Menthol cigarettes: moving toward a broader definition of harm

Tax incidence for menthol cigarettes by race: Evidence from Nielsen Homescan data

We use Nielsen Homescan data to examine whether the incidence of cigarette taxes on menthol products varies with race. We find that taxes are shifted at significantly lower rates to Black smokers of menthol cigarettes than any other smokers. One possible explanation is that the industry targets price promotions to Black menthol smokers because they tend to be more responsive to cigarette prices relative to other smokers. We find evidence that Black smokers receive significantly more price discounts for menthol products than white menthol smokers. Our findings indicate that increasing cigarette taxes would effectively reduce menthol smoking among Black Americans because tax pass-through rate for Black menthol smokers is still substantially above zero.

Does removing menthol cigarettes in convenience stores reduce susceptibility to cigarette smoking? An experimental investigation in young people

BACKGROUND

Evidence for the effectiveness of menthol cigarette bans comes mostly from studies of adults that smoke. This experiment evaluated whether the absence of menthol products from a convenience store influenced young people's susceptibility to cigarette smoking after they shopped in the store.

METHODS

This experiment took place in the RAND StoreLab (RSL), a life-sized research convenience store. A three-group, between-subjects design was used. Study conditions differed in the mix of flavored tobacco products the RSL displayed: 1) All tobacco-, sweet-, and menthol-flavors displayed; 2) only tobacco- and menthol-flavors displayed; and 3) only tobacco-flavors displayed. Participants were randomly assigned to shop in the RSL under one of these conditions and after shopping, completed measures of their susceptibility to cigarette smoking, one measure for menthol cigarettes and one for unflavored cigarettes (scores on each susceptibility measure was dichotomized: 0 = not susceptible; 1 = susceptible).

RESULTS

Multivariable logistic regression assessed the main effects of condition on susceptibility to smoking menthol and unflavored cigarettes. There was no condition effect on susceptibility to smoking unflavored cigarettes. However, removing menthol-flavored products significantly increased participants' susceptibility to smoking menthol cigarettes compared to when all flavored products were available (OR = 3.66, 95% CI [1.33, 10.03]). This significant effect was only found among young people with some pre-existing risk of cigarette smoking (OR = 5.92, 95% CI [1.81, 19.39]).

CONCLUSION

Results suggest the need to consider that menthol bans could unintentionally increase the appeal of menthol cigarettes among youth already at risk of smoking.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

OBJECTIVES

Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.

METHODS

We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.

RESULTS

The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.

CONCLUSIONS

The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Menthol cigarette use in substance use disorder treatment before and after implementation of a county-wide flavoured tobacco ban

INTRODUCTION

This study examined the impact of a San Francisco City and County ban on all flavoured tobacco products, including menthol cigarettes, among clients in residential substance use disorder (SUD) treatment.

METHODS

We conducted cross-sectional surveys of clients at two residential SUD programmes before the County began enforcing the ban (n=160) and twice after enforcement began (n=102, n=120). The samples were compared on demographic characteristics, smoking status, smoking behaviours and the proportion reporting menthol as their usual cigarette. Menthol smokers were asked whether they smoked only menthol cigarettes, mostly menthol, both menthol and non-menthol or mostly non-menthol. Post-ban samples were asked about awareness of the ban and access to menthol cigarettes.

RESULTS

In multivariate analyses, we found no evidence that the ban was associated with decreased number of cigarettes per day or increased readiness to quit among current smokers. However, odds were lower post-ban for reporting menthol as the usual cigarette (OR=0.80, 95% CI 0.72 to 0.90), and for smoking only menthol cigarettes (OR=0.19, 95% CI 0.18 to 0.19). Perhaps most importantly, and with the ability to influence all other findings, 50% of self-identified menthol smokers reported purchasing menthol cigarettes in San Francisco nearly 1 year after the ban was implemented.

CONCLUSION

In subgroups where smoking has remained elevated, like those receiving SUD treatment, local menthol bans may have only modest impacts on smoking behaviour. Broader regional, state or national bans, that effectively restrict access to menthol products, may be needed to show stronger effects on smoking behaviour.

