Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016-2018 ITC Four Country Smoking and Vaping Surveys

The influence of sociodemographic, tobacco use, and mental health characteristics on treatment adherence among adults enrolled in a community-based tobacco cessation program

Background

While counseling and pharmacological interventions are known to facilitate smoking cessation, poor adherence can impact their effectiveness. Therefore, this study aimed to identify personal and clinical factors that influenced adherence to smoking cessation treatment among socioeconomically disadvantaged adult Oklahomans enrolled in a publicly available tobacco treatment program and observational research study.

Methods

Adult participants (N = 442) were enrolled in a community-based tobacco treatment program. Logistic regression models identified sociodemographic, mental health, and substance use characteristics associated with treatment adherence. Adherence was measured by counseling session attendance and weeks of moderate/high medication adherence assessed via the Medication Adherence Questionnaire. Analyses were conducted using SAS 9.4 with p < 0.05.

Results

Participants (mean age of 53, 55 % female, and 42.3 % racially minoritized), smoked 16 (SD = 10) cigarettes/day for 30 years on average (SD = 15), and 44.8 % reported depression (Center for Epidemiological Studies Depression Scale [CESD] score ≥ 10). Self-efficacy, White race, increasing age, and years of smoking were positively associated with counseling adherence, while menthol use, being uninsured, and depression predicted lower counseling adherence. Medication adherence was lower among individuals who used menthol cigarettes, lived with someone who smoked, and had higher levels of expired carbon monoxide.

Conclusions

This study highlights key factors that influenced adherence to smoking cessation treatment in a socioeconomically disadvantaged population. Tailored interventions are needed to address social, behavioral, and environmental factors, such as living situations and mental health, in smoking cessation interventions to enhance treatment outcomes for underserved populations. Future tobacco cessation programs should consider these factors to improve adherence and, ultimately, success rates.

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

Restrictions of cigarette and e-cigarette flavor and filter ventilation on demand and substitution in the Experimental Tobacco Marketplace

SIGNIFICANCE

Tobacco product design features, including flavors and cigarette filter ventilation, are subject to regulation. This study examined the effects of cigarette and e-cigarette flavors on demand and substitution by preferred cigarette flavor and ventilation in the Experimental Tobacco Marketplace (ETM).

METHODS

In a mixed between-group (usual cigarette flavor and ventilation)/within-subject design (policy conditions), individuals who use tobacco (n=176 cigarette (60.5 % female); n=91 multiple products (26.7 % female)) were recruited using Ipsos and InnovateMR, completed purchasing trials with increasing cigarette prices in the ETM. Participants were exposed to four conditions in a 2×2 factorial design with cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted.

RESULTS

In individuals who exclusively smoke cigarettes: 1) Cigarette menthol restrictions decreased willingness to purchase cigarettes (OR: 0.001; 95 % CI: 0.00002, 0.015) for individuals that prefer menthol cigarettes and increased willingness to purchase NRT (OR: 4.02; 95 % CI: 1.47, 11.0), 2) cigarette menthol restrictions reduced demand for cigarettes in individuals who smoke menthol cigarettes (p<0.001), 3) e-cigarette flavor restrictions reduced the degree of e-cigarette substitution in individuals who smoke menthol cigarettes (p=0.028), and 4) preference for higher cigarette filter ventilation was associated with higher demand for cigarettes (p=0.003) and lowered substitution of smokeless tobacco products (p=0.028). In individuals who use multiple tobacco products, restrictions did not impact product purchasing.

CONCLUSION

Strategies to reduce flavored product sales and increase cessation resource accessibility may improve population health by reducing smoking and increasing NRT use in individuals who use menthol cigarettes.

Is It Time to Ban Flavored Cigarettes in Asia-Pacific Countries? A Scoping Review

Flavored cigarettes encourage youth smoking and deter quitting. No country in Asia-Pacific, a region with some of the world's highest smoking rates, has regulated tobacco flavors. We examined market data, academic literature, and gray literature to describe what is known on flavored cigarettes in the Asia-Pacific region. Of the 12 countries for which market data were available, ten had substantial flavored cigarette market shares ranging from 10% to 97%. With no regulations and growing markets for flavor capsule variants, the tobacco industry's ongoing promotion of flavored cigarettes, which targets primarily youth and women, is expected to drive further increases in smoking prevalence. There are significant research and monitoring gaps on the industry's marketing tactics and use of flavored cigarettes in the region. Given the large market shares, Asia-Pacific countries stand to benefit substantially from a tobacco flavors ban.

Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity

INTRODUCTION

This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017).

AIMS AND METHODS

Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol.

RESULTS

Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories.

CONCLUSIONS

After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity.

IMPLICATIONS

Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

It's Not Just: Evaluation of a Media Campaign to Motivate Action Around Targeting of Menthol Tobacco in Black Communities

Introduction

For more than 60 years, tobacco companies have aggressively marketed menthol tobacco products in Black communities. In 2021, New York State Department of Health-funded grantees launched a media campaign aimed toward civically engaged New York adults to educate and mobilize community action to prevent targeted marketing of menthol tobacco. This study examined audience reactions to the campaign and associations between campaign awareness and key outcomes.

Methods

Following campaign implementation, we administered 2 online, cross-sectional surveys to 2,000 civically engaged New York adults to assess campaign awareness, audience reactions, and campaign-related attitudes and behaviors. We examined sociodemographic differences in audience reactions and assessed multivariate associations between campaign awareness and key outcomes.

Results

Overall, 40% of respondents were aware of the campaign. Perceived advertisement (ad) effectiveness was higher among Black, Hispanic, and nonsmoking respondents and those aware of the campaign. Negative reactions to ads were higher at wave 1, among non-Hispanic White and male respondents, and among current smokers. Campaign awareness was positively associated with campaign-related beliefs. The association between campaign awareness and support for a menthol ban varied by survey wave and race, with positive associations at wave 2 and among non-Hispanic White respondents only. Among wave 2 respondents only, campaign awareness was positively associated with actions to reduce the targeting of menthol in Black communities.

Conclusion

Media campaigns can play an important role in raising awareness of menthol tobacco product targeting in Black communities and building public support for local and statewide menthol restrictions that may be implemented before federal product standards are in place.

Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999-2018

Introduction

Monitoring menthol cigarette use allows for identification of potential health disparities. We examined sociodemographic and temporal differences in menthol cigarette use among US adults who smoke.

Methods

We analyzed data from the 1999-2018 National Health and Nutrition Examination Survey for adults aged 20 years or older who smoke (N = 11,431) using binary logistic regression.

