Us Smokers' Reactions to a Brief Trial of Oral Nicotine Products

RESEARCH Open Access

US smokers’ reactions to a brief trial of oralnicotine productsRichard J O’Connor1*, Kaila J Norton1, Maansi Bansal-Travers1, Martin C Mahoney1, K Michael Cummings2,Ron Borland2

Abstract

Background: It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery productsto reduce their health risks if informed of the relative risk difference. However, it is important to assess howsmokers are likely to use cigarette alternatives before making predictions about their potential to promoteindividual or population harm reduction.

Objectives: This study examines smokers’ interest in using a smokeless tobacco or a nicotine replacement productas a substitute for their cigarettes.

Methods: The study included 67 adult cigarette smokers, not currently interested in quitting, who were given anopportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewalldissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information aboutthe relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supplyof each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of theirpreferred product to see if using such products reduced or eliminated cigarette use.

Results: After multiple product sampling, participants preferred the Commit lozenges over the three smokelesstobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling forgender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significantdecline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers ofexposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

Conclusions: Findings from this study show that smokers, who are currently unwilling to make a quit attempt,may be willing to use alternative products in the short term as a temporary substitute for smoking. However, thisuse is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather thancomplete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacementproduct over a tobacco-based product.

BackgroundWhile the harms of tobacco smoking have been welldocumented for decades, more than 20% of US adultscontinue to smoke[1]. This seeming lack of progress hasled to interest in harm reduction as a complementarytobacco control strategy, particularly with products thatoffer reduced toxicity to individual users[2]. Two

products that have received substantial discussion aspotential harm reduction options are smokeless tobacco(particularly low-toxin forms such as Swedish snus) andnicotine replacement therapy (medicinal nicotine),which is currently approved only for limited durationuse in smoking cessation[3-7]. However, the promotionof reduced harm products, especially smokeless tobacco,remains controversial. Commonly expressed concernsinclude a lack of reliable data on health risk reduction(as opposed to exposure), impacts on smoking behavior(e.g., dual use and continued nicotine dependence), and

* Correspondence: [email protected] of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY,USAFull list of author information is available at the end of the article

O’Connor et al. Harm Reduction Journal 2011, 8:1http://www.harmreductionjournal.com/content/8/1/1

© 2011 O’Connor et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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the potential attractiveness of products to former andnon-users of tobacco, especially youth[2,8-11]. Furthercomplicating matters is the fact that since 2005, majorcigarette manufacturers have, either through partnershipor acquisition, moved into the smokeless tobacco busi-ness. This has allowed tobacco manufacturers to intro-duce smokers to new smokeless tobacco products foruse in situations where smoking is restricted[12-14].Consumer perceptions and responses are key compo-

nents to understanding the adoption and maintenanceof new and modified tobacco products[15]. The FamilySmoking Prevention and Tobacco Control Act of 2009(FSPTCA) empowers the FDA to regulate tobacco pro-ducts by considering consumer perceptions in decisionsabout regulations “appropriate for the protection of pub-lic health”[16]. So, knowing what users believe aboutproducts, and their reactions to those products, arerecognized to be important to understanding how smo-keless tobacco and medicinal nicotine are likely to beused and thus their potential as substitutes for cigar-ettes. However, independent research has been limitedin this area. Timberlake [17] found only 13% of Califor-nia smokers were receptive to using smokeless tobaccoinstead of smoking. Studies outside North America havefound that 34% of New Zealand smokers and 48% ofAustralian smokers were interested in trying smokelesstobacco[18,19]. Interest in switching from cigarettes toan alternative form of nicotine delivery may depend onsmokers’ preexisting beliefs about alternative products.Data consistently show that consumers incorrectlybelieve nicotine causes cancer,[20-22] and that smoke-less tobacco products are as, if not more, dangerousthan cigarettes[23-26]. So, the information presentedabout products may be an important factor in influen-cing interest. Shiffman and colleagues [27] presentedsmokers with descriptions of both medicinal nicotineand tobacco-based products positioned as smoking sub-stitutes, and found that smokers generally preferred themedicinal nicotine products to the tobacco-based pro-ducts. On the other hand, Heavner and colleagues[28]surveyed smokers in Edmonton, Canada, and reportedthat 75% were willing to try a hypothetical product car-rying 99% less risk than smoking. However, neither ofthese studies involved direct experience.Recently, Carpenter and Gray [29] reported that, com-