The impact of menthol cigarette use on quit attempts and abstinence among smokers with opioid use disorder

An exceedingly high proportion of persons with opioid use disorder (OUD) smoke cigarettes. Smokers with OUD face multiple barriers to smoking cessation. While menthol cigarette use has been associated with low cessation rates, research has not explored the impact of menthol cigarette use on tobacco use outcomes among smokers with OUD. Participants were current smokers, in methadone treatment for OUD, participating in randomized controlled trials of smoking cessation therapies. We examined the use of menthol cigarettes, and the association between menthol cigarette use and achieving 24-hour quit attempts and seven-day point prevalence abstinence. Of 268 participants, 237 (88.4%) reported menthol use. A similar proportion of menthol and non-menthol smokers achieved a 24-hour quit attempt (83.1% vs. 83.8%, p = 0.92). Though fewer menthol smokers (vs. non-menthol smokers) achieved abstinence (12.7% vs. 22.6%), this did not reach statistical significance (p = 0.14). In this sample of smokers with OUD, menthol smoking was nearly ubiquitous. Menthol smoking was not associated with differences in quit attempts, but was associated with differences in cessation that were not statistically significant. Menthol smoking may contribute to the challenges in achieving abstinence among smokers with OUD.

The Relationship Between Menthol Cigarette Use, Smoking Cessation, and Relapse: Findings From Waves 1 to 4 of the Population Assessment of Tobacco and Health Study

INTRODUCTION

Some, but not all, studies suggest that menthol cigarette smokers have more difficulty quitting than non-menthol cigarette smokers. Inconsistent findings may be a result of differences in smoker characteristics (eg, daily vs. non-daily smokers) across studies. This study examines the relationship between menthol cigarette use, cessation, and relapse in a longitudinal, nationally representative study of tobacco use in the United States.

AIMS AND METHODS

Data come from four waves of the Population Assessment of Tobacco and Health Study. Waves 1-4 were conducted approximately annually from September 2013 to January 2018. Generalized estimating equation models were used to prospectively examine the relationship between menthol cigarette use, cessation, and relapse in non-daily and daily adult (18+) smokers. Cessation was defined as smokers who had not used cigarettes within the past 30 days at their subsequent assessment. Relapse was defined as cessation followed by past 30-day smoking in the next assessment.

RESULTS

Among daily smokers (n = 13 710), 4.0% and 5.3% of menthol and non-menthol smokers quit after 1 year, respectively. In an adjusted model, menthol smokers were less likely to quit compared with non-menthol smokers (odds ratio [OR] = 0.76 [0.63, 0.91]). When the sample was stratified by race/ethnicity, African American (OR = 0.47 [0.24, 0.91]) and White (OR = 0.78 [0.63, 0.97]) daily menthol users were less likely to have quit. Among non-daily smokers (n = 3608), there were no significant differences in quit rates. Among daily and non-daily former smokers, there were also no differences in relapse rates between menthol and non-menthol smokers.

CONCLUSIONS

Menthol cigarette use is associated with lower odds of cessation.

IMPLICATIONS

Findings from this study suggest that menthol cigarette use is associated with lower odds of cessation, but not relapse. Removing menthol cigarettes from the market may improve cessation rates.

Menthol additives to tobacco products. Reasons for withdrawing mentholated cigarettes in European Union on 20th may 2020 according to tobacco products directive (2014/40/EU)

Menthol, which is a natural cyclic monoterpene alcohol with a minty smell, is one of the main constituents of essential oils that naturally occur in some aromatic plants, such as Mentha × piperita L. This natural compound shows many biological properties, such as anesthetic, analgesic, antibacterial and antifungal, immunomodulating, and skin penetration-enhancing. It is added to a variety of goods, such as food, oral-care products, OTC products, cosmetics, and tobacco products. Menthol is not just a simple flavoring agent, especially when it comes to tobacco products. Its ability to 'mask' the negative effects of nicotine and its additional positive sensory effects makes it the most common additive in such products. For the customers, mentholated tobacco products may be mistakenly perceived as less harmful for health, which may increase their consumption. However, as the evidence shows, menthol cigarettes are no safer than conventional cigarettes and may lead to more frequent disease exacerbation during prolonged exposure to smoke from such products. In addition, because of its complex interactions with nicotine, menthol may affect smoking behavior and may increase addiction to nicotine. For those reasons, the European Union banned flavored cigarettes (whose sale size reached more than 3% of the total tobacco product market) by implementing the Tobacco Products Directive (2014/40/EU) on 20th May 2020. While the menthol ban was based on health concerns, the ultimate effect on consumers, regarding potential quitting, is yet to be determined.

