Risk perceptions of menthol cigarettes compared with nonmenthol cigarettes among New Jersey adults

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults

OBJECTIVE

E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults.

METHODS

In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018.

RESULTS

Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03).

CONCLUSIONS

Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Nicotine self-administration with menthol and audiovisual cue facilitates differential packaging of CYP2A6 and cytokines/chemokines in rat plasma extracellular vesicles

In this study, we investigated whether intravenously self-administered nicotine with menthol and audiovisual cue modulates nicotine-metabolizing CYP2A6, oxidative stress modulators, and cytokines/chemokines in plasma extracellular vesicles (EVs) in rats. We assigned rats to self-administered nicotine with: (a) audiovisual cue (AV), (b) menthol, and (c) menthol and AV cue. We found increased levels of CD9 in plasma EVs after self-administered nicotine with menthol and AV cue. Moreover, expression of CYP2A6 in plasma EVs was significantly increased after self-administered nicotine in response to menthol and AV cue. However, despite an upward trend on SOD1 and catalase, increase was not found to be statistically significant, while total antioxidant capacity was found to be significantly increased in plasma and plasma EVs obtained after self-administered nicotine with menthol and AV cue. Among cytokine and chemokine profiling, we found a significant increase in the levels of MCP-1 after self-administered nicotine with menthol and AV cue and complete packaging of IL-1β in EVs. Taken together, the study provides evidence that nicotine in response to menthol and AV cues can package altered levels of CYP2A6, and cytokines/chemokines in plasma EVs that may contribute to cell–cell communication, nicotine metabolism, and inflammation upon cigarette smoking.

Fresher with flavour: young women smokers' constructions and experiences of menthol capsule cigarettes and regular cigarettes

Background

Flavour capsule cigarettes are one of the fastest growing segments of the tobacco market, and there is evidence that Australian young people are increasingly using menthol flavoured capsule cigarettes. This qualitative research examines how young women construct and experience menthol flavour capsule cigarettes as part of their smoking practices, and explores the perceived differences between menthol capsule cigarettes and regular cigarettes. Semi-structured face-to-face in-depth interviews were conducted with 41 Australian young women smokers, using a constructivist grounded theory approach.

Results

Findings reveal that the perceived fresh and improved taste of menthol and the ability to customise the smoking process positively contributed to young women’s experiences of smoking menthol capsule cigarettes. In particular, menthol capsule flavour cigarettes were constructed by the young women as “fresh”, “light” and “minty”, and “popping” the menthol capsule allowed the young women to personalise their smoking experience.

Conclusion

These results indicate that specific public health campaigns and legislation should be developed to counter the powerfully alluring effects and the innovative appeal of menthol capsule cigarettes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01297-2.

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.

Perceptions of Menthol Cigarettes and Reasons for Unsuccessful Quits in an African American Community Sample

This study aimed to better understand African Americans' perceptions of menthol tobacco and reasons for unsuccessful quit attempts among menthol smokers. A cross-sectional survey of 407 U.S.-born African American adults from Minnesota assessed menthol perceptions and experiences trying to quit menthol cigarettes. A majority of the sample (59%) was either unsure of the relative harm of menthol cigarettes or perceived that menthol cigarettes are less harmful than non-menthol cigarettes. Menthol smokers were more likely than nonsmokers to perceive that menthol makes it easier to start smoking and harder to quit, and that menthol cigarettes are marketed to African Americans more than other groups (ps < .05). Nearly half (45%) of menthol smokers who reported a failed quit attempt identified cravings as a reason why they were unsuccessful. Media campaigns and educational interventions that highlight the dangers of menthol and promote cessation resources are needed to help reduce the pernicious effects of menthol in the African American community.

Perceptions of Use Patterns and Health Consequences Associated With Mentholated Cigarettes Among U.S. Adults

Despite declines in overall cigarette smoking in the United States, menthol cigarette smoking prevalence has increased among young adults (18-25 years) and remains constant among older adults (26 years and older). Disparities in menthol cigarette use exist, with higher prevalence among younger adult smokers and among racial/ethnic minority populations. Menthol in cigarettes has been shown to play a role in increasing smoking initiation and making it more difficult to quit smoking. Little research focuses on perceptions of the addictive potential and health consequences of menthol cigarette use. This analysis uses data from a national panel of U.S. adults (n = 1,303) surveyed in 2016. Participants were asked to what extent they agreed with various statements regarding menthol use among demographic and tobacco use subgroups. These data reveal disparities in perceptions of the impact of menthol use, with Black, non-Hispanic, and Hispanic adults and adults with lower income and less education misperceiving the health effects and addiction potential of menthol in cigarettes. Determining how and to what extent population subgroups understand the effect of menthol cigarette use can inform public education strategies and, in turn, policy efforts to ban or restrict menthol cigarette availability.