pared to continued smoking, use of Ariva or Stonewallcompressed tobacco lozenges reduced cigarette con-sumption and increased intentions to quit. A series ofstudies by Schneider and colleagues [30-32] examinedpreferences among different nicotine replacement pro-ducts, concluding that individuals have varied reactionsto different nicotine delivery modes, and sampling oftreatments can identify key reactions that predict laterquitting success. Caldwell and colleagues [33] found

that, among heavy smokers given two-weeks experience,snus or Zonnic oral nicotine sachet were preferred overnicotine gum. Cobb and colleagues [34] using a series oflaboratory sessions with smokers, showed that non-com-bustible products (Ariva, Camel Snus, Marlboro Snus,Commit) delivered less nicotine than smokers usualbrand of cigarettes and failed to suppress tobacco absti-nence symptoms as effectively as cigarettes. Overall, theliterature suggests that it is important to try to assesssmokers’ reactions to proposed cigarette alternativesbefore making predictions about their potential to pro-mote harm reduction relative to continued smoking.The present study was designed to examine smokers’

interest in using a smokeless tobacco (SL) or nicotinereplacement product (NR) as a substitute for their cigar-ettes. Specifically, we set out to address three questions:1) Among various options, which alternative source oforal nicotine delivery do smokers prefer? 2) When givenan opportunity to use their preferred product, howwould they use it (i.e., complete or partial substitution)?3) Would brief ad libitum use of the oral nicotine sub-stitute alter exposure to cigarettes as assessed by CPD,carbon monoxide and nicotine levels?

MethodsStudy ParticipantsRecruitment occurred via community flyers and adver-tisements in local newspapers, which sought smokersinterested in trying alternative tobacco and nicotine pro-ducts. Participants were eligible if they smoked ten ormore cigarettes per day for at least one year, were notcurrently using any other nicotine or tobacco product,were able to read and write in English, had no medicalcontraindications (e.g., heart disease) for nicotine repla-cement use, had not made a quit attempt in the pre-vious 30 days, and were not planning to quit in the next30 days. Sixty-seven participants met eligibility criteria,of whom 44 completed the entire study. Demographicsfor those who did or did not complete the study areshow in Table 1. Overall, only prior use of NRT signifi-cantly differentiated the completers from those lost tofollow-up.

Study designParticipants visited the laboratory for four separate ses-sions (each one week apart) between June and Decem-ber 2008, as part of a broader study of the effects ofinformation on knowledge of tobacco and nicotineharms (Borland et al., in preparation). Figure 1 outlinesthe study course for participants. Sessions 1 and 2 pre-sented information about the relative risks of smokelesstobacco and nicotine replacement products compared tocigarettes to provide a health-based rationale for consid-ering these products as alternatives. The findings related


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to knowledge will not be presented here. At the end ofSession 2, after completing a questionnaire, participantswere offered the opportunity to sample four different SLand NR products (Multiple-Product Sampling). Partici-pants were given one package of each of four SL/NRproducts (detailed below), with instructions to use eachproduct at least once and then to use as much of theseproducts as they wished over the following week. Base-line carbon monoxide (CO) and saliva samples (e.g, sali-vary cotinine) were obtained at this time. One weeklater, participants returned for Session 3, completed aquestionnaire about their experiences with the four trialproducts and were given the opportunity to select theirpreferred SL/NR product out of the four trial productsand use it for one more week (Single-Product Trial).Participants were provided with this additional week-long supply of their chosen product at no cost andasked to record their usage patterns in a daily diary.They were asked to bring all of their tins and anyunused portions to their next lab visit to confirm self-reported usage. One week later, participants completedSession 4, consisting of a follow-up questionnaire and

collection of CO and saliva samples. Participantsreceived $10 per visit for completion of the first 3 visitsand $25 for completion of the fourth visit for a maxi-mum possible compensation of $55. The study protocolwas approved by the Roswell Park Cancer InstituteInstitutional Review Board, and all participants provideddocumented informed consent prior to participation.

