Menthol and non-menthol cigarette use among Black smokers in Southern California

Prevalence, perceptions and factors associated with menthol cigarette smoking: findings from the ITC Kenya and Zambia Surveys

BACKGROUND

Menthol masks the harshness of cigarette smoke, promotes youth smoking and encourages health-concerned smokers who incorrectly believe that menthols are less harmful to smoke menthols. This study of smokers in Kenya and Zambia is the first study in Africa to examine menthol use, smokers' beliefs about its harmfulness and the factors associated with menthols.

METHODS

Data were from the International Tobacco Control (ITC) Kenya Wave 2 (2018) and Zambia Wave 2 Survey (2014), involving nationally representative samples of smokers. This study focuses on 1246 adult smokers (644 in Kenya, 602 in Zambia) who reported smoking a usual brand of cigarettes (menthol or non-menthol).

RESULTS

Overall, menthol use was significantly higher among smokers in Zambia than in Kenya (48.0% vs 19.0%), females (45.6% vs 31.2% males), non-daily smokers (43.8% vs 30.0% daily) and those who exclusively smoked factory-made (FM) cigarettes (43.0% vs 15.2%). The erroneous belief that menthols are less harmful was more likely among smokers in Zambia than in Kenya (53.4% vs 29.3%) and among female smokers (38.5% vs 28.2%). In Kenya, menthol smoking was associated with being female (adjusted odds ratios (AOR)=3.07; p=0.03), worrying about future health (AOR=2.28; p=0.02) and disagreeing with the statement that smoking was calming (AOR=2.05; p=0.04). In Zambia, menthol use was associated with being female (AOR=3.91; p=0.002), completing primary school (AOR=2.14; p=0.03), being a non-daily smoker (AOR=2.29; p=0.03), exclusively using FM cigarettes (AOR=14.7; p<0.001), having a past quit attempt (AOR=1.54; p=0.02), believing that menthols are less harmful (AOR=3.80; p<0.001) and choosing menthols because they believed it was less harmful (AOR=3.52; p<0.001).

CONCLUSIONS

Menthols are highly prevalent among females in both countries. There is a need in African countries to combat the myth that menthols are less harmful and to ban menthol and other flavourings.

Pain and Menthol Use Are Related to Greater Nicotine Dependence Among Black Adults Who Smoke Cigarettes at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health (PATH) Study

Burdens related to pain, smoking/nicotine dependence, and pain-smoking comorbidity disproportionately impact Black Americans, and menthol cigarette use is overrepresented among Black adults who smoke cigarettes. Menthol may increase nicotine exposure, potentially conferring enhanced acute analgesia and driving greater dependence. Therefore, the goal of the current study was to examine associations between pain, menthol cigarette use, and nicotine dependence. Data was drawn from Black adults who were current cigarette smokers (n = 1370) at Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study. Nicotine dependence was assessed using the Wisconsin Inventory of Smoking Dependence Motives. ANCOVA revealed that moderate/severe pain (vs. no/low pain) was associated with greater overall nicotine dependence (p < .001) and greater negative reinforcement, cognitive enhancement, and affiliative attachment smoking motives (ps < .001). Menthol smokers with moderate/severe pain also endorsed greater cigarette craving and tolerance, compared to non-menthol smokers with no/low pain (ps < .05). Findings support the notion that among Black individuals who smoke cigarettes, the presence of moderate/severe pain (vs. no/low pain) and menthol use may engender greater physical indices of nicotine dependence relative to non-menthol use. Compared to no/low pain, moderate/severe pain was associated with greater emotional attachment to smoking and greater proclivity to smoke for reducing negative affect and enhancing cognitive function. Clinical implications include the need to address the role of pain and menthol cigarette use in the assessment and treatment of nicotine dependence, particularly among Black adults. These data may help to inform evolving tobacco control policies aimed at regulating or banning menthol tobacco additives.

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use

INTRODUCTION

Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use.

METHODS

This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022.

RESULTS

Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7).

CONCLUSIONS

Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

An Analysis of Twitter Posts About the U.S. Food and Drug Administration's Menthol Ban

INTRODUCTION

Although the U.S. Food and Drug Administration (FDA) banned characterizing flavors in cigarettes in 2009, this initial ban exempted menthol. After examining numerous reports on the adverse health effects of menthol cigarettes, the FDA proposed a menthol ban in April 2022. This study analyzed Twitter data to describe public reaction to this announcement.

AIMS AND METHODS

Posts containing the word "menthol" and/or "#menthol" were collected from April 21, 2022 to May 5, 2022 from Twitter's Streaming Application Programming Interface (API). A random sampling procedure supplied 1041 tweets for analysis. Following an inductive approach to content analysis, posts were classified into one or more of 11 themes.

RESULTS

Posts discussed the FDA announcement (n = 153, 14.7%), racial discrimination (n = 101, 9.7%), distrust in government (n = 67, 6.4%), inconsistencies between policies (n = 52, 5.0%), public health benefits (n = 42, 4%), freedom of choice (n = 22, 2.1%), and health equity (n = 21, 2.0%). Posts contained misinformation (n = 20, 1.9%), and discussed the potential for illicit markets (n = 18, 1.7%) and the need for cessation support (n = 4, 0.4%). 541 (52.0%) tweets did not fit into any of the prescribed themes.