Harm Perceptions of Menthol and Nonmenthol Cigarettes Differ by Brand, Race/Ethnicity, and Gender in US Adult Smokers: Results from PATH Wave 1

INTRODUCTION

Harm perceptions of menthol cigarettes may contribute to their appeal and use. African-Americans, women, and younger smokers disproportionately use menthol cigarettes, and may misperceive harm of menthol cigarettes.

METHODS

Data were from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Weighted analyses of current adult smokers (18 and older) were used to estimate the correlates of menthol smoking among all cigarette brands and separately for the top three cigarette brands (Newport, Camel, and Marlboro). Adjusted models examined the main effect of menthol smoking on harm perceptions of one's own brand of cigarette and interactions with race/ethnicity, age, and gender.

RESULTS

Menthol cigarettes were used by nearly 40% of current smokers, although the prevalence of menthol smoking differed across the top three brands (94% Newport, 46% Camel, and 18% Marlboro). Among menthol smokers, 80% perceived their cigarette as equally harmful, 14% perceived their brand as more harmful, and 7% perceived their brand as less harmful. In adjusted models, menthol smokers were more likely than nonmenthol smokers to misperceive their own brand as more harmful than other brands (compared to no difference in harm). Race and gender emerged as moderators of the association between menthol brand preference and harm perceptions.

CONCLUSIONS

In adjusted analyses, menthol smokers were more likely than nonmenthol smokers to perceive their brand as more harmful than other brands, with differences by sub-groups who disproportionately use menthol.

IMPLICATIONS

Menthol cigarettes have been historically marketed with messages conveying lower harm than other cigarettes. Little is known about how contemporary adult menthol smokers perceive the harm of their usual brand, and potential differences by race, gender, and young adult versus older adult age group. After adjusting for other factors, menthol smokers were more likely than nonmenthol smokers to perceive their cigarette brand as more harmful than other brands. Further, the association between menthol smoking and harm perceptions differed by race and gender, but not by age group (young adult vs. older adult). This type of large-scale study identifies critical links between menthol smoking and harm perceptions among vulnerable smokers that will inform regulatory actions designed to decrease smoking-related harm.

In Their Own Words: Young Adults' Menthol Cigarette Initiation, Perceptions, Experiences and Regulation Perspectives

Background

Menthol cigarettes are disproportionately used by young people and have been called smoking starter products. However, limited qualitative research exists on young adults' perceptions of and experiences with these products, with much of it based on document reviews of the tobacco industry's research.

Methods

We conducted six focus groups with young adult (ages 18-24) menthol smokers in New Jersey (half with black smokers) between December 2014 and March 2015. Participants were asked open-ended questions about their menthol smoking initiation, preference reasons, substitution behaviors, and perceptions of menthol cigarette risks and regulation.

Results

Participants' menthol cigarette initiation and preference were influenced by their perceived popularity, brand recognition, taste, smoothness, satisfaction and access (including as "loosies," typically available for Newport). Some believed menthol cigarettes were less harmful than non-menthol cigarettes when initiating smoking. Many currently believed menthol cigarettes were more harmful because they contained extra "additives," were stronger (ie, requiring fewer cigarettes to feel satisfied), and/or based on hearsay. Many had tried new brand Camel Crush, which was perceived to be especially minty, fun, and attractive for newer smokers. While some used non-menthol cigarettes when menthols were unavailable, many said they would never or almost never substitute. Many acknowledged a menthol cigarettes ban would likely help them quit smoking, even though they did not support the idea.

Conclusions

Menthol cigarette initiation is influenced by an interplay of multiple factors including their sensory properties, marketing, perceived popularity and availability. The FDA should continue to pursue closing this flavored cigarette loophole.

Implications

In this first qualitative study of menthol cigarette use among young adults, we found further evidence that menthol cigarettes can act as starter products because they are perceived as easier to smoke and taste and smell better than non-menthol cigarettes. We also add to the literature in finding that menthol cigarettes are perceived by young people who smoke menthol cigarettes as delivering satisfaction with fewer cigarettes, being accessible as "loosies", and being popular among their peers. Many did not understand the reasons behind a potential menthol ban. Any future regulation of menthol cigarettes should include a public educational campaign to support buy-in.