Results

Among US adults who smoke, 28.8% used menthol cigarettes. After adjusting for age, sex, race and ethnicity, education, income-to-poverty ratio, and health status, the prevalence of menthol use among adults who smoke increased on average by 3.8% (95% CI, 2.7%-4.9%) annually. Non-Hispanic Black adults had the highest average prevalence of menthol cigarette use, 73.0% (95% CI, 70.9%-75.2%), and Mexican American adults had higher average annual increase in menthol cigarette use, 7.1% (95% CI, 4.0%-10.3%). Adults with fair or poor health status had a 4.3% annual increase in menthol cigarette use (95% CI, 2.5%-6.1%). The adjusted prevalence ratios of menthol cigarette use were 1.61 (95% CI, 1.39-1.83) for adults aged 20-29 years compared with those aged 65 years or older, 1.41 (95% CI, 1.32-1.49) for female adults compared with male adults, and 1.17 (95% CI, 1.07-1.27) for high school graduates or higher compared with those with no high school diploma.

Conclusion

Non-Hispanic Black adults who smoke had the highest prevalence of menthol cigarette use among all racial and ethnic groups; the prevalence of menthol cigarette use among adults who smoke increased especially among Mexican American adults, younger adults, and adults who reported fair to poor health status.

Should menthol e-cigarettes be banned? Reaction of adult smokers and users of e-cigarettes to hypothetical bans

INTRODUCTION

This study examines how current smokers using menthol cigarettes or flavoured cigars, and current users of flavoured e-cigarettes may respond to three hypothetical flavour-ban scenarios: (1) banning only menthol cigarettes and flavoured cigars; (2) also banning e-cigarettes with any non-tobacco flavours except menthol; and (3) also banning e-cigarettes with any non-tobacco flavours, including menthol.

METHODS

Recruited from mTurk, respondents were asked if they would quit all tobacco-nicotine use or continue or start using products that were still legally available. The patterns of responding to each ban scenario, for both flavoured smokers and users of non-tobacco flavoured e-cigarettes, were summarised. Multinomial logistic regressions were used to estimate associations between demographics, smoking or e-cigarette use status and reactions to a ban.

RESULTS

A ban on menthol cigarettes and flavoured cigars would lead to 12%-20% of flavoured smokers trying to quit all tobacco use and 32%-52% switching to non-flavoured smoking, with the remaining switching to e-cigarettes or other products. Compared with a ban on only menthol cigarettes and flavoured cigars, also banning flavoured e-cigarettes would increase the likelihood of quitting all tobacco-nicotine use (OR=2.58) but also increase the likelihood of switching to non-flavoured smoking (OR=1.74).

CONCLUSIONS

Our results indicate that a ban on menthol cigarettes and flavoured cigars would decrease smoking. However, it is unclear if adding a ban of menthol e-cigarettes would lead to additional benefits because without menthol e-cigarettes as an alternative, some smokers and e-cigarette users may switch to non-flavoured tobacco smoking, rather than quit all tobacco use.

Illicit cigarette purchasing after implementation of menthol cigarette bans in Canada: findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys

OBJECTIVE

To examine the impact of menthol cigarette bans on use and purchasing of illicit cigarettes among menthol and non-menthol smokers in seven Canadian provinces.

METHODS

Data from 1098 non-menthol smokers and 138 menthol smokers in Canada who completed the ITC Four Country Smoking and Vaping Survey in 2016 (pre-ban) and 2018 (post-ban). Brand validation analysis was conducted to (1) compare self-reported use of menthols versus actual use of menthols as regular brand, and verify self-reported purchasing of menthols among pre-ban menthol smokers at post-ban; and (2) assess pre-post ban changes in purchasing of illicit cigarettes from First Nations reserves among non-menthol smokers and menthol smokers.

RESULTS

Among the subset of 138 pre-ban menthol smokers, 36 (19.5%) reported smoking menthols at post-ban. Brand validation analyses showed that 19 (9.0%) were actually using a non-menthol brand; of the 17 (10.5%) who were actually using a menthol brand, 13 (7.9%) bought a menthol brand at last purchase, and 4 (2.6%) bought a non-menthol brand. Among the full sample of smokers who purchased cigarettes from First Nations reserves at both pre-ban and post-ban, there was no change in purchasing of menthols (n=9 menthol smokers; 51.2% vs 51.2%, p=1.00), non-menthols (n=1024 non-menthol smokers; 9.1% vs 8.7%, p=0.69) or all cigarettes (menthol+non-menthol) (n=1086 smokers; 9.7% vs 9.2%, p=0.56).

CONCLUSIONS

Actual rates of brand-verified menthol smoking were substantially lower than self-reported rates at post-ban. After Canada's menthol ban, there was no increase in illicit purchasing of menthol or non-menthol cigarettes from First Nations reserves.

A randomized controlled trial of potential tobacco policies prohibiting menthol flavor in cigarettes and e-cigarettes: a study protocol

BACKGROUND

Menthol cigarette use remains a large public health problem and disproportionately affects Black adults in the United States. The Food and Drug Administration has proposed prohibiting menthol flavor in cigarettes to protect public health. However, e-cigarettes are available in menthol flavor and are a popular alternative product adults might switch to if menthol is prohibited in cigarettes. Research is needed to understand how availability of menthol (vs. tobacco) flavored e-cigarettes could impact cigarette use among adults who smoke menthol cigarettes.

METHODS

We will recruit 150 adults who currently smoke menthol cigarettes and will randomize them to 1 of 3 conditions modeling different regulatory scenarios. We will recruit equal numbers of participants identifying as Black vs. non-Black and will stratify randomization by race. To promote standardization and adherence, cigarette and e-cigarette products will be provided for 8 weeks based on the assigned condition: (A) no menthol restriction (menthol cigarette and menthol flavored e-cigarette), (B) menthol prohibited in cigarettes only (non-menthol cigarette and menthol flavored e-cigarette), (C) menthol prohibited in both cigarettes and e-cigarettes (non-menthol cigarette and tobacco flavored e-cigarette). A follow-up visit will occur at week 12 to assess tobacco use status. The study aims are to (1) examine the impact of prohibiting menthol flavor in cigarettes and e-cigarettes on smoking behavior and (2) investigate whether outcomes differ by race to understand the impact of menthol policies on Black (vs. non-Black) individuals given high rates of menthol cigarette use in this population. The primary outcome will evaluate changes in the number of cigarettes smoked per day during the 8-week study period and will examine differences by regulatory scenario. Secondary outcomes will compare percent days smoke-free, changes in nicotine dependence, and motivation, confidence, and intentions to quit smoking by the regulatory scenarios. We will examine whether changes in the outcomes differ by Black vs. non-Black participants to compare the magnitude of the effect of the various menthol policy scenarios by race.

DISCUSSION

Results will contribute critical information regarding menthol in cigarettes and e-cigarettes to inform regulatory policies that maximize reductions in cigarette smoking and reduce tobacco-related health disparities.

TRIAL REGISTRATION

NCT05259566. Yale IRB protocol #2000032211, last approved 12/8/2023.

Menthol and Other Flavor Chemicals in Cigarettes from Vietnam and the Philippines

INTRODUCTION

Tobacco product flavors can increase product appeal, adolescent initiation and experimentation, and difficulty quitting. Flavored tobacco products are not restricted in Vietnam or the Philippines despite the high smoking prevalence among those 15 years of age and older (24% and 23%, respectively). There are no published reports to our knowledge on the levels of flavor chemicals in the cigarettes sold in these two countries.