CONCLUSIONS

Twitter posts with the word "menthol" commonly discussed distrust in government and mentioned racial discrimination. Findings demonstrated the possibility of near real-time Twitter monitoring of public opinion on a menthol ban. These data may be valuable for designing tobacco control health communication campaigns in the future.

IMPLICATIONS

The U.S. FDA proposed a ban on menthol cigarettes in April 2022. This study's content analyzed Twitter posts over a 2-week period to understand the public's response to the proposed menthol ban. Twitter posts with the word "menthol" often discussed distrust in government and mentioned racial discrimination. Findings demonstrated the possibility of near real-time Twitter monitoring of public opinion of regulatory action. Findings underscore the need to educate the public about the potential health benefits of banning menthol from cigarettes, particularly for populations that experience tobacco-related health disparities.

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study

PURPOSE

Describe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies.

METHODS

Using data on US young adults (ages 18-34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users.

RESULTS

Any flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users.

DISCUSSION

Racial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

Perceived harm of menthol cigarettes and quitting behaviors among menthol smokers in Minnesota

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There is a need to understand what influences quitting among menthol smokers.

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Links between menthol smokers’ perceived harms of menthol and quitting are unknown.

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Higher menthol harm perceptions were associated with menthol smokers’ quit attempts.

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Findings may inform public health interventions to increase quit attempts.

Although overall smoking prevalence in Minnesota has declined, the proportion of current smokers who smoke menthol cigarettes has increased. While studies have examined associations between smokers’ perceived risks of smoking and quitting, similar studies on menthol smoking are lacking. This study examined whether perceived harm of menthol cigarettes was associated with menthol smokers’ quitting behaviors.

Data from the 2018 Minnesota Adult Tobacco Survey were examined. Respondents were categorized as current menthol smokers (n = 200), current nonmenthol smokers (n = 527), or nonsmokers (n = 5324). All were asked four questions to assess their perceptions of menthol cigarettes’ harm compared to nonmenthols. Sum scores were calculated (range 0–4); higher scores indicated perceptions of similar or greater harm. Data on menthol smokers’ quitting behaviors were analyzed to identify associations between sum scores and quitting behavior. Data were analyzed using Wilcoxon Rank Sum tests and Spearman Rank Correlation tests. Additional analyses examined whether gender, age, race/ethnicity, education or income moderated the association between sum scores and past 12-month quit attempts.

Menthol smokers were less likely to answer the harm perception questions correctly than nonmenthol smokers. Among menthol smokers, perceived harm of menthol cigarettes was positively associated with past 12–month quit attempts (p = 0.006), use of counseling/behavioral support (p = 0.012), and number of quit attempts (p = 0.004). No demographic characteristics moderated the association between sum scores and past 12-month quit attempts.

Findings suggest that efforts to increase menthol smokers’ perceptions of menthol cigarettes’ harm may potentially increase quitting behaviors. Understanding this association can inform interventions to increase quit attempts.

“Because There’s Just Something About That Menthol”: Exploring African American Smokers’ Perspectives on Menthol Smoking and Local Menthol Sales Restrictions

Introduction

Local governments are pursuing policies to limit the availability of menthol cigarettes at the point-of-sale. Although African Americans are disproportionately impacted by menthol cigarettes, little is known about African American smokers’ perspectives on emerging menthol policy. The purpose of this study was to fill a gap in the literature by exploring African American adult (25+) smoker perspectives on menthol and a local menthol sales restriction.

Methods

In-depth semi-structured interviews were conducted with African American smokers (n = 27) in the Minneapolis–St. Paul area June–September 2017. Interviews explored smoking behaviors, harm perceptions, perspectives of menthol in the community and reactions to local menthol sales restrictions. The framework method guided identification of key themes and synthesis of findings.

Results

Almost all (96%) participants smoked Newport cigarettes. The majority of participants indicated that menthol cigarettes were more harmful than non-menthol cigarettes, citing strength and additives and because they were targeted to African Americans. Some participants were receptive to policy change while others viewed the policy as inconvenient and unfair. Overall, there was a lack of understanding of the policy’s intended public health impact. Some participants indicated that the policy would have no impact on their purchasing or smoking behaviors while others who were contemplating quitting noted that a menthol restriction was encouragement to prompt a quit attempt.

Conclusions

Sales restrictions can provide a unique opportunity to persuade menthol smokers to quit. Efforts are needed to increase awareness and support of these policies as well as to support African American menthol smokers achieve cessation.

Implications

There is growing momentum to restrict local menthol tobacco sales; however, little is known about perceptions among populations most impacted. In Minneapolis–St. Paul, where menthol restrictions were passed in 2017, African American smokers expressed limited awareness and uneven policy support. While some participants were unconvinced the restriction would impact smoking, others indicated it would encourage decreased consumption and prompt quit attempts. There is a need for public education to increase awareness of menthol’s harms, to help menthol smokers quit, and to increase support for menthol policies.

Assessing cigarette packaging and labelling policy effects on early adolescents: results from a discrete choice experiment

INTRODUCTION

Cigarette packaging is a primary channel for tobacco advertising, particularly in countries where traditional channels are restricted. The current study evaluated the independent and interactive effects of cigarette packaging and health warning label (HWL) characteristics on perceived appeal of cigarette brands for early adolescents in Mexico.