Influence of Electronic Cigarette Characteristics on Susceptibility, Perceptions, and Abuse Liability Indices among Combustible Tobacco Cigarette Smokers and Non-Smokers

This study assessed how electronic cigarette (ECIG) characteristics amenable to regulation-namely nicotine content, flavor, and modified risk messages-impact ECIG use susceptibility, harm/addiction perceptions, and abuse liability indices among combustible tobacco cigarette (CTC) smokers and non-smokers. CTC smokers and non-smokers varying in ECIG use recruited via Amazon Mechanical Turk (MTurk) completed an online survey in 2016 (analytic n = 706). Participants were randomly assigned to one of eight conditions differing in ECIG characteristics: nicotine content (no, low, high), flavor (menthol, tobacco, fruit), or modified risk message (reduced harm, reduced carcinogen exposure). Regressions assessed ECIG susceptibility, harm/addiction perceptions, and abuse liability indices (purchase task measures of breakpoint/intensity) within each regulatory domain (nicotine content, flavor, message) and their interactions with CTC/ECIG status. Differential effects on ECIG susceptibility, harm/addiction perceptions, and abuse liability indices were observed by regulatory domain with many effects moderated by CTC/ECIG status. ECIG nicotine content and flavor conditions were the most influential across outcomes. Greater nicotine content, tobacco-flavored and reduced carcinogen exposure ECIGs were more highly preferred by CTC smokers with some differing preferences for non-users. Findings reinforce consideration of discrete ECIG preferences across tobacco use status to improve regulatory efficacy.

Menthol cigarettes and the public health standard: a systematic review

Background

Although menthol was not banned under the Tobacco Control Act, the law made it clear that this did not prevent the Food and Drug Administration from issuing a product standard to ban menthol to protect public health. The purpose of this review was to update the evidence synthesis regarding the role of menthol in initiation, dependence and cessation.

Methods

A systematic review of the peer-reviewed literature on menthol cigarettes via a PubMed search through May 9, 2017. The National Cancer Institute’s Bibliography of Literature on Menthol and Tobacco and the FDA’s 2011 report and 2013 addendum were reviewed for additional publications. Included articles addressing initiation, dependence, and cessation were synthesized based on study design and quality, consistency of evidence across populations and over time, coherence of findings across studies, and plausibility of the findings.

Results

Eighty-two studies on menthol cigarette initiation (n = 46), dependence (n = 14), and cessation (n = 34) were included. Large, representative studies show an association between menthol and youth smoking that is consistent in magnitude and direction. One longitudinal and eight cross-sectional studies demonstrate that menthol smokers report increased nicotine dependence compared to non-menthol smokers. Ten studies support the temporal relationship between menthol and reduced smoking cessation, as they measure cessation success at follow-up.

Conclusions

The strength and consistency of the associations in these studies support that the removal of menthol from cigarettes is likely to reduce youth smoking initiation, improve smoking cessation outcomes in adult smokers, and in turn, benefit public health.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4987-z) contains supplementary material, which is available to authorized users.

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.

Perceived Relative Harm of Selected Cigarettes and Non-Cigarette Tobacco Products-A Study of Young People from a Socio-Economically Disadvantaged Rural Area in Poland

The perceived health risk of recently introduced nicotine and tobacco products may influence both their uptake and continued use. The aim of the study was to assess how adolescents rate relative harmfulness of slim and menthol cigarettes, water pipes, e-cigarettes, and smokeless tobacco compared to regular cigarettes. Cross-sectional survey data from students aged 13-19 years from Piotrkowski district, Poland were analyzed. Among the sample of 4050 students, 3552 respondents completed anonymous, confidential, self-administered questionnaire adapted from the Global Youth Tobacco Survey (GYTS). The study results indicate that the students perceived slim cigarettes and menthol cigarettes as less harmful, which is in line with the message created by tobacco companies. On the other hand, less popular products such as water pipes and smokeless tobacco were considered as more harmful. The current study indicates insufficient and misleading perception of harmfulness of different tobacco/nicotine products available on the Polish market. Simultaneously, there is insufficient countrywide public health education in this matter. Preventive measures are necessary to discourage young people from smoking uptake and to ensure that potential consumers can, based on objective data, make informed decisions about cigarettes and non-cigarette tobacco products.