Menthol, Nicotine, and Flavoring Content of Capsule Cigarettes in the US

Objectives

Characterize physical design features of cigarette brands sold in the US according to the delivery method of menthol that may affect sensory perception among users.

Methods

Twelve cigarette brands, mentholated and non-mentholated, were purchased for analyses of the physical design characteristics, quantification of nicotine and menthol, and identification of flavor additives.

Results

Physical design characteristics did not differ significantly between the various cigarette brands. However, significant differences were seen in levels of menthol. Menthol levels were greatest in products that had dual delivery methods of menthol (6.7mg/cigarette; SE=0.27) followed by products mentholated in a filter capsule only (5.7mg/cigarette; SE=0.25), and those mentholated in the tobacco only (3.8mg/cigarette; SE=0.12); products that were not mentholated had the least (0.38mg/cigarette; SE=0.31). Finally, flavor additives with a mint flavor profile other than menthol were identified, such as pulegone and limonene, and differed between cigarette brands, which are likely contributing to the menthol flavor experience associated with use of these products.

Conclusions

The regulation of menthol delivery method, flavorings added to the capsule, and/or menthol concentration may be beneficial for the public health as these factors are likely creating unique sensory experiences.

Menthol Cigarettes and Smoking Cessation among Adult Smokers in the US

Objectives: In this study, we identified differences in cessation, nicotine dependence, and quit attempts between smokers using non-menthol cigarettes and smokers using menthol cigarettes differing in menthol delivery method (eg, menthol in the tobacco only, crushable capsules only or both). Methods: We analyzed data from the Population Assessment of Tobacco and Health Study, Waves 1 and 2 (W1 and W2), to determine associations of delivery method of menthol with cessation, nicotine dependence, and quit attempts among current adult cigarette smokers. Results: Nearly 40% of US smokers reported using a mentholated cigarette product with most using a product mentholated in the tobacco only. Smokers included in this analysis had a moderate to low heaviness of smoking index score. The lowest average score was among those using products mentholated in a filter capsule only (1.3, SE = .10), and the highest among those using non-mentholated products (2.4, SE = .03). About 12% of smokers quit between W1 and W2. Cessation, nicotine dependence, and quit attempts at W2 were not associated with delivery method of menthol at W1. Conclusions: Method of menthol delivery did not impact cessation, nicotine dependence, and quit attempts.

Menthol facilitates dopamine-releasing effect of nicotine in rat nucleus accumbens

Menthol is a significant flavoring additive in tobacco products. Accumulating clinical evidence suggests that menthol may promote tobacco smoking and nicotine dependence. Our previous studies demonstrated that menthol enhanced nicotine reinforcement in rats. However, it is unclear whether menthol interacts with nicotine at the neurochemical level. The present study used intracranial microdialysis to examine whether and the ways in which menthol affects nicotine-induced dopamine release in rats in the nucleus accumbens core (NAc), a terminal field of brain reward circuitry. To make comparisons with our previous work that showed an enhancing effect of menthol on nicotine self-administration behavior, male Sprague-Dawley rats were first trained in 20 daily 1-h sessions to press a lever for intravenous nicotine self-administration (15 μg/kg/infusion). Dopamine levels were then measured in the right NAc using intracranial microdialysis coupled with high-performance liquid chromatography. Five minutes before microdialysis, the rats received an intraperitoneal injection of menthol (0, 1, 2.5, and 5 mg/kg), a subcutaneous injection of nicotine (0.2 mg/kg or its vehicle), or both. Menthol alone did not affect dopamine levels in dialysates, whereas nicotine alone elevated dopamine levels. Combined nicotine and menthol administration significantly increased dopamine levels compared with nicotine alone. These data indicate a facilitating effect of menthol on nicotine-induced dopamine release in the NAc. These findings shed light on our understanding of the neurobiological mechanisms that underlie the menthol-induced enhancement of nicotine reinforcement.