METHODS

A discrete choice experiment (DCE) was conducted with early adolescents, aged 12-14 years (n=4251). The DCE involved a 3×25 design with six attributes: brand (Marlboro, Pall Mall, Camel), tobacco flavour (regular, menthol), flavour capsule (none, 1 or 2 capsules), presence of descriptive terms, branding (vs plain packaging), HWL size (30%, 75%) and HWL content (emphysema vs mouth cancer). Participants viewed eight sets of three cigarette packs and selected a pack in each set that: (1) is most/least attractive, (2) they are most/least interested in trying or (3) is most/least harmful, with a no difference option.

RESULTS

Participants perceived packs as less attractive, less interesting to try and more harmful if they had plain packaging or had larger HWLs, with the effect being most pronounced when plain packaging is combined with larger HWLs. For attractiveness, plain packaging had the biggest influence on choice (43%), followed by HWL size (19%). Interest in trying was most influenced by brand name (34%), followed by plain packaging (29%). Perceived harm was most influenced by brand name (30%), followed by HWL size (29%).

CONCLUSION

Increasing the size of HWLs and implementing plain packaging appear to reduce the appeal of cigarettes to early adolescents. Countries should adopt these policies to minimise the impact of tobacco marketing.

A Conceptual Framework for Understanding Multiple Tobacco Product Use and the Impact of Regulatory Action

INTRODUCTION

Over 35% of the adult tobacco-using population regularly use more than one tobacco product. Although rates of tobacco use in the United States have declined over the last decade, rates of multiple tobacco product (MTP) have either remained stable (among adults) or increased (among youth).

METHODS

In this paper, we review the literature and propose a framework for understanding both MTP use and how regulatory actions on any single tobacco product (STP) may influence the use of other tobacco products.

RESULTS AND CONCLUSIONS

Within the framework, Product, Person, and Context/Situational factors (and their interactions) influence product cross-substitution and thus patterns of use of MTPs. In addition, we propose that Context/Situation effects specifically increase the complexity of MTP-use patterns resulting in "dynamic complementarity" in addition to substitution-like relationships between tobacco products. Experimentation with, and use of, various tobacco products results in reinforcement histories that affect which products are used, in what contexts, and by whom, which in turn has downstream impacts on toxicant exposure and health. We conclude our analysis with an examination of how regulation of STPs can have impacts on the use of other STP and MTP use and provide research questions for further examining MTP use.

IMPLICATIONS

Though rates of tobacco use have declined in the United States, over 35% of the adult tobacco-using population regularly uses more than one tobacco product. This paper provides a framework for understanding MTP use and how regulatory actions on any STP may influence the use of other tobacco products. We conclude our analysis by providing research questions for further examining MTP use.

Does Experienced Discrimination Explain Patterns of Menthol Use Among Young Adults? Evidence from the 2014 San Francisco Bay Area Young Adult Health Survey

BACKGROUND

Young adults are at high risk for using flavored tobacco, including menthol and underrepresented populations, such as Latino and African American young adults, are at particular risk.

OBJECTIVES

The purpose of this study is to identify sociodemographic correlates of menthol use among young adult smokers and examine the potential role of experienced discrimination in explaining any associations.

METHODS

We conducted a probabilistic multimode household survey of young adults (aged 18-26) residing in Alameda and San Francisco Counties in California in 2014 (n = 1,350). We used logistic regression to evaluate associations between menthol cigarette use and experienced discrimination among young adult smokers as well as with respect to sociodemographic, attitudinal, and behavioral predictors. Interactions between experienced discrimination and race/ethnicity, sex and LGB identity were also modeled.

RESULTS

Latino and non-Hispanic Black young adult smokers were more likely to report current menthol use than non-Hispanic Whites, while those with college education were less likely to do so. Experienced discrimination mediated the relationship between race and menthol use for Asian/Pacific Islander and Multiracial young adult smokers with odds of use increasing by 32 and 42% respectively for each additional unit on the experienced discrimination scale. Conclusions/Importance: Latino and African American young adult smokers have disproportionately high menthol use rates; however, discrimination only predicted higher use for Asian/Pacific Islander and Multiracial young adult smokers. Limits on the sale of menthol cigarettes may benefit all nonwhite race/ethnic groups as well as those with less education.

Differences in Subjective Experiences to First Use of Menthol and Nonmenthol Cigarettes in a National Sample of Young Adult Cigarette Smokers

Purpose

Menthol has been hypothesized to ease the harshness of cigarette smoke. Thus, sensory experiences at first cigarette use may be one mechanism by which menthol facilitates progression to regular smoking. This study examined differences in subjective experiences to the first use of a menthol versus nonmenthol cigarette among new young adult smokers.

Methods

Data were drawn from waves 5-8 of the Truth Initiative Young Adult Cohort Study, a national sample of 18-34 year olds assessed every 6 months. Analyses included a subset of young adult current smokers (n = 251) who initiated smoking in the past 6 months. Subjective responses to first cigarette use were assessed across menthol and nonmenthol initiators in bivariate analyses and adjusted models controlling for smoking correlates.