Young Adults' Risk Perceptions of Various Tobacco Products Relative to Cigarettes: Results From the National Young Adult Health Survey

Objectives Tobacco product risk perceptions may influence whether individuals use those products instead of or in addition to regular cigarettes. This study aimed to explore risk perceptions of various tobacco products relative to traditional cigarettes with young adults, a group with higher rates of tobacco use. Method We examined risk perception responses among a nationally representative sample of young adults (age 18-34 years; n = 2,871, including tobacco and non-tobacco users) from the 2011 National Young Adult Health Survey. Results Most (57.8%) respondents believed that e-cigarettes were less risky than cigarettes. Respondents were more likely to rate combustible products hookah (24.5%) and cigars (13.9%) as being less risky compared to noncombustible snus (10%) and other smokeless tobacco (SLT) products (7.1%) relative to cigarettes. Few (2.5%) rated menthol cigarettes as less risky. For e-cigarettes, hookah, and SLT, less risky beliefs were significantly higher among ever or current versus never product users. Between 22% and 33% of all respondents believed that SLT, snus, menthol cigarettes, and cigars were more risky than cigarettes, but differences in this belief between current and nonusers of these products were small and insignificant. Younger young adults were more likely to rate e-cigarettes and hookah as being "less risky" and rate cigars and SLT as being "more risky" than older young adults. Conclusion The public's views of comparative tobacco risk perceptions vary widely by tobacco product type and age-group. While "less risky" perceptions may be associated with product use, perceptions that products are "more risky" than cigarettes may not necessarily dissuade people from their use.

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.

Sociodemographic and substance use correlates of tobacco use in a large, multi-ethnic sample of emergency department patients

Strong evidence suggests marked disparities among ethnic minorities in relation to tobacco use. To date, a majority of the data available discusses tobacco use in the general population. Using a sample of Latino, non-Latino Black (NLB), and non-Latino White (NLW) patients presenting to the emergency departments, the present study examined sociodemographic and substance use correlates of past 3-month tobacco use. Over 48,000 patients were interviewed as part of a screening and brief intervention program in southern California. Overall, although NLB adults reported the greatest prevalence of tobacco use compared to NLWs and Latinos (43% vs. 34% and 22% respectively), associations between tobacco use, demographics and substance use were similar across groups. Males, younger individuals, those with lower income, and being at higher risk for alcohol and drug use were more likely to report recent tobacco use. Future tobacco interventions in emergency settings should highlight these specific risk factors for Latinos, NLBs, and NLWs.

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: putting the pieces together

Objective

To integrate information on cigarette companies' understanding and use of menthol as summarised in published research based on previously internal tobacco industry documents with results from large population-based surveys of tobacco use and other independent sources.

Data sources

Papers published in this supplement of Tobacco Control, together with papers identified using PubMed searches.

Results

Tobacco companies shaped consumer perceptions of menthol cigarettes. Menthol is not just a flavouring agent. Cigarette companies use menthol's ability to mask irritation and provide sensory effects to make menthol cigarettes appeal to youth and health-concerned smokers, in part because menthol makes low-tar cigarettes more palatable. Consistent with targeted marketing, youths, women and African Americans disproportionately smoke menthols. There appear to be complex interactions with addictive effects of nicotine. The ubiquitous addition of menthol by tobacco companies to over 90% of all tobacco products, whether labelled ‘menthol’ or not, demonstrates that menthol is not simply a flavour or brand. Menthol imparts sensory characteristics to cigarettes and has a complex interaction with nicotine that affects smoking behaviour whether it is perceived or not, or whether cigarettes containing menthol are marketed as ‘menthol’ or not. Adding menthol increases fine particles in cigarette smoke, which have immediate adverse effects on the risk of heart attack.

Conclusion

Information from industry documents, confirmed by independent scientific literature, consistently demonstrates that menthol increases population harm from smoking by increasing initiation and reducing cessation in some groups. Menthol facilitates and increases smoking, which causes disease and death.

Ethnoracial differences in emergency department patients' tobacco use

INTRODUCTION

This study examined ethnoracial differences in lifetime and recent tobacco use and related problems in a large convenience sample of Latino, Black, and Non-Latino White emergency department (ED) patients. In addition, ED patients' use rates were compared with those of a statewide sample.

METHODS

Trained bilingual/bicultural health educators screened almost 53,000 ED patients in 8 ED/trauma units throughout San Diego County over a 2-year period. Measures included sociodemographic characteristics and tobacco use measures from the Alcohol, Smoking, and Substance Involvement Screening Test brief screening instrument.

RESULTS

A consistent finding was the lower prevalence of tobacco use among Latino patients compared with Black and Non-Latino White patients. Compared with their general population counterparts, Non-Latino White, Latino, and Black patients were more likely to have used tobacco in their lifetime and on a daily basis.