METHODS

Cigarettes were purchased in Vietnam (32 brand variants) and the Philippines (19 brand variants) during 2020. Chemical analyses gave the mg/filter, mg/rod, and mg/stick (= mg/(filter + rod)) values for 180 individual flavor chemicals. Values were calculated for menthol, clove-related compounds, and "other flavor chemicals" (OFCs).

RESULTS

Five flavor groupings were found among the brand variants purchased in Vietnam: menthol + OFCs (n = 15), OFCs only (n = 8), nonflavored (n = 7), menthol + OFCs with a clove flavorant (n = 1) and menthol only (n = 1). Three flavor groupings were found among the brand variants purchased in the Philippines: menthol + OFCs (n = 10), nonflavored (n = 5), and menthol only (n = 4).

CONCLUSIONS

A range of flavored cigarette products are being offered by tobacco companies in Vietnam and the Philippines, presumably to maximize cigarette sales. Regulation of flavor chemicals should be considered in these two countries.

IMPLICATIONS

Article 9 of the WHO Framework Convention on Tobacco Control (FCTC), ratified by both Vietnam and the Philippines, states that "there is no justification for permitting the use of ingredients, such as flavoring agents, which help make tobacco products attractive." Flavors increase product appeal, adolescent initiation and experimentation, and difficulty quitting. These analyses found that cigarettes purchased in Vietnam and the Philippines contained menthol and other flavor chemicals. Tobacco companies are offering multiple flavor chemical profiles and nominally nonflavored versions in these countries; regulation of flavor chemicals should be considered in these two countries.

The Impact of Menthol Cigarette Bans: A Systematic Review and Meta-Analysis

INTRODUCTION

This review investigates the impacts of banning the sale of menthol cigarettes at stores.

METHODS

A systematic search of studies published in English up to November 2022 was conducted. The following databases were searched: PubMed/Medline, CINAHL, PsycINFO, Web of Science, and Embase, as well as a non-indexed journal. Studies evaluating either the impact of real-world or hypothesized menthol cigarette bans were included. Primary outcomes include tobacco use behaviors. Secondary outcomes include cigarette sales, retailer compliance, and the tobacco industry's response to a menthol ban. Data on tobacco use behavior after a menthol ban were pooled using random-effects models. Two pairs of reviewers independently extracted data and assessed study quality.

RESULTS

Of the 964 articles that were identified during the initial search, 78 were included in the review and 16 were included in the meta-analysis. Cessation rates among menthol cigarette smokers were high after a menthol ban. Pooled results show that 24% (95% confidence interval [95% CI]: 20%, 28%) of menthol cigarette smokers quit smoking after a menthol ban, 50% (95% CI: 31%, 68%) switched to non-menthol cigarettes, 12% (95% CI: 3%, 20%) switched to other flavored tobacco products, and 24% (95% CI: 17%, 31%) continued smoking menthol cigarettes. Hypothesized quitting and switching rates were fairly close to real-world rates. Studies found the tobacco industry attempts to undermine menthol bans. National menthol bans appear more effective than local or state menthol bans.

CONCLUSIONS

Menthol cigarette bans promote smoking cessation suggesting their potential to improve public health.

IMPLICATIONS

Findings from this review suggest that menthol cigarette bans promote smoking cessation among menthol cigarette smokers and have the potential to improve public health.

Determinants of Hardcore Smoking in a MULTI-ETHNIC Study of Cigarette Smokers in Singapore

Smokers who are resistant to quitting are not well studied in Asia, particularly in multi-ethnic populations. We compared the characteristics of hardcore smokers in Singapore, a multi-ethnic Asian population, with other daily smokers, and investigated the role of ethnicity as an effect modifier on identified determinants, including cigarette flavor preferences, using cross-sectional data from Singapore Smokers' Survey (n = 1,501). Multivariable logistic regression was used to assess the association. 22.8% of adult daily smokers were hardcore smokers. Novel findings on hardcore smokers' preference for regular flavored cigarettes (AOR = 1.54; 95%CI: 1.14, 2.07) suggest there is room for interventions among hardcore smokers through regulation of cigarette flavors and nicotine content. Although ethnicity was not a significant factor, it was an effect modifier with peers' disapproval of smoking (p-value for interaction = 0.024), significantly lowering odds of Malays being hardcore smokers (stratified odds ratio, AOR stratified, Malay = 0.35; CI: 0.17, 0.71), but not Chinese (AOR stratified, Chinese = 1.27; CI: 0.70, 2.42) and Indian smokers (AOR stratified, Indian = 0.62; CI: 0.18, 2.28), suggesting that smoking cessation policies utilizing social norm change strategies may be more effective when tailored to the differing roles of peer norms among different ethnic groups, in Singapore and other multi-ethnic Asian populations.

Substitutability of menthol cigarette alternatives: a clinical trial

INTRODUCTION

This study assessed the substitutability of plausible combustible menthol cigarette alternatives (MCAs) for usual brand menthol cigarettes (UBMCs) in adults who smoke menthol cigarettes.

METHODS

Following three in-lab sampling sessions, 80 adults aged 21-50 who smoke menthol cigarettes chose their preferred MCA: (1) a menthol roll-your-own cigarette (mRYO), (2) a menthol filtered little cigar (mFLC) or (3) a non-menthol cigarette (NMC). Participants were instructed to completely substitute their preferred MCA for their UBMC for 1 week and complete daily diaries documenting adherence and subjective effects. At the final lab visit, participants completed concurrent choice and cross-price elasticity tasks with their substitute product and UBMC as the comparator.

RESULTS

Most (65%) participants chose mRYO as their preferred product, followed by NMC and mFLC. Adherence to MCA was high for all products across the week (range: 63%-88%). Positive subjective effects for mRYO decreased over time but remained numerically higher than the other MCA products; craving reduction also decreased for NMC across phases. In the progressive ratio task, participants chose their UBMC in 61.7% of choices; this did not differ by preferred MCA, although the median breakpoint was highest for mRYO and similar for mFLC and NMC. Cross-price elasticity comparing UBMC and the preferred product indicated high substitutability of each MCA at phase 3 (I values -0.70 to -0.82).

CONCLUSIONS AND RELEVANCE

mRYOs were the most preferred MCA among the study products, but all MCAs were acceptable substitutes for UBMC using behavioural and economic measures in a short-term trial period.Trial registration number NCT04844762.

Impact of Canada's menthol cigarette ban on quitting among menthol smokers: pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the USA

INTRODUCTION

Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA.

METHODS

Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health.

RESULTS

After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans).

CONCLUSIONS

This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

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.