ProductsAll test products were purchased on the open market in2008 and previous studies have examined characteristicsof these or similar products[35-37]. At the end of Ses-sion 2, participants were provided with samples of threesmokeless tobacco products [one container each ofCamel Snus, 20 pouches; Marlboro Snus, 12 pouches;and Stonewall Hard Snuff, 20 tablets] and one packageof oral nicotine replacement product (Commit®

Lozenge, 24 4 mg lozenges). The smokeless productscontained varying amounts of free nicotine - from 0.7mg/g (Marlboro Snus Mint) to 1.5 mg/g (Stonewall) to6.4 mg/g (Camel Snus Frost)[36,37]. For standardizationpurposes, all products were offered only in their ‘mint’

Table 1 Demographic characteristics of study participants (N = 67)

Variable Levels Lost to follow-up Completed Study p-value*

(n = 23) (n = 44)

Gender Female 52.247.8 52.3 0.994

Male 47.7

Highest Level of Education Less than HS 39.1 20.5 0.053

HS Graduate 34.8 22.7

More than HS 26.1 56.8

Age < 40 30.4 18.2 0.379

41 - 54 60.9 63.6

55 + 8.7 18.2

Race White 56.5 67.4 0.183

Black 43.5 25.6

Other 0 7

Intention to Quit in the next year No 8.7 15.9 0.411

Yes 91.3 84.1

How addicted do you consider yourself? Very 78.3 72.7 0.274

Somewhat 17.4 27.3

Not at all 4.3 0

Prior use of NR Yes 26.1 52.3 0.04

No 73.9 47.7

Prior use of ST Yes 8.7 11.488.6 0.735

No 91.3

Cigarettes per Day Mean 21.4 22.2 0.519

(SE) -3.7 -1.9

Minutes to First Cigarette after Waking Median 5 5 0.662

(IQR) (2-15) (5-15)

* categorical variables compared by chi-square; continuous variables compared by Wilcoxon test, p-value < 0.05.

HS = High school.


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versions, so that the availability of specific flavors wouldnot drive selections. At the end of Session 3, partici-pants selected one of these four products to use for anadditional week and received 7 containers/packages ofthat product.

MeasuresQuestionnaire items focused on the specific SL/NRproducts offered and their experiences with the pro-ducts, including which product overall they likedmost/least, willingness to use the products instead ofsmoking under a range of scenarios, and interest inactually continuing to use such products as a partial orcomplete replacement for cigarettes. Participants werealso asked a series of questions pertaining to their will-ingness to pay for the smokeless and nicotine replace-ment products. Daily diaries were used to tracknumbers of cigarettes and substitute products usedeach day. At baseline participants self-reported theirusual number of cigarettes per day and time to firstcigarette after waking, which were recoded into the

Heavy Smoking Index (HSI) [38]. Exhaled CO wastested using a Micro 4 Smokerlyzer (Bedfont, UK)using standard protocols. Cotinine in saliva was testedusing the EIA method by an outside laboratory (Sali-metrics LLC, University Park, PA).

Data analysisAll analyses were performed using SPSS 16.0 (Chicago,IL). Descriptive statistics and frequencies were used toinitially characterize the data. Kendall’s tau-b was usedto examine concordance between product rankings.Change in responses over time was examined usingpaired t-tests. Cotinine values were transformed usingthe natural logarithm to normalize the distribution priorto analysis. Generalized estimating equations (GEE) withlog link and first-order autoregressive working correla-tion matrix were applied to examine daily patterns ofproduct use; a normal distribution best fit models ofcigarette use, while a gamma distribution best fit modelsof alternative product use. Statistical significance wasaccepted at a p-value of <0.05.

Figure 1 Flowchart detailing study involvement of participants.