CONCLUSIONS

Results indicate the high tobacco risk status of ED patients, regardless of ethnicity. More work is needed to develop effective approaches for ED-initiated tobacco interventions for patients in various racial/ethnic groups. Offering tobacco cessation support in opportune venues such as the ED holds great potential to improve accessibility to public health interventions for many underserved communities who may not have regular interaction with a primary care provider.

Beyond light and mild: cigarette brand descriptors and perceptions of risk in the International Tobacco Control (ITC) Four Country Survey

AIMS

To examine perceptions of risk related to type of cigarette brand.

DESIGN AND SETTING

Cross-sectional findings from wave 5 of the ITC Four Country Survey, conducted with nationally representative samples of smokers in 2006.

PARTICIPANTS

A total of 8243 current and former adult (≥18 years) smokers from Canada (n=2022), the United States (n=2034), the United Kingdom (n=2019) and Australia (n=2168).

MEASUREMENTS

Outcomes included beliefs about the relative risks of cigarettes, including perceptions of 'own' brand. Correlates included socio-demographic, smoking-related covariates and brand characteristics.

FINDINGS

One-fifth of smokers believed incorrectly that 'some cigarette brands could be less harmful' than others. False beliefs were higher in both the United States and United Kingdom compared to Canada and Australia. Smokers of 'light/mild', 'slim' and 100 mm/120 mm cigarettes were more likely to believe that some cigarettes could be less harmful [odds ratio (OR)=1.29, 95% confidence interval (CI)=1.12-1.48 and that their own brand might be a little less harmful (OR=2.61, 95% CI=2.01-3.41). Smokers of 'gold', 'silver', 'blue' or 'purple' brands were more likely to believe that their 'own brand might be a little less harmful' compared to smokers of 'red' or 'black' brands (OR=12.48, 95% CI=1.45-107.31).

CONCLUSIONS

Despite current prohibitions on the words 'light' and 'mild', smokers in western countries continue to falsely believe that some cigarette brands may be less harmful than others. These beliefs are associated with descriptive words and elements of package design that have yet to be prohibited, including the names of colours and long, slim cigarettes.

Marketing of menthol cigarettes and consumer perceptions

In order to more fully understand why individuals smoke menthol cigarettes, it is important to understand the perceptions held by youth and adults regarding menthol cigarettes. Perceptions are driven by many factors, and one factor that can be important is marketing. This review seeks to examine what role, if any, the marketing of menthol cigarettes plays in the formation of consumer perceptions of menthol cigarettes. The available literature suggests that menthol cigarettes may be perceived as safer choices than non-menthol cigarettes. Furthermore, there is significant overlap between menthol cigarette advertising campaigns and the perceptions of these products held by consumers. The marketing of menthol cigarettes has been higher in publications and venues whose target audiences are Blacks/African Americans. Finally, there appears to have been changes in cigarette menthol content over the past decade, which has been viewed by some researchers as an effort to attract different types of smokers.

Perceptions of menthol cigarette use among U.S. adults and adult smokers: findings from the 2009 HealthStyles survey

INTRODUCTION

Perceptions of menthol cigarette use may have implications for smoking initiation and cessation. This study explores harm and health perceptions of menthol cigarette use among a national sample of U.S. adults and current smokers.

METHODS

We examined data from the 2009 HealthStyles survey (n = 4,556), an annual mail survey of adults ≥18 years of age that collects information on attitudes and behaviors, including smoking. Frequencies and weighted percentages were calculated by sex, race/ethnicity, age, education level, household income, and smoking status. Unadjusted odds ratios (OR) were used to compare perceptions of menthol cigarette use between demographic groups.

RESULTS

Close to half of adults (45.8%) believed that menthol cigarettes are just as harmful as nonmenthol cigarettes, and 40.9% of adults did not know whether menthol cigarettes are more or less harmful than nonmenthol cigarettes. Few adults (0.6%), including smokers, perceived menthol cigarettes to be less harmful than nonmenthol cigarettes. Blacks (OR = 3.22, 95% CI = 1.80-5.76) were more likely to believe that menthol cigarettes have health benefits when compared with Whites. Almost half of current smokers believed menthol cigarettes are equally addictive as nonmenthol cigarettes and 74.9% believed menthol and nonmenthol cigarettes are equally hard to quit.

CONCLUSIONS

Findings suggest directions for targeted public health messages for menthol cigarette use. Future research is needed among a nationally representative sample to capture more subtle differences in perceptions among menthol and nonmenthol smokers.