Disparities in retail marketing for menthol cigarettes in the United States, 2015

This study describes retail marketing for menthol cigarettes and its relationship with neighborhood demographics in a national sample of tobacco retailers in the United States. Mixed-effects models were used to examine three outcomes: menthol cigarette exterior advertising, menthol cigarette price promotions, and the pack price of menthol and non-menthol cigarettes. Thirty-eight percent of retailers displayed at least one menthol advertisement on the store exterior and 69% advertised price promotions. Retail advertising was more common in neighborhoods in the second (OR = 1.5 [1.1, 2.0]) and fourth (OR = 1.9 [1.3, 2.7]) quartiles of Black residents as compared to the lowest quartile. Menthol advertising was more prevalent in the third (OR = 1.4 [1.0, 1.9]) and lowest (OR = 1.6 [1.2, 2.2]) income quartiles as compared to the highest quartile. Price promotions for Newport were more common in neighborhoods with the highest quartile of Black residents (OR = 1.8 [1.2, 2.7]). Prices of Newport were cheaper in neighborhoods with the highest quartiles of youth, Black residents, and lower-income households. Policies that restrict the sales and marketing of menthol cigarettes are needed to address disparities.

Effects of menthol and its interaction with nicotine-conditioned cue on nicotine-seeking behavior in rats

RATIONALE

Increasing clinical evidence suggests that menthol, a significant flavoring additive in tobacco products, may contribute to smoking and nicotine dependence. Relapse to smoking behavior presents a formidable challenge for the treatment of tobacco addiction. An unresolved issue is whether the mentholation of tobacco products precipitates relapse to tobacco use in abstinent smokers.

OBJECTIVES

The present study examined the effects of menthol on the perseverance and relapse of nicotine-seeking behavior in rats.

METHODS

Male Sprague-Dawley rats were trained to press a lever for intravenous nicotine self-administration (0.03 mg/kg/infusion) under a fixed-ratio five schedule of reinforcement. Each nicotine infusion was signaled by the presentation of a sensory stimulus that was established as a discrete nicotine-conditioned cue. Five minutes prior to the sessions, the rats received an intraperitoneal injection of menthol (0.1 mg/kg) or vehicle. In the subsequent extinction test sessions, nicotine was unavailable with or without menthol and/or the nicotine-conditioned cue. The reinstatement tests were performed the following day after the extinction criterion was met. Menthol was also tested on food-seeking responses. In a subset of nicotine-trained rats, a transient receptor potential melastatin 8 (TRPM8) antagonist RQ-00203078 was given prior to menthol administration.

RESULTS

Continued administration of menthol sustained responses on the previously active and nicotine-reinforced lever in the extinction tests. The readministration of menthol after extinction reinstated active lever responses. In both the extinction and the reinstatement tests, a combination of pre-session menthol administration and cue representation during the session produced a more robust behavioral effect than either menthol or the cue alone. No such effects of menthol was observed in food trained rats. RQ-00203078 did not change menthol effect on nicotine seeking.

CONCLUSION

These data demonstrated that menthol specifically sustained and reinstated nicotine-seeking behavior, and this effect was independent of TRPM8 activity. These findings suggest that menthol in most tobacco products, even not menthol labeled, may contribute to the perseverance of and relapse to tobacco-seeking behavior.

Little Cigars vs 3R4F Cigarette: Physical Properties and HPHC Yields

OBJECTIVE

Our objective was to characterize physical properties and semivolatile harmful and potentially harmful constituent yields in the mainstream smoke (MSS) of 4 popular little cigars compared to the 3R4F reference cigarette.