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ResultsMultiple-product samplingOf the initial 67 participants, 59 remained in the studyto sample products. However, seven were lost to follow-up and two were excluded because they did not use theprovided products. Table 2 presents information on useof each product and opinions related to each product asassessed at Session 3. Participants did not use a largeamount (between 10% and 20%) of each product sup-plied, and they appear to have distributed their productusage approximately equally across all products. How-ever, their post-sampling choices were non-random,with Commit lozenge the most well-liked and Stonewallthe least liked products (Kendall’s tau-b = -0.314, p =0.011). Further, participants believed Camel Snus tocontain the most nicotine, while Commit was consid-ered to have the least. No relationship was observedbetween perceived nicotine content and positive productrating (Kendall’s tau-b = -0.119, p = 0.338) or negativeproduct rating (Kendall’s tau-b = 0.024, p = 0.832).There were no significant associations between the pre-ferred product and participant gender, age, intention toquit smoking, HSI score, or ever use of ST or NRproducts.Patterns of useAs illustrated in Figure 2, over the course of the seven-day sampling phase, both cigarette use (12.0 cigaretteson day 1 to 10.8 cigarettes on day 7; p = 0.509) andalternative product use (3.2 units on day 1 to 3.3 unitson day 7; p = 0.512) were fairly consistent. This wasconfirmed in GEE models controlling for gender, age(categorized as <40, 41-54, ≥55 years), level of educa-tion, Heavy Smoking Index score, and alternative pro-duct most preferred, where we observed no significanteffect of day for cigarettes and alternative products (see

Table 3). HSI score was positively associated with cigar-ette use over the sampling week, but not with alternativeproduct use.

Single-product trialOf the 50 participants who sampled multiple products,49 selected a preferred product to use for one additionalweek, while one declined to use any products. Of these,five did not complete the final visit. As expected, choiceof product following the one week trial period closelymirrored reports of which product participants likedmost after multiple-product sampling (Kendall’s tau-b =0.907, p < 0.001), with 14% choosing Camel Snus, 29%choosing Marlboro Snus, 12% choosing Stonewall, and45% choosing Commit Lozenge. While no overall signif-icant effects by product were observed, Table 4 suggestsparticipants who preferred Camel Snus anticipated usingit in addition to cigarettes, moreso than those preferringother alternative products. However, they differed signif-icantly in the median amount they were willing to payfor a container/package of that product, from a low of$2 for Stonewall to $5 for Commit Lozenge, with sub-stantial inter-individual variability. 80% of participantsreported that they were very or somewhat likely to pur-chase their preferred product in the next year.Patterns of UseAs illustrated in Figure 3, over the course of the seven-day trial phase, daily cigarette use decreased from 11.8to 8.7 cigarettes on average (a 25% reduction; p =0.004), while alternative product was relatively stable(4.7 units at day 1 to 4.7 units at day 7; p = 0.777). Noparticipant stopped using cigarettes completely. Table 3shows results of GEE models controlling for gender,age, level of education, HSI score, and alternative pro-duct chosen. We observed a significant effect of day [p

Table 2 Alternative product preferences (N = 50)

Camel Snus Marlboro Snus Stonewall Commit 4 mg

Proportion of supplied units used (Median, IQR) 10 16.7 10 12.5 c2(3) = 589.31

(5-25) (8-58) (5-28) (4-33) p = 0.003 a

Proportion of all products used (Median, IQR) 20 23.4 22.2 25 c2(3) = 142.2

(9-25) (9-35) (8-33) (15-50) p = 0.524 a

c2(3) = 005.31

Product Liked Most (%) 12.5 31.2 12.5 43.8 p = 0.004 b

c2(3) = 333.8

Product Liked Least (%) 27.1 10.4 39.6 22.9 p = 0.040 b

c2(3) = 519.8

Product believed to contain most nicotine (%) 42.6 21.3 23.4 12.8 p = 0.030 b

c2(3) = 944.31

Product selected for one-week trial (%)c 14.3 28.6 12.2 44.9 p = 0.004 b

IQR = interquartile range.

a. Friedman test; b. One-sample chi-square test.

c. One participant declined to use any product for the one-week trial.


