High Rates of Menthol Cigarette Use Among Pregnant Smokers: Preliminary Findings and Call for Future Research

Characterizing the use, preferences, and perceptions of flavors in cigars in pregnant women

BACKGROUND

Flavors contribute to the appeal of tobacco products, but less is known about flavors in cigar products. The current study is the first to focus on characterizing the use and perceptions of flavors in cigar products among pregnant women.

METHODS

Pregnant women (N = 124) reported their use, preferences (liking, attractiveness, smoothness, interest), perceptions of harm (general, pregnancy-specific, fetal), and postpartum intention to use eight flavor categories (menthol/mint, spices, fruit, chocolate, alcohol, other beverages, candy/sweet, tobacco). We utilized correspondence analysis of contingency tables to investigate clustering of preferences and perceptions of flavors across the sample, and examined how preferences and perceptions of flavors may differ based on history of cigar use (none vs. lifetime vs. prenatal).

RESULTS

Overall, 37% reported never trying cigars, 51% reported lifetime use, and 12% reported prenatal use. Fruit (37%), tobacco (36%), and alcohol (14%) were the most common cigar flavors participants reported ever trying. Correspondence analysis revealed clustering in preferences for alcohol, fruit, and candy flavors compared to other flavors, and revealed lower intentions to use menthol/mint and tobacco flavors compared to other flavors. Participants who reported prenatal cigar use also reported more positive perceptions and greater intentions to use (1) spice and alcohol flavors compared to those who reported lifetime use (ps < .05); and (2) spice, alcohol, fruit, and tobacco cigar flavors compared to participants reporting never using cigars (ps < .04).

CONCLUSIONS

Regulations to restrict the availability of flavors, especially fruit, spice, and alcohol, may reduce the appeal and use of cigar products in pregnant women.

Addicted to green: priming effect of menthol cigarette packaging on brain response to smoking cues

INTRODUCTION

Mentholated tobacco cigarettes are believed to be more addictive than non-menthol ones. Packaging of most menthol cigarette brands includes distinctive green hues, which may act as conditioned stimuli (ie, cues) and promote menthol smoking. To examine the cue properties of menthol cigarette packaging, we used a priming paradigm to assess the effect of packaging on the neural substrates of smoking cue reactivity. We hypothesised that menthol packaging will exert a specific priming effect potentiating smoking cue reactivity in menthol compared with non-menthol smokers.

METHODS

Forty-two menthol and 33 non-menthol smokers underwent functional MRI while viewing smoking and neutral cues. The cues were preceded (ie, primed) by briefly presented images of menthol or non-menthol cigarette packages. Participants reported craving for cigarettes in response to each cue.

RESULTS

Menthol packaging induced greater frontostriatal and occipital smoking cue reactivity in menthol smokers than in non-menthol smokers. Menthol packaging also enhanced the mediation by neural activity of the relationship between cue exposure and cigarette craving in menthol but not non-menthol smokers. Dynamic causal modelling showed stronger frontostriatal-occipital connectivity in response to menthol packaging in menthol compared with non-menthol smokers. The effects of non-menthol packaging did not differ between categories of smokers.

CONCLUSIONS

Our findings demonstrate heightened motivational and perceptual salience of the green-hued menthol cigarette packaging that may exacerbate menthol smokers' susceptibility to smoking cues. These effects could contribute to the greater addiction severity among menthol smokers and could be considered in the development of science-based regulation and legal review of tobacco product marketing practices.

Assessing the Health and Economic Impact of a Potential Menthol Cigarette Ban in New York City: a Modeling Study

Menthol in cigarettes increases nicotine dependence and decreases the chances of successful smoking cessation. In New York City (NYC), nearly half of current smokers usually smoke menthol cigarettes. Female and non-Latino Black individuals were more likely to smoke menthol-flavored cigarettes compared to males and other races and ethnicities. Although the US Food and Drug Administration recently announced that it will ban menthol cigarettes, it is unclear how the policy would affect population health and health disparities in NYC. To inform potential policymaking, we used a microsimulation model of cardiovascular disease (CVD) to project the long-term health and economic impact of a potential menthol ban in NYC. Our model projected that there could be 57,232 (95% CI: 51,967-62,497) myocardial infarction (MI) cases and 52,195 (95% CI: 47,446-56,945) stroke cases per 1 million adult smokers in NYC over a 20-year period without the menthol ban policy. With the menthol ban policy, 2,862 MI cases and 1,983 stroke cases per 1 million adults could be averted over a 20-year period. The model also projected that an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers, could be saved over a 20-year period due to the implementation of a menthol ban policy. Results from subgroup analyses showed that women, particularly Black women, would have more reductions in adverse CVD outcomes from the potential implementation of the menthol ban policy compared to males and other racial and ethnic subgroups, which implies that the policy could reduce sex and racial and ethnic CVD disparities. Findings from our study provide policymakers with evidence to support policies that limit access to menthol cigarettes and potentially address racial and ethnic disparities in smoking-related disease burden.

