Commentary on Nardone et al. (2016): Satisfaction, dissatisfaction and complicating the nicotine-reduction strategy with more nicotine Additional ways of assessing and reporting satisfaction/ dissatisfaction and compliance with very low nicotine cigarettes are needed. Mixing more satisfying nicotine products with fully toxic, less satisfying low nicotine cigarettes will probably influence net satisfaction, longevity of their use and health effects.Nardone et al.[1] extend a previous publication [2] by reporting that lower 'satisfaction' from very low nicotine cigarettes (VLNC) predicts non-compliance with VLNC. While only 39% of participants reported non-compliance, a new objective measure indicates that 78% were probably smoking other cigarettes. Smokers lacked something in VLNC.Mandatory VLNC have been advanced as a tobacco control strategy [3,4], but not without criticism [5][6][7]. Compliance with VLNC by healthy, well-paid volunteers sheds light upon challenges smokers might face, even if greater challenges could befall mentally ill, alcohol-abusing smokers [6,8].
MEASURING SATISFACTIONThe three-item cigarette evaluation scale (CES) satisfaction scale was used: 'Was smoking satisfying?', 'Did the cigarettes taste good?' and 'Did you enjoy the sensations in your throat and chest?'. This measure employs seven-point scales often with descriptors: 1, not at all; 2, very little; 3, a little; 4, moderately; 5, a lot; 6, quite a lot; and 7, extremely [9]. Nardone et al. report ratios of geometric means and 95% confidence intervals (CI) = 0.70 (0.58-0.85). It would be valuable to know what participants answered on average. Were VLNC only 'very little' or 'a little' satisfying? Another VLNC report [10] used a 0-100 scale for 'satisfaction.' Usual brand was 83.6 ± 1.4, a regular nicotine test cigarette was 61.4 ± 4.1 and the VLNC was 36.8 ± 4.1. These scores suggest frank dissatisfaction with VLNC. Future research would benefit from adding direct, natural-language comparisons of satisfaction from usual and test brands (cf. [11,12]). Even within reliable, multi-item scales, looking at individual questions can be valuable [13]. Do differences in satisfaction represent VLNC being only less satisfying than usual brands, but still substantially satisfying, or are they significantly dissatisfying?
THE SIMPLIFIED, THEORETICAL WORLD OF MANDATORY NICOTINE REDUCTION HAS EVOLVING CONTRADICTIONS AND UNKNOWN REALITIES TO FACEThe two decades of history of the strategy can be characterized as moving from 'deprivation' towards 'satisfaction'. In the beginning [3], they hoped that their cigarettes 'may provide enough nicotine for taste and sensory stimulation' but, quite logically, they offered no supplemental nicotine at all. Acknowledging undiminished toxins in VLNC, they hoped that the '…risk may be offset by the long-term benefit of a greater likelihood that they will stop smoking (as cigarettes become less satisfying)' and by the prevention of addiction in non-smokers. Four years later [14], unsatisfying, nicotine-replacement me...