Results

Fifty-two percent of new young adult smokers used a menthol cigarette at first use. First use of a menthol cigarette was higher in those aged 18-24 (vs. 25-34). Most black smokers (93.1%) were menthol initiators compared to 43.9% of white smokers. More than half of menthol and nonmenthol initiates felt relaxed or calm, dizzy, lightheaded, liking the taste and a rush or buzz at first use. Menthol initiators were less likely in bivariate and multivariable analyses to experience feeling nauseated at first use (adjusted odds ratio = 0.45; p = .020) compared to nonmenthol initiators.

Conclusions

While few differences were found between menthol and nonmenthol initiators in their subjective experiences, fewer menthol initiates felt nauseated at first cigarette use. Future research needs to identify additional mechanisms linking menthol initiation to smoking progression.

Implications

Menthol initiators were more likely to be younger (18-24 vs. 25-34), and black (vs. white) compared to nonmenthol initiators. Our finding that menthol initiators were less likely to feel nauseated at first cigarette use compared to nonmenthol initiators suggests that menthol may reduce aversion to early cigarette use among young smokers and thus has the potential to facilitate continued experimentation. Interventions and policy approaches to reduce tobacco use initiation and progression are urgently needed in young people.

Perceived nicotine content of reduced nicotine content cigarettes is a correlate of perceived health risks

BACKGROUND

Reducing cigarette nicotine content may reduce smoking. Studies suggest that smokers believe that nicotine plays a role in smoking-related morbidity. This may lead smokers to assume that reduced nicotine means reduced risk, and attenuate potential positive effects on smoking behaviour.

METHODS

Data came from a multisite randomised trial in which smokers were assigned to use cigarettes varying in nicotine content for 6 weeks. We evaluated associations between perceived and actual nicotine content with perceived health risks using linear regression, and associations between perceived nicotine content and perceived health risks with smoking outcomes using linear and logistic regression.

FINDINGS

Perceived-not actual-nicotine content was associated with perceived health risks; compared with those perceiving very low nicotine, individuals who perceived low (β=0.72, 95% CI 0.26 to 1.17), moderate (β=1.02, 95% CI 0.51 to 1.53) or high/very high nicotine (β=1.66, 95% CI 0.87 to 2.44) perceived greater health risks. Nevertheless, individuals perceiving low (OR=0.48, 95% CI 0.32 to 0.71) or moderate nicotine (OR=0.42, 95% CI 0.27 to 0.66) were less likely than those perceiving very low nicotine to report that they would quit within 1 year if only investigational cigarettes were available. Lower perceived risk of developing other cancers and heart disease was also associated with fewer cigarettes/day at week 6.

CONCLUSIONS

Although the perception of reduced nicotine is associated with a reduction in perceived harm, it may not attenuate the anticipated beneficial effects on smoking behaviour. These findings have implications for potential product standards targeting nicotine and highlight the need to clarify the persistent harms of reduced nicotine combusted tobacco products.

Perceptions of Menthol Cigarettes Among Twitter Users: Content and Sentiment Analysis

Background

Menthol cigarettes are used disproportionately by African American, female, and adolescent smokers. Twitter is also used disproportionately by minority and younger populations, providing a unique window into conversations reflecting social norms, behavioral intentions, and sentiment toward menthol cigarettes.

Objective

Our purpose was to identify the content and frequency of conversations about menthol cigarettes, including themes, populations, user smoking status, other tobacco or substances, tweet characteristics, and sentiment. We also examined differences in menthol cigarette sentiment by prevalent categories, which allowed us to assess potential perceptions, misperceptions, and social norms about menthol cigarettes on Twitter. This approach can inform communication about these products, particularly to subgroups who are at risk for menthol cigarette use.

Methods

Through a combination of human and machine classification, we identified 94,627 menthol cigarette-relevant tweets from February 1, 2012 to January 31, 2013 (1 year) from over 47 million tobacco-related messages gathered prospectively from the Twitter Firehose of all public tweets and metadata. Then, 4 human coders evaluated a random sample of 7000 tweets for categories, including sentiment toward menthol cigarettes.

Results

We found that 47.98% (3194/6657) of tweets expressed positive sentiment, while 40.26% (2680/6657) were negative toward menthol cigarettes. The majority of tweets by likely smokers (2653/4038, 65.70%) expressed positive sentiment, while 91.2% (320/351) of nonsmokers and 71.7% (91/127) of former smokers indicated negative views. Positive views toward menthol cigarettes were predominant in tweets that discussed addiction or craving, marijuana, smoking, taste or sensation, song lyrics, and tobacco industry or marketing or tweets that were commercial in nature. Negative views toward menthol were more common in tweets about smoking cessation, health, African Americans, women, and children and adolescents—largely due to expression of negative stereotypes associated with these groups’ use of menthol cigarettes.

Conclusions

Examinations of public opinions toward menthol cigarettes through social media can help to inform the framing of public communication about menthol cigarettes, particularly in light of potential regulation by the European Union, US Food and Drug Administration, other jurisdictions, and localities.