Use and perceptions of menthol versus non-menthol cigarettes among pregnant women

BACKGROUND

Menthol cigarette use among women who smoke cigarettes during pregnancy is high, but little is known about the factors that contribute to preference for menthol cigarette use during pregnancy.

OBJECTIVE

This study investigated preferences, perceptions, and intentions to use menthol vs. non-menthol cigarettes in a sample of pregnant women.

METHODS

Pregnant women (N = 124, M_age = 26.2 years, 50% minorities) completed a study investigating the impact of maternal smoking on biobehavioral markers of fetal risk. During the third trimester, participants self-reported preferences (liking, attractiveness, smoothness, interest), perceptions of harm (general, pregnancy-specific), and intentions to use menthol and non-menthol cigarettes. We examined differences in responses based on whether participants endorsed (1) cigarette use during pregnancy (yes/no) and (2) lifetime cigarette use (yes/no).

RESULTS

Sixty-two participants endorsed cigarette smoking during pregnancy (85.5% smoked menthol cigarettes), and 94 participants reported lifetime use. Overall, menthol cigarettes were perceived as more likeable and smoother vs. non-menthol (ps < .001) - even among participants who never smoked cigarettes (ps < .05). All participants rated both menthol and non-menthol cigarette use as harmful. Compared to participants who did not smoke during pregnancy, participants who smoked during pregnancy rated menthol cigarettes as less harmful for pregnant women (p = .001), while there were no differences between groups in harm perceptions toward non-menthol cigarettes.

CONCLUSIONS

Menthol may increase cigarettes appeal for pregnant women. Implications for regulation of menthol cigarettes are discussed. Future studies may investigate the role of sensory perception, marketing, and health education in influencing these factors.

Measures of dependence in menthol and nonmenthol smokers - A comprehensive narrative review

Introduction. More than a decade ago, concerns were raised that menthol in cigarettes might enhance addiction to smoking. This article provides a comprehensive review of published studies examining cigarette dependence among menthol and nonmenthol smokers. The purpose of the review is to evaluate the scientific evidence to determine if menthol increases cigarette dependence. Materials and Methods. The published literature was searched in 2019 for studies that provide evidence on cigarette dependence among menthol compared to nonmenthol smokers. Included in this review are published studies that compare menthol and nonmenthol smokers based on widely accepted and validated measures of dependence, or other established predictors of dependence (age of smoking initiation [first cigarette]/age of progression [regular/daily smoking]) and indicators of dependence (smoking frequency, cigarettes smoked per day, time to first cigarette after waking, night waking to smoke, smoking duration). Results and Conclusion. Based on a review of the available studies, including those with adjusted results and large representative samples, reliable and consistent empirical evidence supports a conclusion that menthol smokers are not more dependent than nonmenthol smokers and thus menthol in cigarettes does not increase dependence.

Gender Differences in the Association between Marijuana and Menthol Cigarette Use among African American Adult Cigarette Smokers

Introduction: Despite the strong relationship between marijuana and tobacco use, especially among African American individuals and males, very few studies have examined the association between marijuana and menthol cigarette use. This study was designed to identify the prevalence of past month, past year and lifetime marijuana use and marijuana dependence among menthol and non-menthol cigarette smokers, as well as the association between marijuana and menthol cigarette use among African American female and male cigarette smokers. Methods: Data were drawn from 1,173 African American adult cigarette smokers in the 2017 National Survey on Drug Use and Health. Results: Overall, 8.8%, 13.9% and 44.7% of African American menthol and non-menthol cigarette smokers reported past month, past year and lifetime marijuana use, respectively. Weighted multivariable logistic regression models revealed a significant interaction between gender and past month marijuana use on menthol cigarette use (AOR = 1.49, 95% CI: 1.21-2.42, p < .05). Past month marijuana use was associated with an increased odds of past month menthol cigarette use (relative to non-menthol cigarette use) among females, but a decreased odds of past of past month menthol cigarette use among males. Conclusions: When stratified by gender, marijuana use is differentially related to menthol cigarette use among African American adults. Given the prevalence of menthol cigarette use among this population, it is important to examine factors such as marijuana use that could be targeted in prevention and treatment interventions for African Americans, especially females, who are at risk for smoking or are currently smoking menthol cigarettes. Implications: This study found that marijuana use was associated with an increased odds of menthol cigarette use among African American females, while marijuana use was associated with a decreased odds of menthol cigarette use among their male counterparts. The impact of marijuana use on menthol cigarette smoking differs among females and males, highlighting the need for gender-tailored interventions that target marijuana use among African American individuals, especially females, who are at risk for smoking or are currently smoking menthol cigarettes.