METHODS

We used the ISO and Canadian Intense Regimen protocols to generate MSS for Cheyenne (Full Flavor and Menthol) and Swisher Sweets (Original and Sweet Cherry) little cigars; and the 3R4F. We examined physical properties such as length, tobacco filler mass, pressure drop, and ventilation for each product. Nicotine, benzo[a]pyrene, and tobacco-specific nitrosamine (TSNA) yields were determined in the MSS.

RESULTS

Little cigars were longer (~15mm), contained more tobacco filler (100-200 mg), and had a higher pressure drop (~1.3X) compared to the 3R4F. Ventilation holes were found only on the filter paper of the 3R4F. Nicotine transmitted to the MSS was similar for all products under the intense smoking protocol. The highest yields of TSNAs and benzo(a)pyrene were measured for the little cigars.

CONCLUSIONS

Little cigars may deliver similar levels of nicotine but higher levels of carcinogens to the MSS compared to cigarettes. Thus, previous reports on the toxicity of tobacco smoke based on cigarettes might not apply to little cigar products.

Enhancing effect of menthol on nicotine self-administration in rats

RATIONALE

Tobacco smoking is a leading preventable cause of premature death in the USA. Menthol is a significant flavoring additive in tobacco products. Clinical evidence suggests that menthol may promote tobacco smoking and nicotine dependence. However, it is unclear whether menthol enhances the reinforcing actions of nicotine and thus facilitates nicotine consumption. This study employed a rat model of nicotine self-administration to examine the effects of menthol on nicotine-taking behavior.

METHODS

Male Sprague-Dawley rats were trained in daily 1-h sessions to press a lever for intravenous nicotine self-administration under a fixed-ratio 5 schedule of reinforcement. In separate groups, rats self-administered nicotine at four different doses (0.0075, 0.015, 0.03, and 0.06 mg/kg/infusion). Five minutes prior to the two test sessions, menthol (5 mg/kg) or its vehicle was administered intraperitoneally in all rats in a counterbalanced design within each group. In separate rats that self-administered 0.015 mg/kg/infusion nicotine, menthol dose-response function was determined. Menthol was also tested on food self-administration.

RESULTS

An inverted U-shaped nicotine dose-response curve was observed. Menthol pretreatment shifted the nicotine dose-response curve to the left. The facilitating effect of menthol on the self-administration of 0.015 mg/kg/infusion nicotine was dose-dependent, whereas it produced similar effects at doses above the threshold of 2.5 mg/kg. Menthol tended to suppress the self-administration of food pellets.

CONCLUSIONS

These data demonstrate that menthol enhances the reinforcing effects of nicotine, and the effect of menthol was specific to nicotine. The findings suggest that menthol directly facilitates nicotine consumption, thereby contributing to tobacco smoking.

The lingering question of menthol in cigarettes

Tobacco use is the single most important preventable cause of cancer-related deaths in the USA and many parts of the world. There is growing evidence that menthol cigarettes are starter tobacco products for children, adolescents, and young adults. Accumulating research also suggests that smoking menthol cigarettes reinforces nicotine dependence, impedes cessation, and promotes relapse. However, menthol cigarettes are exempt from the US Food and Drug Administration ban on flavored cigarettes due, in part, to the lack of empirical evidence describing the health consequences of smoking menthol cigarettes relative to regular cigarettes. Determining the biological effects of menthol cigarette smoke relative to regular cigarette smoke can clarify the health risks associated with the use of respective products and assist regulatory agencies in making scientifically based decisions on the development and evaluation of regulations on tobacco products to protect public health and to reduce tobacco use by minors. We highlight the inherent shortcomings of the conventional epidemiologic, clinical, and laboratory research on menthol cigarettes that have contributed to the ongoing debate on the public health impact of menthol in cigarettes. In addition, we provide perspectives on how future investigations exploiting state-of-the-art biomarkers of exposure and disease states can help answer the lingering question of menthol in cigarettes.

Switching between menthol and nonmenthol cigarettes: findings from the U.S. Cohort of the International Tobacco Control Four Country Survey

INTRODUCTION

This article examines trends in switching between menthol and nonmenthol cigarettes, smoker characteristics associated with switching, and associations among switching, indicators of nicotine dependence, and quitting activity.

