Evid Based Nurs 17:19-20 doi:10.1136/eb-2012-101160
  • Health promotion
  • Randomised controlled trial

Adding very low nicotine content cigarettes to nicotine replacement therapy and behavioural support increases abstinence at 6 months after the quit date

  1. Sharon Cummins
  1. Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California, USA
  1. Correspondence to : Dr Sharon Cummins
    Department of Family and Preventive Medicine, University of California, San Diego (UCSD), 9500 Gilman Drive, MC0905, La Jolla, CA 92093-0905, USA; scummins{at}

Commentary on Google Scholar

Implications for practice and research

  • Adding very low nicotine content (VLNC) cigarettes to nicotine replacement therapy (NRT) and behavioural support may help some smokers become abstinent.

  • Use of VLNCs did not increase serious adverse health events when used with NRT.

  • We cannot assume VLNCs would be as safe without NRT because there may be more compensatory smoking.


There are proven interventions to help smokers quit, both behavioural (group, individual, telephone-based counselling) and pharmacological (NRT, medications).1 This study examined using VLNCs to help smokers quit. VLNCs mimic the act of smoking and are thought to address non-nicotine aspects of smoking including hand-to-mouth behaviour, smell, taste and possible addiction to other components in smoke.

Studies have shown that smokers often engage in compensatory smoking behaviours (longer or stronger drags) when smoking VLNCs. Compensatory smoking increases carbon monoxide levels significantly, which could result in VLNCs being even more harmful to a smoker's health.2

This study examined whether smokers who call a telephone-based cessation programme for help with quitting are more successful when they are provided with VLNCs in addition to standard smoking cessation helpline services (ie, NRT and behavioural support). It also examined whether VLNCs increased serious adverse events.


Smokers who called the New Zealand Quitline (N=9970) were assessed for inclusion; 1410 met the criteria and provided consent. Participants were randomly assigned to usual care (8 weeks of low cost nicotine patches, gum or lozenges and behavioural support) or to an intervention that included usual smoking cessation helpline care plus a 6-week supply of VLNCs to be used whenever they had an urge to smoke. The VLNCs had a nicotine yield of ≤0.05 mg and a tar content of 4 mg/cigarette (vs 1 mg of nicotine and 8–10 mg of tar in a standard cigarette). Outcome data were collected by telephone at 3 and 6 weeks and 3 and 6 months after the quit date. The primary outcome was self-reported 7-day abstinence defined as ‘no smoking of regular cigarettes, not a single puff’, in the previous 7 days 6 months after quit day.


Intervention participants were significantly more likely to have quit for 7 days at 6 months than usual care participants (33% vs 28%, p=0.037). This led the authors to conclude that adding VLNCs to standard treatment helps some smokers become abstinent.

There was no significant difference in serious adverse effects between the two conditions. It should be noted that all participants had access to 8 weeks of NRT. Only 10% of intervention participants used VLNCs without using another source of nicotine (either regular cigarettes or NRT). Smokers who receive nicotine from other sources may engage less in compensatory smoking behaviours.


This study was well powered, used stratified randomisation (sex, ethnicity and nicotine dependence), followed CONSORT recommendations, used appropriate measures and intention to treat analysis and supported the hypothesis that adding VLNCs to standard smoking cessation helpline treatment increased abstinence.

The findings raise an interesting question about whether there is a place for VLNCs in the market, either as primary products or as an adjunct to cessation treatment. This is a timely topic, particularly in the USA, as the Food and Drug Administration (FDA) was recently given authority to regulate the manufacture, distribution and marketing of tobacco products. The FDA is interested in research into the reduction of addiction to tobacco, which includes the potential impact of modifying nicotine levels and how the use of reduced nicotine products affects consumer perceptions of consumers’ ability to quit using tobacco.3

It is not clear how using VLNCs led to the extinction of smoking, since mimicry could reinforce smoking behaviour. VLNCs might address the non-nicotine aspects of smoking as described in the article. Another possibility is that they might simply function as another coping strategy, a tangible behaviour to perform while waiting for an urge to pass. If so, one might make a case for selecting a product with a lower risk profile, such as nicotine inhalers or the increasingly popular electronic cigarettes.4 A future study might compare the use of VLNCs to another product to tease out the mechanism of the effect. At this point, it would be premature to conclude that VLNCs should be provided on a routine basis as an additional smoking cessation helpline service.


  • Competing interests None.


No Related Web Pages

Free Sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of EBN.
View free sample issue >>

EBN Journal Chat

The EBN Journal Chat offers readers the opportunity to participate in discussion about research articles and commentaries from Evidence Based Nursing (EBN).

How to participate >>

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.