Impact of Menthol Smoking on Nicotine Dependence for Diverse Racial/Ethnic Groups of Daily Smokers

Introduction: The aims of this study were to evaluate whether menthol smoking and race/ethnicity are associated with nicotine dependence in daily smokers. Methods: The study used two subsamples of U.S. daily smokers who responded to the 2010–2011 Tobacco Use Supplement to the Current Population Survey. The larger subsample consisted of 18,849 non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic (HISP) smokers. The smaller subsample consisted of 1112 non-Hispanic American Indian/Alaska Native (AIAN), non-Hispanic Asian (ASIAN), non-Hispanic Hawaiian/Pacific Islander (HPI), and non-Hispanic Multiracial (MULT) smokers. Results: For larger (smaller) groups the rates were 45% (33%) for heavy smoking (16+ cig/day), 59% (51%) for smoking within 30 min of awakening (Sw30), and 14% (14%) for night-smoking. Overall, the highest prevalence of menthol smoking corresponded to NHB and HPI (≥65%), followed by MULT and HISP (31%–37%), and then by AIAN, NHW, and ASIAN (22%–27%) smokers. For larger racial/ethnic groups, menthol smoking was negatively associated with heavy smoking, not associated with Sw30, and positively associated with night-smoking. For smaller groups, menthol smoking was not associated with any measure, but the rates of heavy smoking, Sw30, and night-smoking varied across the groups. Conclusions: The diverse associations between menthol smoking and nicotine dependence maybe due to distinction among the nicotine dependence measures, i.e., individually, each measure assesses a specific smoking behavior. Menthol smoking may be associated with promoting smoking behaviors.

Differences in Quit Attempts and Cigarette Smoking Abstinence Between Whites and African Americans in the United States: Literature Review and Results From the International Tobacco Control US Survey

INTRODUCTION

While cigarette smoking prevalence is declining among US adults, quit rates may differ between white and African American smokers. Here, we summarize the literature on smoking cessation behaviors in whites and African Americans across four study designs and report the findings of new analyses of International Tobacco Control (ITC) US Survey cohort data.

METHODS

We reviewed 32 publications containing 39 relevant analyses that compared quit attempts and abstinence between US whites and African Americans. Two additional longitudinal analyses were conducted on 821 white and 76 African American cigarette smokers from Waves 7 and 8 of the ITC US Survey (mean follow-up = 19 months).

RESULTS

Of 17 total analyses of quit attempts, nine (including the ITC US Survey) observed that African American smokers were more likely than whites to attempt to quit during a given year; seven found no differences. Whites were more likely than African Americans to be abstinent in five of six retrospective cohort analyses and in two of five considered community- and population-based cohort studies. Four of these 11 analyses, including one from the ITC US Survey, found no differences.

CONCLUSIONS

Of 11 population- or community-based analyses, all seven that found significant differences indicated that whites were more likely to quit than African Americans. These findings, combined with the similar results from population-based birth cohort analyses, support the conclusion that white smokers are more likely to quit than African American smokers. Efforts to encourage and support quitting among all tobacco users remain a priority.

IMPLICATIONS

This article provides a review of the literature on smoking cessation among African American and white smokers, and adds new analyses that compare quit attempts and abstinence between US African Americans and whites. Results demonstrate a clear distinction between the findings of cross-sectional and retrospective cohort studies with those of cohort studies. Reasons for these differences merit further study.

Predictors, indicators, and validated measures of dependence in menthol smokers

This article presents a comprehensive review of the menthol cigarette dependence-related literature and results from an original analysis of the Total Exposure Study (TES), which included 1,100 menthol and 2,400 nonmenthol adult smokers. The substantial scientific evidence available related to age of first cigarette, age of regular use, single-item dependence indicators (smoking frequency, cigarettes per day, time to first cigarette, night waking to smoke), smoking duration, numerous validated and widely accepted measures of nicotine/cigarette dependence, and our analysis of the TES do not support that menthol smokers are more dependent than nonmenthol smokers or that menthol increases dependence.

Smoking, menthol cigarettes and all-cause, cancer and cardiovascular mortality: evidence from the National Health and Nutrition Examination Survey (NHANES) and a meta-analysis

Background

The U.S. Food and Drug Administration has the authority to regulate tobacco product constituents, including menthol, if the scientific evidence indicates harm. Few studies, however, have evaluated the health effects of menthol cigarette use.

Objective

To investigate associations of cigarette smoking and menthol cigarette use with all-cause, cancer and cardiovascular risk in U.S. adults.

Methods

We studied 10,289 adults ≥ 20 years of age who participated in the National Health and Nutrition Examination Survey from 1999-2004 and were followed through December 2006. We also identified studies comparing risk of all-cause mortality, cardiovascular disease and cancer for menthol and nonmenthol cigarette smokers and estimates were pooled using random-effects models.

Results

Fifty-five percent of participants were never smokers compared to 23%, 17% and 5% of former, current nonmenthol and current menthol cigarette smokers, respectively. The adjusted hazard ratios (95% CI) for former, current nonmenthol and current menthol cigarette smokers compared to never smokers were 1.24 (0.96, 1.62), 2.40 (1.56, 3.71) and 2.07 (1.20, 3.58), respectively, for all-cause mortality; 0.92 (0.62, 1.37), 2.10 (1.02, 4.31) and 3.48 (1.52, 7.99) for cardiovascular mortality; and 1.91 (1.21, 3.00), 3.82 (2.19, 6.68) and 2.03 (1.00, 4.13) for cancer mortality. Using data from 3 studies of all-cause mortality, 5 of cardiovascular disease and 13 of cancer, the pooled relative risks (95% CI) comparing menthol cigarette smokers to nonmenthol cigarette smokers was 0.94 (0.85, 1.05) for all-cause mortality, 1.28 (0.91, 1.80) for cardiovascular disease and 0.84 (0.76, 0.92) for any cancer.