Reactions to using other nicotine and tobacco products instead of menthol cigarettes: A qualitative study of people who smoke menthol cigarettes in the United States

The US Food and Drug Administration is considering banning menthol cigarettes, which could result in some people who smoke menthol cigarettes switching to other tobacco products (OTPs). This qualitative study explored reactions to using OTPs instead of menthol cigarettes. People who smoke menthol cigarettes (N=40) completed a behavioral economic assessment of the effects of menthol cigarette price increases on OTP purchasing. At the highest price, most participants could not afford menthol cigarettes. Instead, they could purchase non-menthol cigarettes, little cigars/cigarillos (LCCs), e-cigarettes, smokeless tobacco, or medicinal nicotine, or they could abstain from tobacco use. Participants used the OTPs they purchased for three days. During follow-up sessions, participants (n=35) completed semi-structured interviews discussing their purchasing-decisions and experiences using OTPs instead of menthol cigarettes. Interviews were analyzed using reflexive thematic analysis methods. Factors influencing purchasing decisions included flavor, price, prior use of OTPs, interest in trying new OTPs, and perceived ability to satisfy nicotine cravings. Participants described positive experiences using e-cigarettes including the "refreshing" menthol flavor, ability to use in places where cigarettes are prohibited, and convenience of use relative to smoking. Among those using non-menthol cigarettes, many reported they were acceptable but less satisfying products compared to menthol cigarettes while others reported negative reactions to them such as tasting like "cardboard". Reactions to smoking LCCs were mostly unfavorable but participants said it gave them "something to light". Multiple considerations may affect switching to OTPs in light of pending menthol cigarette regulation including the availability of menthol-flavored alternatives and (dis)satisfaction with OTPs.

Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: findings from the 2020-21 ITC Netherlands Surveys

BACKGROUND

The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers.

METHODS

Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data.

RESULTS

Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand.

CONCLUSIONS

There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Who's Quitting? Who Needs Additional Support? Cessation Disparities by Race, Education, and Income, 2007 to 2018

PURPOSE

The current study (1) examines how disparities in quitting cigarette and other tobacco product use have changed by race and socioeconomic status and (2) utilizes an expanded measure, any tobacco quit ratio (aQR), that extends previous work on cigarette quit ratios and captures use and cessation in a growing tobacco marketplace.

DESIGN

Repeated cross-sectional representative survey; Setting: Minnesota.

SUBJECTS

Adult Minnesotans from the 2007 and 2018 Minnesota Adult Tobacco Survey (combined N=9,258).

MEASURES

Cigarette QR (cQR), aQR (cigarette, cigar, smokeless, pipe, e-cigarette, hookah), past year quit attempts, and recent cessation.

ANALYSIS

Weights ensured statewide representativeness. Regression analyses tested for differences by race (Black vs White), income (low vs medium/high), and education (low vs medium/high) across survey years.

RESULTS

cQRs and aQRs were relatively high among White respondents and those with medium-high education and income. The disparity in aQR between White and Black respondents decreased from 2007 to 2018. Black respondents were more likely to try to quit than White respondents but were less likely to report recent cessation.

CONCLUSION

Cessation disparities by race and socioeconomic status have changed little between 2007 and 2018, and the magnitude of the disparity for several cessation indicators remains large. Public health professionals and medical practitioners can play a key role in reducing disparities by supporting public policies and cessation interventions that target social determinants of health and associated barriers to quitting.

Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study

INTRODUCTION

The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs).

METHODS

After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060.

RESULTS

As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications.

CONCLUSIONS AND RELEVANCE

Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.

Profile of menthol cigarette smokers in the months following the removal of these products from the market: a cross-sectional population survey in England

INTRODUCTION

In May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics.

METHODS

Cross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored.

RESULTS

Between July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April-June 2021 and fit the data better than linear and null (no change) models (χ2(2)=2519.7, p=0.06; χ2(3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16-24=25.2%; 25-34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021.

CONCLUSIONS

A substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April-June 2021 warrants further monitoring.

Effects of menthol use and transitions in use on short-term and long-term cessation from cigarettes among US smokers

OBJECTIVES

To estimate the effect of menthol use and transitions in use (switching to or from menthol) on short-term and long-term cessation from cigarette smoking and whether this differed across demographic groups (age, sex, race).

METHODS

We compared the probability of 30+ day and 12-month abstinence from cigarette smoking by menthol use status using two cohorts of US adult cigarette smokers who attempted to quit smoking in the Population Assessment of Tobacco and Health (wave 1 to wave 3 and wave 2 to wave 4; n=5759), inverse probability of treatment weighting and adjusted risk ratios (aRRs).

RESULTS

Using menthol (vs non-menthol) prior to a quit attempt decreased the probability of 30+ day abstinence by 28% (aRR=0.78; 95% CI 0.67 to 0.91) and the probability of 12-month abstinence by 53% (aRR=0.65; 95% CI 0.47 to 0.88). Additionally, switching from menthol (vs maintaining menthol use) increased the probability of 30+ day abstinence by 58% (aRR=1.58; 95% CI 1.00 to 2.50) and the probability of 12-month abstinence by 97% (aRR=1.86; 95% CI 0.92 to 3.74). Switching to menthol (vs maintaining non-menthol use) was associated with a lower probability of 30+ day (aRR=0.70; 95% CI 0.42 to 1.16) and 12-month abstinence (aRR=0.64; 95% CI 0.30 to 1.36), but these associations were imprecise. The effects of menthol use on impaired quitting were slightly larger for non-Hispanic Black smokers, but not different for other demographic groups.

CONCLUSION

These results demonstrate that menthol impaired menthol smokers' attempts to quit smoking but switching from menthol improved success. This suggests that removing menthol may improve menthol smokers' success during quit attempts.

Manipulation of Menthol and Nicotine Content in Cigarettes: Effects on Smoking Behavior and Toxicant Exposure in Women Menthol Smokers

BACKGROUND

The purpose of this study was to determine the effects of smoking and other outcomes of assigning cigarettes with reduced nicotine and/or no menthol to female menthol smokers.

AIMS AND METHODS

Nontreatment-seeking female menthol smokers (N = 263) participated in a randomized controlled trial in which levels of menthol and nicotine in cigarettes were manipulated using experimental cigarettes. After a baseline period, participants were assigned to the following conditions for 6 weeks: (1) their own brand of cigarette (conventional nicotine with menthol), (2) a conventional nicotine cigarette with no menthol, (3) a cigarette with reduced nicotine (RNC) with menthol, or (4) a RNC cigarette and no menthol. Participants then returned to using their own brand and were followed for another 6 weeks. Outcomes included cigarettes smoked, biomarkers of exposure, and dependence measures.

RESULTS

Results indicated that, after an initial increase, rates of smoking of all three experimental cigarettes were at or below baseline rates of smoking of one's own brand. Levels of biomarkers also decreased during the experimental phase but rebounded somewhat after participants resumed smoking their own brand. There was evidence that the overall amount of smoking decreased similarly among women who switched to non-menthol and/or RNC cigarettes.

CONCLUSIONS

These results suggest that no detrimental effect will occur in nicotine or toxicant exposure levels with a ban on characterizing menthol and/or a product standard on nicotine content in cigarettes.

