Estimations and predictors of non-compliance in switchers to reduced nicotine content cigarettes

Natalie Nardone, Eric C. Donny, Dorothy K. Hatsukami, Joseph S. Koopmeiners, Sharon E. Murphy, Andrew A. Strasser, Jennifer W. Tidey, Ryan Vandrey, Neal L. Benowitz

Research output: Contribution to journalArticlepeer-review

39 Scopus citations


Background and Aims: Clinical trials on the impact and safety of reduced nicotine content cigarettes (RNCs) are ongoing, and an important methodological concern is participant compliance with smoking only RNCs. Our aims were to measure non-compliance biochemically with urine cotinine (COT) and total nicotine equivalents (TNEs), compare with self-reported non-compliance and identify associated covariates. Design: Secondary analysis of a double-blind, parallel, randomized clinical trial. Setting: Research centers from the United States, enrolling participants from June 2013 to July 2014. Participants: Volunteer sample of 242 participants (55% Caucasian), average age of 41.2 years, smoking at least five cigarettes per day (CPD). Intervention: Smoking very low nicotine cigarettes (VLNCs; 0.4 mg nicotine/g tobacco) for 6 weeks. Measurements: The primary outcome was biochemically verified non-compliance, measured as thresholds of COT/CPD and TNE/CPD ratios, considering changes in nicotine content from conventional levels to VLNCs, and as an absolute threshold of week 6 TNEs. Self-reported non-compliance was measured via daily phone calls. Key predictors included age, sex, race, menthol preference, nicotine metabolite ratio, time to first cigarette, dependence, CPD, TNEs, tar level and cigarette evaluation. Findings: Estimates of non-compliance with smoking the VLNCs exclusively include: the biochemical ratios (both 78%), the week 6 TNE threshold (76%) and self-report (39%). Of the key covariates, age, dependence and cigarette evaluations of satisfaction were significant; for age, younger participants more likely to be non-compliant [P = 0.01; odds ratio (OR) = 0.98, 95% confidence interval (CI) = 0.96–0.99]. Dependence was associated significantly with self-reported non-compliance (P = 0.01; OR = 1.28, 95% CI = 1.06–1.55). Cigarette evaluations of satisfaction were associated significantly with non-compliance (P = 0.001; OR = 0.71, 95% CI = 0.61–0.82). Conclusions: Among smokers volunteering to smoke only very low nicotine cigarettes for 6 weeks, non-compliance was common and biochemical assessments detected more cases of non-compliance than self-report. Despite high levels of non-compliance, smokers reduced their intake of nicotine by an average of 60%.

Original languageEnglish (US)
Pages (from-to)2208-2216
Number of pages9
Issue number12
StatePublished - Dec 1 2016

Bibliographical note

Funding Information:
Research reported in this publication was supported by the National Institute on Drug Abuse and FDA Center for Tobacco Products (CTP) (U54 DA031659) and R01 CA78603 from the National Cancer Institute (N.L.B.).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.

Publisher Copyright:
© 2016 Society for the Study of Addiction


  • Biomarkers
  • cigarette smoking
  • cotinine
  • nicotine reduction
  • reduced nicotine content cigarettes
  • total nicotine equivalents


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