption intensity and self-perceived health are the characteristics associated with reduction: smoking reduction was associated with being a smoker >20 cigarettes/day (RR = 3.25; 95% CI: 1.69–6.25) and individuals who declared having a suboptimal health showed a 3-fold risk of reducing smoking (RR = 3.13; 95% CI: 1.52–6.43). Conclusion Heavy smokers and smokers with poor health are those smokers more likely to reduce their tobacco consumption. Specific actions targeting them could lead to increase reduction and even smoking cessation.

Background. The aim of this study was to examine the extent and gender distribution of unassisted tobacco reduction and cessation in a cohort of moderate and heavy smokers and to identify possible predictor variables associated with these changes in smoking behavior. Methods. This was a prospective population study of 3,791 moderate and heavy smokers, 15 g tobacco/day or more, who were enrolled in the Copenhagen City Heart Study in 1976–1978 and attended a reexamination 5 years later. Data on smoking behavior were collected at baseline and follow-up. Smoking reduction was defined as a decrease in mean daily tobacco consumption of 10 g or more. Using multivariate logistic regression, subjects who reported reduced smoking or who reported smoking cessation were compared with subjects who continued the habit unchanged. Results. After 5 years 13% of the men and 9% of the women had reduced their tobacco consumption, and 9 and 7%, respectively, had quit altogether. Smoking reduction was strongly associated with high tobacco consumption (25+ g/day) at baseline and also with severely impaired lung function (FEV 1 25). Predictors of smoking cessation included impaired lung function and a tobacco consumption of 15–24 g/day. Additional determinants of smoking reduction and cessation such as inhalation habits and sociodemographic variables differed by gender. Conclusions. Several predictors of smoking reduction and cessation were identified, indicating that these subgroups of smokers differ substantially from continuing smokers. This should be taken into account when assessing potential health benefits from these changes in smoking behavior.

Background. This paper describes a natural, prospective, open-label study designed to evaluate the impact of free nicotine patches with minimal support for smoking cessation. Methods. Surveys were administered to 223 participants who received nicotine patches from the American Lung Association. All participants received a 6-week supply of 15-mg/16-h transdermal nicotine patches, a self-help book Freedom from Smoking , and information about area smoking cessation classes. Follow-up telephone surveys were administered 6 weeks after the patches were distributed. Abstinence was measured through self-report exclusively. Results. The overall quit rate at 6-weeks was 21% (47/223). Among nonquitters, the mean number of cigarettes smoked per day dropped from 25 at baseline to 14 at 6 weeks. There was a significant difference in the average number of patches used by quitters and nonquitters (26 versus 11, P Conclusions. Nicotine patches with minimal support can be effective in smoking cessation and smoking reduction. The availability of patches may have motivated participants to quit. Efforts to increase access to and use of nicotine patches may result in increased attempts to quit and successful quitting.

Background. In Canada, with universal single-payer health care insurance and a lower proportion of the gross domestic product going to health care costs, employers may be less motivated than their U.S. counterparts to develop health promotion programs for their employees. This study determined the extent to which nongovernmental workplaces in Canada have made smoking-related information, policies, and programs available to their employees. Several characteristics of those workplaces most likely to have engaged in such activities were identified. Methods. A secondary analysis of data collected in the 1992 National Workplace Survey was conducted. All Canadian provinces, except Saskatchewan, were included. Dunn and Bradstreet's register of companies was used to select companies randomly from those with 20 or more employees. Questionnaires were distributed to 10,000 workplaces. The response rate was 35.5% ( N = 3,549). There were no significant differences found between responders and nonresponders in a phone survey. Results. One-half of workplaces reported some kind of smoking-related initiative. Most of the initiatives were smoking policies; only 11.7% of workplaces provided smoking cessation programs. The number of employees and the number of other lifestyle and occupational health and safety programs available are most predictive of smoking-related programs. Conclusion. If Canadians are going to achieve a smoke-free society, greater efforts to assist smokers to quit will be necessary. The workplace provides an excellent opportunity for such efforts. Health promotion advocates must communicate the cost savings and other benefits to employers garnered from workplace smoking reduction efforts.

Background. Smoking is associated with a large burden of illness in both developed and developing countries. Effective prevention of the uptake of smoking and achieving high rates of smoking cessation are essential to significantly reducing this problem. Therefore, researchers have sought to identify effective smoking reduction strategies which might be implemented in the community. Despite this wealth of research, making choices from among the available strategies with demonstrated effectiveness remains a difficult task. Methods. The study aimed to explore the level of agreement among experts on the perceived relative effectiveness and cost effectiveness of 29 smoking reduction strategies in a given environment. Experts were selected at random from tobacco control organizations in Australia. Fifty experts completed a mailed questionnaire. Results. It was found that there was little agreement among the experts regarding the perceived relative effectiveness and cost effectiveness of 29 smoking reduction strategies. Conclusions. It was concluded that the results suggest that experts may not be able to provide clear and consistent direction to health organizations on how best to reduce smoking rates. This is a concern given the current need for an effective, well-targeted worldwide attack on tobacco-related mortality and morbidity.