Conclusions

In a representative sample of U.S. adults, menthol cigarette smoking was associated with increased all-cause, cardiovascular and cancer mortality with no differences compared to nonmenthol cigarettes. In the systematic review, menthol cigarette use was associated with inverse risk of cancer compared to nonmenthol cigarette use with some evidence of an increased risk for cardiovascular disease.

Health beliefs, treatment preferences and complementary and alternative medicine for asthma, smoking and lung cancer self-management in diverse Black communities

OBJECTIVE

The purpose of this literature review is to characterize unconventional health beliefs and complementary and alternative medicine (CAM) for asthma, smoking and lung cancer as those that are likely safe and those that likely increase risk in diverse Black communities. These findings should provide the impetus for enhanced patient-provider communication that elicits patients' beliefs and self-management preferences so that they may be accommodated, or when necessary, reconciled through discussion and partnership.

METHODS

Original research articles relevant to this topic were obtained by conducting a literature search of the PubMed Plus, PsychINFO and SCOPUS databases using combinations of the following search terms: asthma, lung cancer, emphysema, chronic obstructive pulmonary disease (COPD), smoking, beliefs, complementary medicine, alternative medicine, complementary and alternative medicine (CAM), explanatory models, African American, and Black.

RESULTS

Using predetermined inclusion and exclusion criteria, 51 original research papers were retained. Taken together, they provide evidence that patients hold unconventional beliefs about the origins of asthma and lung cancer and the health risks of smoking, have negative opinions of standard medical and surgical treatments, and have favorable attitudes about using CAM. All but a small number of CAM and health behaviors were considered safe.

CONCLUSION

When patients' unconventional beliefs and preferences are not identified and discussed, there is an increased risk that standard approaches to self-management of lung disease will be sub-optimal, that potentially dangerous CAM practices might be used and that timely medical interventions may be delayed.

PRACTICE IMPLICATIONS

Providers need effective communication skills as the medical dialog forms the basis of patients' understanding of disease and self-management options. The preferred endpoint of such discussions should be agreement around an integrated treatment plan that is effective, safe and acceptable to both.

Menthol use among smokers with psychological distress: findings from the 2008 and 2009 National Survey on Drug Use and Health

OBJECTIVE

The Food and Drug Administration is considering regulation of menthol cigarettes. While persons with mental distress are known to smoke cigarettes at high rates, little is known about their use of menthol. The authors examined the association of psychological distress and menthol use in a national sample of adult smokers.

METHODS

Data were from the 2008 and 2009 National Survey on Drug Use and Health. Past month smokers (N=24,157) were categorised for menthol or non-menthol use. Psychological distress was categorised as none/mild, moderate or severe on the Kessler six-item scale.

RESULTS

The prevalence of menthol use was higher among individuals with severe psychological distress, women, young adults, African-Americans, Native Hawaiians/Pacific Islanders, persons with fewer years of education and lower income, and the unmarried and uninsured. In a multivariate model controlling for socio-demographic factors, smoking intensity and time to first cigarette, smokers with severe (adjusted OR (AOR) 1.23, 95% CI 1.04 to 1.46, p=0.02) but not moderate (AOR 1.03, 95% CI 0.92 to 1.15, p=0.58) psychological distress were significantly more likely to smoke menthols compared with smokers with none/mild distress.

CONCLUSION

An elevated prevalence of menthol use was found among persons with severe psychological distress, suggesting another group that could potentially benefit from the regulation of menthol cigarettes.

Targeted advertising, promotion, and price for menthol cigarettes in California high school neighborhoods

OBJECTIVES

To describe advertising, promotions, and pack prices for the leading brands of menthol and nonmenthol cigarettes near California high schools and to examine their associations with school and neighborhood demographics.

METHODS

In stores (n = 407) within walking distance (0.8 km [1/2 mile]) of California high schools (n = 91), trained observers counted ads for menthol and nonmenthol cigarettes and collected data about promotions and prices for Newport and Marlboro, the leading brand in each category. Multilevel modeling examined the proportion of all cigarette advertising for any menthol brand, the proportion of stores with sales promotions, and the lowest advertised pack price in relation to store types and school/neighborhood demographics.

RESULTS

For each 10 percentage point increase in the proportion of Black students, the proportion of menthol advertising increased by 5.9 percentage points (e.g., from an average of 25.7%-31.6%), the odds of a Newport promotion were 50% higher (95% CI = 1.01, 2.22), and the cost of Newport was 12 cents lower (95% CI = -0.18, -0.06). By comparison, the odds of a promotion and the price for Marlboro, the leading brand of nonmenthol cigarettes, were unrelated to any school or neighborhood demographics.

CONCLUSIONS

In high school neighborhoods, targeted advertising exposes Blacks to more promotions and lower prices for the leading brand of menthol cigarettes. This evidence contradicts the manufacturer's claims that the availability of its promotions is not based on race/ethnicity. It also highlights the need for tobacco control policies that would limit disparities in exposure to retail marketing for cigarettes.

Smokers have varying misperceptions about the harmfulness of menthol cigarettes: national survey data

OBJECTIVE

To describe the prevalence of menthol use and perceptions of relative harmfulness among smokers in an ethnically diverse population where tobacco marketing is relatively constrained (New Zealand).