METHODS

Participants were 5,932 U.S. adult smokers who were interviewed annually as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Generalized estimating equations (GEEs) were used to examine the prevalence of menthol cigarette use and switching between menthol and nonmenthol cigarettes (among 3,118 smokers who participated in at least 2 consecutive surveys). We also evaluated characteristics associated with menthol cigarette use and associations among switching, indicators of nicotine dependence, and quitting activity using GEEs.

RESULTS

Across the entire study period, 27% of smokers smoked menthol cigarettes; prevalence was highest among Blacks (79%), young adults (36%), and females (30%). Prevalence of switching between menthol and nonmenthol cigarettes was low (3% switched to menthol and 8% switched to nonmenthol), and switchers tended to revert back to their previous type. Switching types was not associated with indicators of nicotine dependence or quit attempts. However, those who switched cigarette brands within cigarette types were more likely to attempt to quit smoking.

CONCLUSIONS

While overall switching rates were low, the percentage who switched from menthol to nonmenthol was significantly higher than the percentage who switched from nonmenthol to menthol. An asymmetry was seen in patterns of switching such that reverting back to menthol was more common than reverting back to nonmenthol, particularly among Black smokers.

Race moderates the effect of menthol cigarette use on short-term smoking abstinence

INTRODUCTION

The Food and Drug Administration is in the process of reviewing evidence of the impact of mentholated cigarettes on smoking behaviors and smoking cessation in order to determine if these products should be removed from the market. More empirical research is needed to inform those decisions. The goal of this study was to examine associations of menthol cigarette use with biochemically verified continuous short-term smoking abstinence, and potential moderation by race, among adult current smokers enrolled in a cohort study (N = 183; 57.4% female; 48.1% non-Hispanic Black, 51.9% non-Hispanic White).

METHODS

Continuation ratio logit models, adjusted for age, race, gender, total annual household income, educational level, employment status, and partner status, were used to examine associations of menthol use with smoking abstinence with and without an interaction term for race.

RESULTS

Menthol cigarette use was not significantly associated with smoking abstinence in the sample as a whole; however, there was a significant interaction of menthol use with race (p = .03). Follow-up analyses stratified by race indicated that among White participants, menthol users had significantly lower odds of maintaining continuous abstinence than nonmenthol users (p = .05). Exploratory analyses suggested that tobacco dependence may lie along the causal pathway and partially explain this effect.

CONCLUSIONS

White menthol smokers in this sample were at increased risk of smoking relapse relative to White nonmenthol smokers, at least partially due to greater tobacco dependence. Results should be replicated among other treatment-seeking samples with a greater representation of White menthol and Black nonmenthol smokers.

Cessation outcomes among treatment-seeking menthol and nonmenthol smokers

BACKGROUND

Menthol cigarettes account for 25% of the market in the U.S. The Food and Drug Administration currently is considering regulatory action on tobacco products, including a ban on menthol cigarettes. With 39% of menthol smokers reporting that they would quit smoking if menthol cigarettes were banned, there is a need to better understand whether existing cessation programs, such as quitlines, are serving menthol smokers.

PURPOSE

This study compared baseline characteristics and cessation outcomes of menthol and nonmenthol smokers who were seeking treatment through a quitline.

METHODS

Data were collected between September 2009 and July 2011 on 6257 participants. A random sample of eligible participants who registered for services between March 2010 and February 2011 was contacted for a follow-up survey 7 months post-registration (n=1147). Data were analyzed in 2011.

RESULTS

Among participants, 18.7% of smokers reported using menthol cigarettes. Menthol smokers were more likely to be female, younger, African-American, and have less than a high school education. Menthol smokers who called the quitline were slightly less likely to enroll in services than nonmenthol smokers (92.2% vs 94.8%, p<0.001). However, for those that did enroll, there were no significant differences in self-reported intent-to-treat 30-day point prevalence abstinence rates between menthol and nonmenthol smokers (17.3% vs 13.8%, p=0.191).

CONCLUSIONS

Quitlines appear to be adequately serving menthol smokers who call for help. Cessation outcomes for menthol smokers are comparable to nonmenthol smokers. However, if a menthol ban motivates many menthol smokers to quit, quitlines may have to increase their capacity to meet the increase in demand.