IMPLICATIONS

The implication of this work is that there would be no risk to women menthol smokers associated with regulations restricting nicotine and eliminating menthol in cigarettes.

Documenting the Impact Potential of a Menthol Cigarette Ban at Point-of-Sale: A Photograph-Based Analysis of the Presence and Placement of Menthol Versus Regular Cigarette Packs on the Shelves of Tobacco Retail Outlets in New York City

INTRODUCTION

To investigate the absolute and proportionate number of menthol versus regular cigarette packs displayed on the shelves inside tobacco retail outlets (TROs) across New York City (NYC).

AIMS AND METHODS

Photographic surveillance methods were used to capture the presence and proportionate amount of all visible cigarette packs on the shelves inside N = 160 TROs. Statistical analyses examined the absolute and proportionate number of menthol packs in each TRO as a function of NYC borough, the local TRO environment, population smoking rates derived from the NYC Community Health Survey, and other demographic indicators from the American Community Survey.

RESULTS

The total number of cigarette packs on the shelves of each TRO and the proportion of menthol packs varied significantly across TROs, averaging about one-quarter of all packs displayed (M = 0.274; SD = .15). Modeling results indicate that the proportion of menthol packs displayed was significantly greater in areas with elevated population smoking rates (odds ratio [OR] = 1.03, CI: 1.01-1.06) and density of TROs per 1000 residents (OR = 1.23; CI: 1.01-1.49), although these associations varied in complex ways with the proportion living under the federal poverty level and the proportion under age 18 years residing within each zip-code.

CONCLUSIONS

Results of this study demonstrate the utility of photograph-based TRO audit methods for objective, reliable documentation of the presence and proportionate amount of menthol versus other cigarette pack types on TRO shelves and highlight the need to account for sources of variation between small areas when examining the TRO product landscape and evaluating the effectiveness of regulatory actions against menthol.

IMPLICATIONS

This study describes use of a "hands-free" surveillance technique that offers valuable advantages over traditional retailer surveillance techniques. Comprehensive photographic surveillance data collection allows for more objective measurements of, in this case, the retail outlet's tobacco power wall, as multiple coders can review the same images and interrater reliability can be empirically tested. The results of this analysis highlight the need to account for local variation between small areas when examining TRO product landscapes and the effects of policy changes at the retailer level.

Effect of restricting menthol flavored cigarettes or E-cigarettes on smoking behavior in menthol smokers

Bans of menthol characterizing flavor in tobacco products have been enacted in some localities and proposed in the United States for cigarettes. To gather data regarding how restrictions for menthol in cigarettes and e-cigarettes may affect current menthol cigarette smokers, 37 African American menthol smokers participated in a pilot study in which they were asked to abstain (n = 18) or not abstain from menthol cigarettes (n = 19) for 8-weeks. All participants received menthol flavored e-cigarettes for 4 weeks and tobacco flavored e-cigarettes for 4 weeks in random order. Number of cigarettes smoked per day (estimated mean ratio [EMR] = 0.31; 95% CI: 0.13, 0.72) and exhaled CO concentrations (EMR = 0.61; 95% CI: 0.43, 0.88) were lower in the menthol cigarette abstainer group compared to the menthol cigarette non-abstainer group. Those in the menthol cigarette abstainer group reported higher scores on motivation to quit (p = 0.03) and perceived effectiveness of quitting skills (p = 0.02). There were no substantial effects seen in amount smoked or exhaled CO based on flavor of e-cigarettes provided. Higher e-cigarette use (based on reported puffs per day) was reported in the menthol cigarette abstainer (vs. non-abstainer) group (p < 0.01) and also during the 4-week period when provided with menthol (vs. tobacco) e-cigarettes (p < 0.01). These data suggest that the potential of e-cigarettes to reduce tobacco related harm may be enhanced if combined with a ban on menthol flavor in combustible cigarettes. Larger studies are needed to determine the effect of limiting menthol in e-cigarettes on smoking behavior among current menthol smokers.

Menthol Cigarette Smoking Trends among United States Adults, 2003-2019

BACKGROUND

Smoking is declining, except among current menthol cigarette smokers. This study examines menthol cigarette smoking in the United States.

METHODS

Cross-sectional data from 35,279 self-respondent current adult smokers who selected menthol cigarettes as their usual type, across the 2003, 2006-2007, 2010-2011, 2014-2015, and 2018-2019 waves of the nationally-representative Tobacco Use Supplement to the Current Population Survey, were analyzed in SAS/SUDAAN. Menthol cigarette smoking among current smokers was assessed by sex, age, race/ethnicity, employment, geography, and educational attainment. Linear contrasts were used to assess trends.

RESULTS

Overall cigarette smoking (12.6% in 2018-2019 from 17.3% in 2003) and menthol cigarette smoking (4.0% in 2018-2019 from 4.7% in 2003) in the population decreased in 2018-2019 from 2003 (both P < 0.001). Using predicted marginals, adjusted by demographics, menthol smoking among current smokers increased to 33.8% in 2018-2019 from 27.9% in 2003 (P < 0.001). Among current smoking adults, increases in menthol smoking were observed among non-Hispanic Black persons (76.8% in 2018-2019 from 73.0% in 2003), young adults (37.7% in 2018-2019 from 31.7% in 2003), and women (39.6% in 2018-2019 from 32.1% in 2003).

CONCLUSIONS

Smoking and menthol smoking in the population has decreased, yet menthol smoking among current smokers increased from 2003 to 2018-2019. Young adult, female, and non-Hispanic Black current smokers were more likely to use menthol cigarettes than their counterparts; these differences have persisted.

IMPACT

Increased menthol smoking among current smokers, notably young adults, women, and non-Hispanic Black individuals, highlights the need for targeted tobacco control interventions for these health disparity populations.

An analysis of cigarette sales during Poland's menthol cigarette sales ban: small effects with large policy implications

BACKGROUND

In May 2020, the European Union Tobacco Products Directive mandated that EU member states, including Poland, ban the sale of menthol cigarettes. With menthol making up 28% of cigarette sales before the ban, Poland is the country with likely the largest menthol cigarette sales share in the world to ban their sale. We analyze how this ban changed the Polish tobacco market.

METHODS

We use monthly NielsenIQ data (May 2018-April 2021) on sales of cigarettes and roll-your-own tobacco by menthol and standard flavor in eight regions of Poland. We set up a bite-style regression model controlling for pre-ban menthol share, climate, border opening status, and Apple movement data to estimate the effect of the May 2020 menthol ban.

RESULTS

We find menthol cigarette sales fell at least 97% after the menthol cigarette ban across Poland and standard cigarette sales replaced them. Regression modeling indicates that total cigarette sales fell, after the ban, an average of 2.2 sticks per capita per month, equal to a 2.9% decline, however, results were not significant (P = 0.199). The bite component of our model reveals total cigarette sales did decline significantly in the regions with the highest pre-ban menthol sales shares. Roll-your-own tobacco sales increased by a statistically insignificant 0.03 stick-equivalents after the ban (P = 0.798). Product prices also fell in the wake of the menthol ban.