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= 0.004], indicating an overall linear decline in cigarettessmoked per day across the week. Cigarette use acrossthe week was also related to education, with smokershaving less than HS education smoking significantlymore cigarettes than those with more than HS educa-tion. Age was also associated with cigarette use, withthose aged 40 or less smoking fewer cigarettes thanthose aged 55 or higher. Alternative product preferredwas not associated with cigarette use during the trialweek. In contrast, GEE models showed no significantchange in alternative product use across the week, indi-cating stability in use. However, HSI was positively asso-ciated with alternative product use during the trialweek–those with higher scores used more units of theirchosen product. We also noted an overall effect of edu-cation [Wald c2(2) = 13.828, p = 0.001], wherein thosehad less than HS education used fewer alternative pro-ducts than those with more than HS education. No sta-tistically significant relationships between alternativeproduct use and gender, age, or preferred product werenoted; model adjusted mean use for those who preferred

Camel Snus was 3.0 units/day over the week, comparedto 3.9 units/day for Marlboro Snus, 4.5 units/day forCommit, and 2.7 units/day for Stonewall.

Biomarkers of exposureExhaled CO decreased significantly from before to afterthe one-week trial. Exhaled CO before any use of alter-native products (Session 2) averaged 18.7 ppm (SD 7.0),and dropped after the one week trial (Session 4) to anaverage of 14.9 ppm (SD 7.2), a decline of 10% [t(43) =4.149; p < 0.001]. Overall, 75% of participants demon-strated a decrease in breath CO levels. Geometric meansalivary cotinine was observed to remain stable; at Ses-sion 2 saliva cotinine was 311.0 ng/mL, compared to311.9 ng/mL at Session 4 [t(41) = -0.043; p = 0.966].We calculated a compensation index for cotinine rela-tive to CO using the formula COMP = 1 - (ln (COT4) -ln(COT2))/(ln(CO4) - ln(CO2)). The median compensa-tion score was 1.02 (IQR 0.38-1.60), suggesting that onaverage, smokers in the study compensated completelyfor their nicotine needs by substituting alternative

Figure 2 Alternative product versus cigarette patterns of use during multiple-product sampling (N = 50) phase.


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Table 3 Parameter Estimates from GEE modeling of cigarette and alternative product use during multiple productsampling and single-product trial phases

Cigarettes Alternative Products

B SE Wald c2 (df = 1) p B SE Wald c2 (df = 1) p

MULTIPLE PRODUCT SAMPLING PHASE

Intercept 1.966 0.354 30.911 <.001 0.682 0.486 1.969 0.161

Day -0.012 0.019 0.436 0.509 -0.015 0.022 0.43 0.512

Female (ref = Male) 0.046 0.104 0.193 0.66 -0.029 0.185 0.024 0.877

Less than HS (ref = More than HS) 0.044 0.117 0.143 0.705 -0.454 0.177 6.611 0.01

HS graduate (ref = More than HS) -0.08 0.149 0.287 0.592 -0.204 0.188 1.173 0.279

40 and under (ref = 55 and older) -0.186 0.186 1.003 0.317 0.036 0.193 0.034 0.854

41-54 (ref = 55 and older) -0.169 0.14 1.457 0.227 0.139 0.203 0.468 0.494

Camel Snus (ref = Stonewall) -0.135 0.187 0.524 0.469 0.489 0.228 4.608 0.032

Marlboro Snus (ref = Stonewall) -0.154 0.145 1.131 0.288 0.418 0.234 3.19 0.074

Commit (ref = Stonewall) -0.274 0.158 3.006 0.083 0.515 0.216 5.685 0.017

HSI 0.211 0.049 18.591 <.001 0.022 0.071 0.092 0.762

SINGLE PRODUCT TRIAL PHASE

Intercept 1.762 0.471 13.987 <.001 0.414 0.526 0.62 0.431

Day -0.039 0.014 8.186 0.004 -0.006 0.023 0.08 0.777

Female (ref = Male) -0.128 0.145 0.787 0.375 -0.084 0.177 0.227 0.634

Less than HS (ref = More than HS) 0.344 0.139 6.307 0.012 -0.568 0.181 9.855 0.002

HS graduate (ref = More than HS) -0.071 0.131 0.295 0.587 -0.026 0.206 0.016 0.898