A ban on menthol cigarettes: impact on public opinion and smokers' intention to quit

OBJECTIVES

We assessed support for a ban by the Food and Drug Administration on menthol in cigarettes and behavioral intentions among menthol smokers in the event of such a ban.

METHODS

We surveyed 2649 never, former, and current smokers and used ordinal logistic regression to calculate weighted point estimates and predictors of support for a menthol ban among the adult population and menthol smokers only. For menthol smokers, we also calculated weighted point estimates and predictors of behavioral intentions.

RESULTS

Overall, 28.2% of adults opposed, 20.0% supported, and 51.9% lacked a strong opinion about a menthol ban. Support was highest among Hispanics (36.4%), African Americans (29.0%), never smokers (26.8%), and respondents with less than a high school education (28.8%). Nearly 40% of menthol smokers said they would quit if menthol cigarettes were no longer available, 12.5% would switch to a nonmenthol brand, and 25.2% would both switch and try to quit.

CONCLUSIONS

Support for a menthol ban is strongest among populations with the highest prevalence of menthol cigarette use. A menthol ban might motivate many menthol smokers to quit.

What would menthol smokers do if menthol in cigarettes were banned? Behavioral intentions and simulated demand

AIMS

  The US Food and Drug Administration must consider whether to ban the use of menthol in cigarettes. This study examines how current smokers might respond to such a ban on menthol cigarettes.

DESIGN

  Convenience sample of adolescent and adult smokers recruited from an online survey panel.

SETTING

  United States, 2010.

PARTICIPANTS

  A total of 471 adolescent and adult current cigarette smokers.

MEASUREMENTS

  Respondents were asked a series of questions about how they might react if menthol cigarettes were banned. In addition, participants completed a simulation purchase task to estimate the demand for menthol and non-menthol cigarettes across a range of prices.

FINDINGS

  Overall, 36.1% of respondents said they always (18.9%) or usually (17.2%) smoked menthol cigarettes. When asked how they might respond to a ban on menthol cigarettes, 35% of current menthol smokers said they would stop smoking, and 25% said they would 'find a way to buy a menthol brand'. Those who reported they might quit tended to have greater current intentions to quit [odds ratio (OR) = 4.47], while those who reported that they might seek illicit menthol cigarettes were far less likely to report current intentions to quit (OR = 0.06). Estimates for demand elasticity for preferred cigarette type were similar for menthol (α = 0.0051) and non-menthol (α = 0.0049) smokers. Demand elasticity and peak consumption were related to usual cigarette type and cigarettes smoked per day, but did not appear to differ by race, gender or age.

CONCLUSIONS

  Preliminary evidence suggests that a significant minority of smokers of menthol cigarettes in the United States would try to stop smoking altogether if such cigarettes were banned.

A cross-sectional study of menthol cigarette preference by 14- to 15-year-old smokers in New Zealand

INTRODUCTION

This study investigates the epidemiology of menthol cigarette preference, its association with smoking initiation, and nicotine addiction measured by loss of autonomy among New Zealand adolescent smokers.

METHODS

Data from the 2006-2009 national surveys among New Zealand Year 10 students (14-15 years old) were analyzed using multiple logistic regression. Menthol preference was an outcome variable; demographic factors and smoking status were covariates. Loss of autonomy and menthol preference were examined using multiple linear regression analysis. The Hooked on Nicotine Checklist measured loss of autonomy as an outcome variable. Menthol status, smoking status, and demographic factors were covariates. All analyses were controlled for clustering of data by school.