CONCLUSIONS

In Poland, the EU state with the one of the largest pre-ban menthol shares, we find mixed evidence that the ban is working as intended.

Impact of Massachusetts' Statewide Sales Restriction on Flavored and Menthol Tobacco Products on Tobacco Sales in Massachusetts and Surrounding States, June 2020

In June 2020, Massachusetts implemented a first in the nation statewide law that restricts sales of menthol and other flavored tobacco. Since implementation, sales data indicate high retailer compliance. Drastic decreases were seen in sales of all flavored tobacco. Most neighboring states did not see increases in overall tobacco sales, although New Hampshire saw an initial increase in menthol sales, which was not sustained. We found that menthol restrictions are effective and that federal-level legislation is important, as some cross-border sales highlight. (Am J Public Health. 2022;112(8):1147-1150. https://doi.org/10.2105/AJPH.2022.306879).

Brazilian smokers are ready for the ban on flavour additives in tobacco to be implemented

Brazil became the first country to approve a national policy to ban all flavour additives in all tobacco leaf products in 2012. However, as of February 2022, the policy remained to be implemented. Cross-sectional data come from the International Tobacco Control (ITC) Brazil Wave 3 Survey among adult smokers (N = 1216) in 2016-2017. The majority of smokers supported a ban on menthol (56.0%; 95%CI: 51.7-60.2%) and a ban on all additives (61.7%; 57.5-65.8%), with no significant differences across sociodemographic groups in adjusted logistic regression models. More than half of menthol smokers reported they would either quit or reduce the amount they smoked if menthol cigarettes were banned. Findings suggest that there is support for Brazil's ban on flavour additives, which is a determinant of successful policy implemented. Continued delays will postpone an important measure with demonstrated public health gains.

Discussions of Flavored ENDS Sales Restrictions: Themes Related to Circumventing Policies on Reddit

OBJECTIVE

To examine conversations among JUUL users on Reddit related to restrictions on flavored ENDS and the shifting policy landscape.

METHODS

Posts and comments (n = 166,169) between May 2019 and May 2020 on the subreddit r/JUUL were scraped using pushshift.io API. Keyword filters were used to identify texts discussing flavored ENDS products (n = 33,884 texts). These were further narrowed down to texts discussing flavor policy workaround strategies (n = 7429) and N-gram analysis was performed. Finally, findings from the N-gram analysis were triangulated through qualitative review of a separate sample of texts (n = 488) from the flavor policy-related posts and comments.

RESULTS

Overall activity on the subreddit r/JUUL peaked around the time of the EVALI outbreak (September 2019) and when FDA issued guidance restricting flavored ENDS product sales (January 2020). The N-gram analysis revealed an active discussion of banned products one can "still get" or "JUUL compatible" alternatives, including specific brands, brick and mortar locations, and specific flavors. Ten dominant themes emerged from the qualitative review, with some posts containing more than one theme.

CONCLUSION

Many users turned to Reddit for information related to the shifting regulatory landscape concerning flavored ENDS. Discussions focused on both legal alternatives to banned products as well as illegal means of acquiring JUUL pods, including residual retail supply, online, and mail vendors.

Evaluating the Outcomes of the Menthol Cigarette Ban in England by Comparing Menthol Cigarette Smoking Among Youth in England, Canada, and the US, 2018-2020

Importance

Menthol cigarettes were prohibited in England in May 2020 and nationally in Canada in October 2017 but remain permitted in the US. Evidence on the outcomes of menthol cigarette bans among youth outside of Canada, and the characteristics of youth smokers, is lacking.

Objectives

To evaluate the outcomes of menthol cigarette bans on youth menthol cigarette smoking and to characterize youth menthol cigarette smokers in terms of demographics and cigarette consumption and dependence.

Design, Setting, and Participants

This survey study uses data from online repeat cross-sectional International Tobacco Control Youth Tobacco and Vaping Surveys conducted in 2018, 2019, February 2020, and August 2020. Participants included past 30-day smokers aged 16 to 19 years. Data analysis was performed from March 2021 to January 2022.

Main Outcomes and Measures

Usually smoke a brand of cigarettes that was menthol, including capsule.

Exposures

Menthol cigarette ban, comparing 3 countries over time: Canada, where a ban already existed, England, where a ban was implemented during the study, and the US, where no national ban was present. Age, sex, race, and consumption and dependence were also examined by menthol smoking in each country, and in England before vs after the ban.

Results

The analytical sample comprised 7067 participants aged 16 to 19 years, of whom 4129 were female and 5019 were White. In England, the weighted percentage of youth smokers who reported smoking a menthol or capsule cigarette brand was stable in the 3 survey waves before the menthol ban (2018 to February 2020, 9.4% vs 12.1%; adjusted odds ratio [AOR], 1.03; 95% CI, 0.99-1.06; P = .15) but decreased to 3.0% after the ban (February 2020 vs August 2020, AOR, 1.07; 95% CI, 1.04-1.10; P < .001). The decrease between February and August 2020 in England was similar across all demographic groups but was greater among youth who perceived themselves as addicted to cigarettes (AOR, 0.37; 95% CI, 0.41-0.97; P = .04). In the 2 comparison countries, menthol or capsule smoking was stable across all waves (2018 to August 2020: US, 33.6%-36.9%; Canada, 3.1%-2.3%) and was more prevalent in the US than in England (AOR, 5.58; 95% CI, 4.63-6.72; P < .001). Menthol or capsule smoking was also more prevalent among smokers in England who were female vs male (10.9% vs 7.2%; AOR, 1.04; 95% CI, 1.01-1.06; P = .002); among smokers in the US who identified as Black vs White (60.6% vs 31.9%; AOR, 1.33; 95% CI, 1.23-1.44; P < .001) or who were frequent smokers (AOR, 1.07; 95% CI, 1.01-1.13; P = .03), smoked more cigarettes per day (2-5 vs 1, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1, AOR, 1.10; 95% CI, 1.03-1.18; P = .007), or had urges to smoke every or most days (AOR, 1.08; 95% CI, 1.02-1.14; P = .006); and among smokers in Canada who perceived themselves as addicted to cigarettes (AOR, 1.02; 95% CI, 1.00-1.03; P = .01).

Conclusions and Relevance

In this survey study, the proportion of youth smokers who smoke menthol (including capsule) cigarettes decreased substantially after the menthol ban in England. This association was consistent across all demographic groups. Perceived addiction among menthol smokers was also lower where menthol cigarettes were banned.

Smoking Quit Rates Among Menthol vs Non-Menthol Smokers: Implications Regarding a US Ban on the Sale of Menthol Cigarettes

BACKGROUND

A ban on the sale of menthol cigarettes in the United States is currently under consideration. A justification is that menthol cigarettes are harder to quit, particularly for African American smokers who use menthols much more frequently than White smokers, but epidemiologic data are limited.