METHODS

The New Zealand (NZ) arm of the International Tobacco Control Policy Evaluation Survey (ITC Project) utilises the NZ Health Survey (a national sample). From this sample we surveyed adult smokers, with Wave 2 (n=923) covering beliefs around menthol cigarettes.

RESULTS

Agreement with the statement that "menthol cigarettes are less harmful than regular cigarettes" was higher in smokers who were: older, Māori, Pacific, Asian, financially stressed and had higher levels of individual deprivation. Most of these associations were statistically significant in at least some of the logistic regression models (adjusting for socio-economic and smoking beliefs and behaviour). In the fully-adjusted model this belief was particularly elevated in Pacific smokers (adjusted odds ratio [aOR] = 7.36, 95% CI = 1.92 - 28.27) and also in menthol smokers (aOR = 4.58, 95% CI = 1.94-10.78). Most smokers in this study (56%), and especially menthol smokers (73%), believed that menthols are "smoother on your throat and chest".

CONCLUSION

Various groups of smokers in this national sample had misperceptions around the relative harmfulness of menthols, which is consistent with most previous studies.

IMPLICATIONS

This evidence, along with a precautionary approach, supports arguments for enhanced regulation of tobacco marketing and tobacco ingredients such as menthol.

Menthol cigarettes and smoking cessation behaviour: a review of tobacco industry documents

OBJECTIVE

To determine what the tobacco industry knew about menthol's relation to smoking cessation behaviour.

METHODS

A snowball sampling design was used to systematically search the Legacy Tobacco Documents Library (LTDL) (http://legacy.library.ucsf.edu) between 15 May to 1 August 2010. Of the approximately 11 million documents available in the LTDL, the iterative searches returned tens of thousands of results. A final collection of 509 documents relevant to 1 or more of the research questions were qualitatively analysed, as follows: (1) perceived sensory and taste rewards of menthol and potential relation to quitting; and (2) motivation to quit among menthol users.

RESULTS

Menthol's cooling and anaesthetic effects mask the short-term negative physiological effects of smoking such as throat pain, burning and cough. This provides superficial physical relief as well as psychological assurance against concerns about the health dangers of smoking that would otherwise motivate smokers to quit. Menthol smokers, particularly women, perceive the minty aroma of menthol cigarettes to be more socially acceptable than non-menthol cigarettes.

DISCUSSION

Consumers believe menthol's sensory effects equate to health protections and that menthol cigarettes are more socially acceptable than non-menthol cigarettes. Menthol in cigarettes may encourage experimenters who find non-mentholated cigarettes too harsh, including young or inexperienced users, to progress to regular smoking rather than quitting, and may lessen the motivation to quit among established menthol smokers. The perception of menthol cigarettes as more socially acceptable lessens the impact of smoking denormalisation on quitting motivation. Menthol makes cigarettes easier and more palatable to smoke and less desirable to quit among established smokers. Fewer smokers quitting contributes to the incidence of tobacco-related diseases.

Menthol cigarettes: moving toward a broader definition of harm

RATIONALE

The current practice of the tobacco industry of primarily focusing on the extent that menthol cigarettes contribute or do not contribute to excess morbidity and mortality in various diseases does not, in and of itself, fully illuminate the harm caused by these products. In fact, this practice actually masks and obscures the public health harm associated with menthol cigarettes. Given this, this commentary develops and presents a broader definition of harm in which to view menthol cigarettes and as the necessary and underlying rationale of why this candy-flavored ingredient should be removed from all tobacco products.

METHODS

This paper relies on the scientific presentations of the 2nd Conference on Menthol Cigarettes, and the peer-reviewed literature on menthol cigarettes.

OUTCOMES

A broader definition of harm from menthol cigarettes must be analyzed from a broad public health perspective and take into account youth uptake and initiation, menthol's ability to augment addiction through unique sensory properties, spurious health messages associated with these products, menthol's role in cessation inhibition and relapse promotion, and the blatant predatory marketing of these products to the most vulnerable sectors of society.

CONCLUSIONS

The Food and Drug Administration (FDA) should apply the same logic that outlawed other candy flavorings and apply it to menthol cigarettes; in the end, all candy flavorings, including menthol, only serve to make the poisons inherent in tobacco smoke go down easier. Additionally, the mobilization of communities most affected by the menthol cigarettes, the FDA, and candy flavorings and the tobacco industry's machinations will be discussed.

The role of menthol in cigarettes as a reinforcer of smoking behavior

INTRODUCTION

The World Health Organization has identified several additives such as menthol in the manufacturing of cigarettes to specifically reduce smoke harshness. These additives may have important implications for reinforcing smoking behavior and motivation to quit smoking. The purpose of this paper is to synthesize research related to the role of menthol's sensory characteristics in strengthening the reinforcing effects of nicotine in cigarettes and the impact on nicotine addiction and smoking behavior.

METHODS

Research reports from 2002 to 2010 on the addictive potential of menthol cigarettes were reviewed that included qualitative focus groups, self-reports and biomarkers of nicotine dependence, human laboratory, and epidemiological studies.