RESULTS

Overall, 17.7% of New Zealand 14- to 15-year-old smokers in this study indicated a preference for menthol cigarette, with greater odds of menthol cigarette preference among girls (odds ratio [OR] = 2.43; 95% CI = 2.15-2.75), ethnic minorities (Māori OR = 1.21; 95% CI = 1.07-1.36, Asians OR = 2.24; 95% CI = 1.79-2.82, Pacific Islanders OR = 1.83; 95% CI = 1.52-2.19), smokers from high socioeconomic status schools (OR = 1.24; 95% CI = 1.03-1.49), when parents smoked (OR = 1.16; 95% CI = 1.03-1.31), and newer smokers (smoked 11-100 cigarettes OR = 1.16; 95% CI = 1.03-1.31, smoking on a monthly OR = 1.17; 95% CI = 1.00-1.37, and a weekly basis OR = 1.29; 95% CI = 1.15-1.44). No significant correlation was found among those who smoked 1-10 cigarettes in total (OR = 1.02; 95% CI = 0.86-1.20) nor was any correlation found between menthol preference and nicotine addiction measured by loss of autonomy (coef. = -.21, p value = .165).

CONCLUSION

This study found inequalities in menthol cigarette preference among New Zealand adolescent smokers, consistent with patterns found in the United States but did not find any significant correlation between menthol preference and loss of autonomy.

Race/ethnicity moderates the effect of prepartum menthol cigarette use on postpartum smoking abstinence

INTRODUCTION

Little is known about the influence of prepartum menthol cigarette use on postpartum smoking abstinence or how race/ethnicity might moderate this relationship. The current study addressed that gap by testing these relationships among racially/ethnically diverse women who quit smoking during pregnancy (N = 244; 33% African American, 31% Latina, 36% White).

METHODS

Continuation ratio logit models were used to examine the effects of prepartum menthol cigarette use on biochemically confirmed, continuous abstinence through 26 weeks postpartum using an intent-to-treat approach. Analyses controlled for age, race/ethnicity, partner status, income, education, treatment, number of prequit cigarettes smoked per day, time to the first cigarette of the day, and time (Week 8 or 26 data collection timepoint). An additional model tested the moderating effects of race/ethnicity by including an interaction term.

RESULTS

Prepartum menthol cigarette use was not significantly associated with postpartum smoking abstinence in the overall sample. However, the interaction between menthol use and race/ethnicity was significant (p = .02). Among White women, menthol use was associated with significantly lower odds of maintaining postpartum smoking abstinence (p = .03; odds ratio = .19 [.04-.89]), and the effect approached significance among African American women (p = .08).

CONCLUSIONS

This study provides the first evidence that prepartum menthol cigarette use may increase the risk of postpartum smoking relapse among White, and possibly African American, women who quit smoking during or immediately before pregnancy. Results suggest that White and African American prepartum menthol users may require different or more intensive cessation services to aid in the maintenance of postpartum smoking abstinence. Replication with larger samples, and a focus on understanding the mechanisms that underlie these relationships, are warranted.

Menthol should not be given a free pass based on studies of biomarkers of toxicity

Exposure and toxicity studies comparing menthol and nonmenthol cigarettes have resulted in mixed results. On the basis of those results, cigarette manufacturers have concluded that there is no increased harm from the addition of menthol to cigarettes. We propose that such a narrow definition of harm is not appropriate in dealing with the issue of menthol, and its broader negative public health impact.

Menthol's potential effects on nicotine dependence: a tobacco industry perspective

OBJECTIVE

To examine what the tobacco industry knows about the potential effects menthol may have on nicotine dependence.

METHODS

A snowball strategy was used to systematically search the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu/) between 22 February and 29 April, 2010. Of the approximately 11 million documents available in the Legacy Tobacco Documents Library, the iterative searches returned tens of thousands of results. We qualitatively analysed a final collection of 309 documents relevant the effects of menthol on nicotine dependence.

RESULTS

The tobacco industry knows that menthol overrides the harsh taste of tobacco and alleviates nicotine's irritating effects, synergistically interacts with nicotine, stimulates the trigeminal nerve to elicit a 'liking' response for a tobacco product, and makes low tar, low nicotine tobacco products more acceptable to smokers than non-mentholated low delivery products.

CONCLUSION

Menthol is not only used in cigarettes as a flavour additive; tobacco companies know that menthol also has sensory effects and interacts with nicotine to produce tobacco products that are easier to smoke, thereby making it easier to expose smokers, especially those who are new and uninitiated, to the addictive power of nicotine.