METHODS

In a cohort of 16,425 mostly low income African American and White current cigarette smokers enrolled during 2002-2009, we computed smoking quit and re-uptake rates at three follow ups conducted means of 4.6, 7.7 and 11 years after entry. Generalized estimation equations were used to compute odds ratios (OR) and 95% confidence intervals (CI) for quitting and resuming smoking for menthol vs non-menthol smokers adjusted for race, age, education, income, and smoking pack years.

RESULTS

Crude annual quit rates among current smokers were 4.3% for menthol and 4.5% for non-menthol smokers, with adjusted ORs of quitting for menthol vs non-menthol smokers of 1.01 (95% CI = 0.91-1.11) overall, 0.99 (95% CI = 0.87-1.12) among African American and 1.02 (95% CI = 0.88-1.20) among White smokers. Crude annual smoking re-uptake rates were somewhat higher among menthol (8.4%) than non-menthol smokers (7.1%), with an adjusted OR of 1.19 (95% CI = 0.97-1.47), but net quit rates remained similar (OR = 1.01 [95% CI = 0.90-1.13] overall; OR = 1.00 [95% CI = 0.86-1.15] among African American participants; and OR = 1.04 [95% CI = 0.87-1.24] among White participants).

CONCLUSIONS

This large-scale prospective survey revealed similar quit rates among menthol and non-menthol smokers. Results contribute to policy discussions, especially if, as a meta analysis suggests, lung cancer risk is higher for non-menthol smokers and a ban leads menthol smokers to switch to non-menthol cigarettes.

Effect on Tobacco Use and Subjective Measures of Including E-cigarettes in a Simulated Ban of Menthol in Combustible Cigarettes

INTRODUCTION

Bans of menthol characterizing flavor in tobacco products have been proposed, however there is limited data regarding the impact on current menthol cigarette smokers of including e-cigarettes in such bans.

METHODS

In this six-week pilot study, menthol smokers were randomized to receive all tobacco products from an experimental marketplace simulating either no menthol ban, a menthol ban for cigarettes but not e-cigarettes or a ban for both ("total menthol ban").

RESULTS

At the first experimental marketplace visit, all but one participant selected cigarettes with e-cigarettes selected by 38%, 69% and 40% of participants in the no ban, menthol cigarette ban and total menthol ban groups, respectively. Over the study period, the total menthol ban group smoked more than the menthol cigarette ban group (estimated mean ratio [EMR] in cigarettes per day = 1.38; 95% CI: 1.1, 1.75; p=0.006). Compared to the no ban condition, the menthol cigarette ban group smoked slightly fewer (EMR = 0.87; 95% CI: 0.68, 1.11) and the total menthol ban group smoked slightly more (EMR = 1.20; 95% CI: 1.00, 1.45) although neither difference reached statistical significance. In both menthol ban conditions, ratings were lower (vs. no ban) on several measures of craving and of cigarette effects and liking.

CONCLUSIONS

Menthol bans that include e-cigarettes may result in different patterns of tobacco use than if only combustible cigarettes are included, although e-cigarettes were not extensively used in any group. Larger studies are needed to determine which policies most likely provide the largest public health benefit.

IMPLICATIONS

Bans of menthol characterizing flavor have been proposed, however the effects on menthol cigarette smokers of including e-cigarettes in such bans are not clear. This study found that smokers randomized to a simulated ban on menthol in both cigarettes and e-cigarettes smoked more cigarettes per day over the 6-week study period than those randomized to a simulated ban on menthol in only cigarettes suggesting that smoking patterns among current menthol smokers differ depending on which products are included in a menthol ban. Larger studies are needed to determine policies most likely to provide the largest public health benefit.

Evaluating the public health impact of partial and full tobacco flavour bans: A simulation study

Background

Methods

Findings

Interpretations

Funding

Illicit trade in tobacco products: recent trends and coming challenges

BACKGROUND

Illicit trade in tobacco products is a menace to the goal of eliminating tobacco consumption. Although tax policy is very effective in reducing consumption, illicit trade can reduce (though not eliminate) its effectiveness.

METHODS

This article discusses the recent evolution of illicit trade and the context in which it occurred; the new methods that have been developed to measure it and, finally, the challenges in the next phase in the control of illicit trade.

RESULTS

There has been a remarkable stability in the penetration of cigarette illicit trade in the past decade. Such a stability, however, occurred in a world of shrinking tobacco consumption, implying a decreasing absolute illicit trade. Most countries have progressed in increasing tobacco taxes and changing tax structures. Prices of illicit cigarettes follow legal cigarette prices. Concomitantly, many new studies, independent from the tobacco industry, have been conducted allowing for better understanding of the illicit trade and providing inputs to its solution. The entry into force of the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products provides both a global and a national policy framework to further curb illicit trade. Instruments such as track-and-trace systems must be promoted and adopted to maximise reductions in illicit trade.

CONCLUSIONS

Global efforts to curb the illicit trade in tobacco products are gaining momentum and progress has been made in many parts of the world. The next decade can witness a decisive decrease in tobacco consumption, both licit and illicit, if countries further engage in international collaboration.

Evolution of tobacco products: recent history and future directions

Declines in cigarette smoking prevalence in many countries and the consolidation of the tobacco industry have prompted the introduction of other forms of nicotine delivery. These include electronic nicotine delivery systems (ENDS), heated tobacco products (HTPs) and oral nicotine products (ONPs). Evolving over time, some of these products now deliver nicotine at levels comparable to cigarettes and may serve as effective substitutes for smokers. However, certain products, especially ENDS like JUUL, have also appealed to youth and non-smokers, prompting concerns about expanding nicotine use (and potentially nicotine addiction). The tobacco industry could shift away from primarily promoting cigarettes to promoting ENDS, HTPs and/or ONPs, though at this time it continues to heavily promote cigarettes in low and middle-income countries. Differing regulatory regimes may place upward and downward pressures on both cigarettes and these newer products in terms of population use, and may ultimately drive the extent to which cigarettes are or are not displaced by ENDS, HTPs and/or ONPs in the coming decade.

"I think it's a good idea for the people that's young, the kids, but for someone like me it's a bad idea." - Interviews about a U.S. menthol cigarette ban with people who smoke menthol cigarettes

OBJECTIVE

The US Food and Drug Administration recently announced its intention to pursue a federal ban on menthol cigarettes. This qualitative study assessed reactions to a potential menthol cigarette ban among people who smoke menthol cigarettes.

METHODS

As part of a laboratory study examining menthol flavor regulations, we conducted follow-up interviews with participants who smoke menthol cigarettes (N = 35). We explored the following topics: (1) menthol cigarette risk perceptions; (2) knowledge, attitudes, and perceptions of menthol cigarette regulations; and (3) anticipated behavior if menthol cigarettes were banned. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis.