Background. Smoking reduction has been introduced as an alternative to smokers unable or unwilling to quit but has never been implemented in a population-based intervention. Methods. Two thousand four hundred eight daily smokers in all motivational stages were included in a randomised population-based intervention study, in Copenhagen, Denmark. Smokers, unwilling or unable to quit, were encouraged to reduce their tobacco consumption. Furthermore, smokers in the high-intensity intervention were offered participation in smoking reduction groups. Results. Twenty-three percent of those who attended both baseline and 1 year visit reported reduction by at least 5 g and 8% reported a halving or more. Halving of tobacco consumption was achieved significantly more often than in the background population, OR = 2.6 (1.6–4.4), even when assuming that non-participants had not reduced, OR = 1.7 (1.0–2.8). Reduction of at least 5 g doubled the probability of increased motivation to quit and a halving increased it more than four times. The reductions were not validated. Less than 2% attended the smoking reduction groups. Conclusion. The smoking reduction intervention was significant in self-reported reduction of tobacco consumption and subsequently increased motivation to quit. This may open new perspectives, with reduction as a first step towards cessation, a possible supplement to smoking cessation strategies.

Background. Smoking during pregnancy is associated with reduced birthweight; this relation can be reversed by smoking cessation. Somebut not all previous studies have shown that smoking reduction (measured as cigarettes/day or urinary cotinine) may also improvebirthweight. The relationship between maternal and spouses’ expired air carbon monoxide (CO) concentrations (EACO) on fetal growth hasnot yet been evaluated.Methods. Eight hundred fifty-six smoking and nonsmoking pregnant women were followed during their pregnancy. Their EACO wasdetermined in the first trimester and during delivery. The spouses’ EACO were also measured at delivery. The main outcome measure was theinfants’ birthweight. Secondary measures included head circumference, Apgar score, and heart rate at delivery. Cord blood fetalcarboxyhemoglobin (FCOHb) served as internal control.Results. Birthweight dose-dependently and significantly decreased with increasing level of maternal (0–5: 3406 F 32; 6–10: 3048 F 57;11–20: 2858 F 54; >20 ppm: 2739 F 34 g, P 20ppm: 3190 F 57 g, P < 0.0001). Even the birthweight of newborns whose mother had EACO between 6 and 10 ppm was significantly lowerthan the birthweight of newborns whose mother had an EACO between 0 and 5 ppm. Spouses’ EACO of delivering women with EACO of0–5 ppm showed similar effect. Head circumference, Apgar score, and normal term gestational age decreased also significantly withincreasing maternal or spouses’ EACO.Conclusions. Both maternal and spouses’ EACO measured during delivery, a proxy of EACO during pregnancy, were dose-dependentlyand inversely associated with fetal growth. Even low maternal (6 to 10 ppm) or spouses’ (11 to 20 ppm) EACO may be associated withsignificantly lower birthweight.D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Background. An outcome evaluation of a high school tobacco control intervention using extracurricular activities developed by teachers and students is reported. Methods. Eligible subjects ( n = 3,028) had participated in a randomized trial of an elementary school smoking prevention curriculum. Their high schools were matched in pairs; one school in each pair was randomly assigned to the intervention condition, the second to a “usual-care” control condition. Data were collected at the end of Grades 9 and 10. Results. For Grade 8 never smokers, regular smoking rates were significantly lower for males from intervention schools (9.8 vs 16.2%, P = 0.02) at the end of Grade 10. There were no significant differences among Grade 10 smoking rates for females, or for students of either gender with previous smoking experience in Grade 8. Conclusions. The extracurricular activities approach to tobacco control is practical to implement and has promise.

Background. Smoking patterns have changed markedly over the past 70 years. Previous studies have shown that examination of smoking patterns within birth cohorts can identify important changes in tobacco adoption and cessation. This paper examines temporal trends in the prevalence of smoking and the age of smoking adoption and cessation for birth cohorts born between 1940 and 1975. Methods. The underlying data were obtained from the Ontario Health Survey (conducted in 1990), which used a multistage stratified area sampling strategy to obtain interviews on 29,843 people age 12 or older. Self-reported smoking histories Swere used as the basis for a reconstructed cohort analysis of prevalence rates. A life events methodology was employed to examine the age at starting smoking and the time of smoking cessation. Results. There has been a steady drop in peak smoking prevalence for men. This trend appears to be continuing among the most recent cohorts. However, for women, peak smoking prevalence increased until the 1960 birth cohort, after which time the peak prevalence has been dropping. Prevalence of smoking was much higher for men then for women among the earlier birth cohorts but, by the 1960 cohort, the prevalence for men and women was essentially the same. Examination of the age of smoking onset reveals that there was a statistically significant interaction between sex and birth cohort on the relative risk of starting smoking. The rate of smoking cessation has increased uniformly across all birth cohorts among both men and women. Conclusions. This study confirms recent trends in smoking reduction and provides no evidence to suggest a diminution of the effect. Trends in recent birth cohorts of women are encouraging. There is a clear need for public health initiatives directed at older children and teenagers in order to further reduce the onset of smoking. Efforts to prohibit advertising directed toward minors, sponsorship of sporting and cultural events, and the sale of tobacco to minors should receive high priority.

The results of the Multiple Risk Factor Intervention Trial showed no significant difference in mortality from coronary heart disease between intervention and control groups despite an apparent success of the intervention against cigarette smoking. A reanalysis of the published data indicates that the effectiveness of the smoking intervention may have been overestimated. The researchers counted those who smoked pipes or cigars at screen as nonsmokers and attempted to classify cigarette smokers who switched to pipes or cigars during the trial as successes whether or not they continued to inhale the smoke. It is unreasonable to assume a priori that inhaling pipe or cigar smoke is less dangerous than cigarette smoke. Moreover, attempting to include pipe and cigar smokers, who may have been inhaling smoke, among the successes makes biochemical validation of claims of abstinence overly lenient. When levels of serum thiocyanate are used to obtain an objective index of smoking reduction, it appears that the effect of intervention was considerably smaller than has been reported, and failed to reach design goals over the first 4 years. This could help to explain the disappointing mortality results.