40 and under (ref = 55 and older) -0.443 0.192 5.31 0.021 -0.283 0.266 1.134 0.287

41-54 (ref = 55 and older) -0.264 0.154 3.299 0.069 0.044 0.216 0.041 0.839

Camel Snus (ref = Stonewall) 0.16 0.203 0.617 0.432 0.091 0.283 0.102 0.749

Marlboro Snus (ref = Stonewall) -0.18 0.171 1.109 0.292 0.358 0.312 1.312 0.252

Commit (ref = Stonewall) 0.007 0.19 0.001 0.97 0.49 0.263 3.467 0.063

HSI 0.245 0.061 16.386 <.001 0.234 0.081 8.265 0.004

NOTE: HSI = Heavy Smoking Index.

Parameter estimates in bold indicate statistically significant effects.

Table 4 Participant likelihood to use, purchase, & pay for alternative products (N = 44)

Preferred product (Overall) Camel Snus Marlb Snus Stone-wall Commit 4 mg Test/p-value*

Likely to use instead of cigarettes (%)

Very 20.5 14.3 15.4 0 31.6 c2(6) = 96.4

Somewhat 45.5 42.9 46.2 40 47.4 p = 0.584

Not at all 34.1 42.9 38.5 60 21.1

Likely to use in addition to cigarettes (%)

Very 47.7 71.4 23.1 40 57.9 c2(6) = 52.6

Somewhat 38.6 28.6 53.8 40 31.6 p = 0.396

Not at all 13.6 0 23.1 20 10.5

Likely to purchase in next year (%)

Very 38.6 28.6 30.8 0 57.9 c2(6) = 12.7

Somewhat 40.9 42.9 46.2 60 31.6 p = 0.302

Not at all 20.5 28.6 23.1 40 10.5

Price willing to pay for one package ($)

Median 5 3 3 2 5 c2(3) = 11.81

(IQR) (3.00-5.75) (2.00-3.00) (2.50-5.00) (1.00-4.00) (5.00-11.00) p < 0.001

* Likelihood variables tested by Pearson chi-square; price tested by Kruskal-Wallis.


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products. Compensation index did not differ by pre-ferred product [Kruskal-Wallis c2(3) = 0.76, p = 0.860].

DiscussionFindings from this study show that smokers who arecurrently unwilling to make a quit attempt may be opento adopting alternative products in the short term as atemporary substitute for smoking. The two-step trialperiod allowed us to explore smokers’ willingness to tryunfamiliar oral nicotine and smokeless tobacco pro-ducts, as well as their perceptions and acceptability ofthese products as an alternative to cigarettes. Data sug-gest that the dominant behavioral pattern was partialsubstitution, with about twice as many cigarettes con-sumed compared to oral nicotine products. Although,we observed that cigarette use declined by nearly one-half during the monitoring interval. We did not collectdata to inform whether low use of the alternatives was aresult of participants ‘rationing’ product, but given thenumber of unused portions returned, this was likely nota major problem. It is more likely that participants had

not settled on a habitual use pattern, and/or the pro-ducts were not sufficiently attractive.Concomitant measurement of biomarkers of exposure

revealed a small but significant decrease in breath COassociated with use of alternative products, without anychange in salivary cotinine levels. The modest reductionin CO exposure, while statistically significant, is unlikelyby itself to qualify as a true reduction in harm. In con-trast, the downward trajectory of cigarette use, pairedwith consistent use of alternative products, suggests thatad libitum use of SL/NR might, over a longer time frame,lead to substantial harm reduction; however, this must beevaluated in longer term studies. The finding of a stablelevel of substitution over the week of use is consistentwith the possibility that smokers, at least those with lowinterest in quitting, may prefer a gradual shift strategy toan immediate changeover model (as occurs with use ofNRT to quit). We cannot predict from the current datawhether this process would continue and result in com-plete substitution, ongoing mixed use, a reversion tocigarettes, or complete cessation of nicotine use.

Figure 3 Alternative product versus cigarette patterns of use during (single-product trial (N = 44) phase.