RESULTS

Many participants thought menthol cigarettes carried more health risks than non-menthol cigarettes. Some participants said regulators wanted to ban menthol cigarettes because they appeal to youth. Others thought a ban would be good for public health because fewer people, particularly youth, would smoke. Several voiced skepticism about banning only menthol cigarettes rather than all cigarettes. Most said they would use other products, including electronic cigarettes or non-menthol cigarettes, but many also thought a menthol ban could motivate them or others to quit smoking.

CONCLUSIONS

Banning menthol cigarettes could lead some people who smoke menthol cigarettes to switch to potentially less harmful products, like e-cigarettes, or quit smoking, which would likely benefit public health; however, others may simply transition to non-menthol cigarettes. As regulators move forward with banning menthol cigarettes, communication campaigns explaining the public health benefits, potentially focusing on the benefits for youth, should be part of the policy implementation plan.

Fresh Take: Pitfalls of the FDA's Proposed Menthol Ban

In April 2021, the U.S. Food and Drug Administration announced its intention to ban menthol flavoring in cigarettes and cigars. The Agency's decision was based in part on the disproportionate impact of menthol flavoring in Black communities.

Do high school friends still matter for health behavior in adulthood? Variations in smoking trajectories by adolescent peer smoking networks, race/ethnicity, and gender

Peers play an influential role in the initiation of smoking during adolescence. However, there has been limited literature examining whether adolescent peers are associated with longer-term patterns of smoking. This study uses data from the National Longitudinal Study of Adolescent to Adult Health to examine whether age-based trajectories of smoking likelihood from adolescence to adulthood are associated with the number of adolescent friends who smoked and how this association differs by race/ethnicity and gender. Findings using multilevel growth curve models indicate that individuals who have more adolescent friends who smoked have higher probabilities of smoking during adolescence than those with no adolescent smoking friends. As individuals age into adulthood, the association between adolescent friends' smoking behavior and individual-level smoking begin to dissipate but does not completely disappear. Further analyses show that there are no differences in this association by gender, but there are differences by race/ethnicity. These findings suggest that high school friends continue to be associated with trajectories of smoking even twenty years after high school. These results indicate that anti-smoking campaigns should take a network approach to preventing smoking in adolescence as well as recognize that the same campaign strategy may not work for all groups.

A Comprehensive Qualitative Review of Studies Evaluating the Impact of Local US Laws Restricting the Sale of Flavored and Menthol Tobacco Products

Objectives

To assess the quality of evidence on the effectiveness of local US laws restricting the sale of flavored tobacco products.

Methods

We conducted a systematic search and qualitative scoping review of English-language papers published through May 2020 that evaluated flavored tobacco sales policies implemented by US jurisdictions during 2010–2019. We constructed a conceptual model for flavored and menthol tobacco sales restriction outcomes, assigned GRADE quality of evidence ratings to policy outcomes evaluated through the included studies, and summarized factors that might explain weak or inconsistent findings.

Results

We found moderate to high quality of evidence associating policy implementation with reduced availability, marketing, and sales of policy-restricted products, and decreased youth and adult tobacco use of these products; however, policy exclusions and exemptions, implementation challenges, tobacco industry actions (e.g., marketing of concept-named flavored products; exploiting policy exemptions for certain store types), and consumer responses (e.g., cross-border or illicit purchasing) might undermine or mitigate intended policy effects.

Conclusions

Flavored and menthol tobacco product sales restrictions implemented and evaluated in US jurisdictions appear to have achieved some of their intended outcomes; however, deficiencies in study designs, methods, and metrics could contribute to equivocal findings on quality of evidence associating policy implementation and outcomes. Gaps in the evidence are beginning to be filled with research using more rigorous study designs, improved measurement and analytic methods, and longer-term follow-up.

Implications

In the absence of comprehensive federal action, US jurisdictions have the obligation to restrict flavored and menthol product sales to protect vulnerable populations from tobacco-related harms. The considerable expenditure of financial resources, political will, and time dedicated to policy adoption and implementation argue for evaluation studies designed to maximize the quality of evidence. This review offers generalizable insights into evaluation findings that can inform efforts to enhance tobacco control policy implementation and impact in the US and globally.

Changes in retail sales of tobacco products in Ontario after a menthol sales restriction

BACKGROUND

Ontario, Canada prohibited menthol tobacco product sales beginning 1 January 2017. We measured retail sales of menthol cigarettes and possible substitute products before and after policy implementation in Ontario.

METHODS

We licensed retail scanner data for tobacco product sales in Ontario and British Columbia (BC), a comparison province without a menthol tobacco policy at that time. We assessed changes in per capita unit sales (per 1000 people) from pre-policy (January-June 2016) to post-policy (January-June 2017) periods. Classification of cigarettes as menthol or non-menthol, or having menthol-suggestive descriptors ('green', 'blue', 'silver' and 'fresh'), was based on scanner data.

RESULTS

Ontario menthol cigarette sales decreased 93%, from 596 to 40 packs per capita compared with a 2% decrease (696 to 679 packs per capita) in BC. Menthol capsule cigarette sales remained low in Ontario (<1% of total cigarette sales) but rose sixfold in BC. Although cigar sales data were unavailable, substitution appeared minimal; sales of non-menthol cigarettes increased 0.4% in Ontario (11 470 to 11 519 packs per capita) while vaping product sales decreased. Ontario had a larger increase in sales of cigarettes with menthol-suggestive descriptors (11% increase) than BC (3% increase). In Ontario, nearly all (>99%) pre-policy sales of cigarettes with 'green' menthol-suggestive descriptors were menthol cigarettes, but post-policy, 94% of 'green' cigarettes sold were non-menthol.

CONCLUSIONS

Ontario's menthol policy was associated with a decrease in retail sales of cigarettes classified as menthol, with little evidence of product substitution. Understanding changes in sales of cigarettes with menthol-suggestive descriptors would be informative.

Australian Smokers' Sensory Experiences and Beliefs Associated with Menthol and Non-Menthol Cigarettes

Many current smokers incorrectly believe that menthol cigarettes are less harmful, likely due to the biological and sensory effects of menthol, which can lead smokers to have favourable sensory experiences. In this study, we measured the extent to which Australian smokers associate certain sensory experiences with smoking menthol and non-menthol cigarettes, and their beliefs about how damaging and enjoyable they find cigarettes with each of these sensory experiences. A sample of 999 Australian 18–69-year-old weekly smokers was recruited from a non-probability online panel; this study focuses on the 245 respondents who currently smoked menthol cigarettes at least once per week. Current menthol smokers were four to nine times more likely to experience menthol rather than non-menthol cigarettes as having favourable sensory experiences, including feeling smooth, being soothing on the throat, fresh-tasting and clean-feeling. Menthol smokers perceived cigarettes with these favourable sensations as less damaging and more enjoyable than cigarettes with the opposite more aversive sensory experience. Efforts to correct these misperceptions about risk will likely require messages that provide new information to help smokers understand that these sensations do not indicate a lower level of risk. Banning menthol in tobacco products—as has recently been done in some nations—would also be a timely and justified strategy for protecting consumers.