RESULTS

Positive sensory effects of menthol cigarette use were identified via reports of early smoking experiences and as a potential starter product for smoking uptake in youth. Menthol cigarettes may serve as a conditioned stimulus that reinforces the rewarding effects of smoking. Nicotine dependence measured by shorter time-to-first cigarette upon waking was increased with menthol cigarette use in most of the studies reviewed. Smoking quit rates provide additional indicators of nicotine dependence, and the majority of the studies reviewed provided evidence of lower quit rates or higher relapse rates among menthol cigarette smokers.

CONCLUSIONS

The effects of menthol cigarette use in increasing the reinforcing effects of nicotine on smoking behavior were evidenced in both qualitative and quantitative empirical studies. These findings have implications for enhanced prevention and cessation efforts in menthol smokers.

Development and validation of a scale to assess attitudes and beliefs about menthol cigarettes among african american smokers

To develop more effective smoking cessation interventions for the 70% of African American smokers who smoke menthol cigarettes, it is important to understand smokers' reasons for choosing menthols verses nonmenthols. This study conducted a focus group of African American smokers about their attitudes and beliefs about menthol cigarettes. These attitudes and beliefs, along with others from the literature, were included in a survey of 720 African American smokers in Los Angeles County, California. Five common factors emerged-Medicinal Effects, Image, Less Harmful, Tradition, and Taste/Sensation. Menthol smokers had significantly higher scores on the Taste/Sensation, Medicinal Effects, and Less Harmful scales than nonmenthol smokers did. Men were significantly more likely than women to endorse Medicinal Effects, Image, and Tradition, whereas women were significantly more likely to endorse Taste/Sensation. Education was inversely associated with endorsement of Medicinal Effects, Image, Less Harmful, and Tradition. Respondents aged 40 years or older had significantly higher scores on Medicinal Effects, Image, and Less Harmful, compared with younger respondents. Smoking cessation interventions for African American menthol smokers should address commonly held myths that menthols have medicinal effects and are less harmful than nonmenthols, especially among smokers who are older, male, and/or have low levels of education. The new measures presented in this article could be useful for tailoring cessation interventions to individual smokers' attitudes and beliefs about menthol cigarettes.

Menthol and non-menthol smoking: the impact of prices and smoke-free air laws

AIMS

To examine the relationship between menthol and non-menthol prices and smoke-free air laws and the choice between menthol and non-menthol cigarettes among current smokers.

DESIGN, SETTING AND PARTICIPANTS

Data were extracted from the nationally representative (USA) 2003 and 2006/07 Tobacco Use Supplements to the Current Population Survey. A total of 57,383 adult smokers (aged 18+) were examined.

MEASUREMENTS

A regression model was used to estimate the probability of being a menthol smoker conditional on being a current smoker who had a distinct preference for either non-menthol or menthol cigarettes. Cigarette prices, smoke-free air laws and socio-economic and demographic characteristics were examined as covariates.

FINDINGS

The prices of menthol and non-menthol cigarettes were associated with the choice between menthol and non-menthol cigarettes. However, smokers did not find menthol and non-menthol cigarettes to be close substitutes for one another. Non-menthol cigarettes were found to be less of a substitute for menthol cigarettes than vice versa. Young adults and African Americans were less responsive to prices with respect to switching between menthol and non-menthol cigarettes than were older adults and non-African Americans, respectively.

CONCLUSIONS

The US Food and Drug Administration (FDA) is grappling with the issue of whether or not to ban menthol cigarettes. The findings from this study suggest that smokers do not find menthol and non-menthol cigarettes to be close substitutes. The strong preference for mentholated cigarettes may serve as a lever to reduce smoking prevalence when combined with increased access to effective cessation treatments.

Nicotine dependence and quitting behaviors among menthol and non-menthol smokers with similar consumptive patterns

AIMS

This study examines the associations between usual cigarette brand (i.e. menthol, non-menthol) and markers for nicotine dependence and quitting behaviors.

DESIGN

The 2003 and 2006/07 Tobacco Use Supplements to the Current Population Surveys were pooled to conduct secondary data analysis.

SETTING

National data were collected using in-person and telephone computer-assisted interviews by the United States Census Bureau among civilian, non-institutionalized people aged 15 years and older.

PARTICIPANTS

Data were analyzed among daily current smokers aged 18+ (n = 46,273).

MEASUREMENTS

The associations between usual cigarette brand and time to first cigarette within 5 and 30 minutes after waking, quit attempts in the past 12 months and length of smoking abstinence in the past 12 months were examined. Bivariate and multivariate logistic regression models were stratified by smoking intensity: ≤5, 6-10, 11-19 and 20+ cigarettes per day.

FINDINGS

Menthol smokers reported a mean of 13.05 compared with 15.01 cigarettes per day among non-menthol smokers (P < 0.001). Multivariate results showed that among smokers consuming 6-10 cigarettes per day, menthol smokers were significantly more likely than non-menthol smokers to consume their first cigarette within 5 minutes after waking (odds ratio = 1.22, 95% confidence interval = 1.05,1.43). The multivariate models did not show significant associations between usual cigarette brand and quit attempts in past 12 months or duration of smoking abstinence >2 weeks in the past 12 months.

CONCLUSIONS

Findings from this national survey of daily smokers demonstrate that menthol smokers in the United States who report consuming 6-10 cigarettes per day show greater signs of nicotine dependence than comparable non-menthol smokers.