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Similar to Shiffman’s survey findings,[27] we alsofound that among smokers willing to try an oral nico-tine product more were interested in using a pharma-ceutical nicotine product (Commit) compared to threealternative smokeless tobacco products. This finding ofwillingness to use a nicotine replacement product fortemporary substitution is consistent with prior literatureshowing substantial use of NRT products for reasonsother than quitting (e.g., smoking reduction, temporaryabstinence) by smokers [39,40] The observed preferencefor the nicotine lozenge counters an implicit assumption[41,42] that smokers would more likely prefer smokelesstobacco to nicotine products. At the same time, thegreater the range of products offered, the greater theproportion of smokers who may find a product they seeas a viable substitute for cigarettes. This is consistentwith the body of literature [29-34] suggesting that smo-kers’ varied reactions to different products may be infor-mative in themselves, meaning a ‘sampling’ approachmay allow smokers to find an appealing alternative pro-duct to cigarettes.Participants identified Camel Snus as containing the

most nicotine and, while it was not preferred by many(14%), a substantial majority (70%) of these reported theywere at least somewhat likely to purchase the product inthe next year (see Table 4). This observation may berelated to the higher ‘free’ nicotine content in CamelSnus relative to the other products offered. In particular,other investigators have pointed out the discrepancybetween Marlboro Snus and Swedish forms in terms offree nicotine [43]. This difference in nicotine may explainthe discrepancy in preference between Camel and Marl-boro Snus, which might seem superficially equivalent.Moist snuff manufactures have altered free nicotine levelsto affect nicotine delivery and appeal to different markets[44,45]. However, for smokers naïve to oral tobacco pro-ducts, the higher free nicotine content of Camel Snusmay initially have been experienced as aversive while thelow free nicotine content of Marlboro Snus may havebeen insufficiently satisfying to sustain use.The findings from this study are subject to a number of

limitations. About 1/3 of initial participants did not com-plete all phases of this study, reflecting the challenges ofmulti-visit studies. The limited number of participantsalso precluded identifying specific demographic predictorsof willingness to substitute or patterns of substitution. Wechose not to include a comparison group who continuedto use only cigarettes, because our primary interest wasobserving what smokers might do when presented theopportunity to try a different form of nicotine delivery.In summary, this study reveals that the nicotine

lozenge was viewed more favorably than smokelesstobacco products, as a substitute for cigarettes, whichcounters some claims that ST would be more acceptable

to smokers. However, we observed no true switching (i.e., abandoning cigarettes), even though SL and NR pro-ducts were provided without cost. It is clear that simplyinforming smokers of the lower risk and providing pro-ducts is not going to result in major immediate shifts tosmokeless alternatives. In the absence of some signifi-cant incentive, it is unlikely that information campaignsalone would lead to migration from use of cigarettestoward less hazardous nicotine sources among UnitedStates smokers. Further work is needed of the longer-term effects on attempts at substitution to see if poten-tially significant effects, in public health terms, can beachieved, or whether encouraging smokeless nicotineuse is not a viable substitution strategy.

AcknowledgementsThis work was funded by the National Cancer Institute via the Roswell ParkCancer Institute Transdisciplinary Tobacco Use Research Center(P50CA114236). The funding body had no role in study design; in thecollection, analysis, and interpretation of data; in the writing of themanuscript; nor in the decision to submit the manuscript for publication.

Author details1Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY,USA. 2Cancer Council Victoria, Melbourne, Australia.

Authors’ contributionsRJO, RB, KMC, MCM, and MBT designed the study. Data was collected byKJN. RJO, KJN, and MBT prepared the first draft. All authors providedsubstantive input on analysis and interpretation of data and the revision ofthe manuscript and have approved the final version of the manuscript.

Competing interestsRJO served as a consultant to the FDA Tobacco Products Scientific AdvisoryCommittee (Tobacco Constituents Subcommittee). KMC has provided experttestimony on behalf of plaintiffs in cases against the tobacco industry.

Received: 18 June 2010 Accepted: 10 January 2011Published: 10 January 2011

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doi:10.1186/1477-7517-8-1Cite this article as: O’Connor et al.: US smokers’ reactions to a brief trialof oral nicotine products. Harm Reduction Journal 2011 8:1.

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