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Keywords:

  • Smoking;
  • initiation;
  • purchasing patterns;
  • menthol;
  • age

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References

Aims  The purpose of this study was to examine the relationship between age of cigarette smoking initiation and cigarette purchasing patterns on menthol smoking among current smokers.

Design  Secondary analyses were conducted using logistic regression with balanced replicated weights.

Setting  Data from the 2003 and 2006/07 Tobacco Use Supplement (TUS) to the Current Population Survey (CPS), collected by the National Cancer Institute, the Centers for Disease Control and Prevention and the Census Bureau, formed the basis for this investigation.

Participants  A total of 66 145 current smokers who participated in the TUS CPS administration in 2003 and 2006/07 were examined.

Measurements  Demographic characteristics (gender, race/ethnicity, age, education and income), smoking frequency, purchase type (pack, carton, or both), age of initiation and menthol cigarette use were assessed.

Findings  One-quarter of the sample smoked menthol cigarettes; most purchased their cigarettes by the pack when rather than by the carton; average age of cigarette smoking initiation was 18 years; and females, ethnic/racial minorities and younger participants were more likely to smoke menthol cigarettes compared with males, whites or older respondents. Other demographic factors associated with menthol cigarette use among current smokers included a high school education (the prevalence of menthol use among this cohort was greater than either those with less education or those with more). The multivariate logistic model only marginally revealed that age of smoking initiation predicted menthol smoking: findings are suggestive that the longer the delay of initiation the more likely that an individual smoked menthol cigarettes [odds ratio (OR) = 1.01; 95% confidence interval (CI): 1.00–1.01]. In addition, relative to those who purchased cigarettes by the pack, smokers who purchased cigarettes by the carton were less (OR = 0.86; 95% CI: 0.81–0.91) likely to be menthol smokers.

Conclusions  Menthol smokers in the United States are more likely to be female, younger, from ethnic minority groups, and to have a high school education. The findings that menthol smokers in the U.S. tend to start smoking later than smokers of other types of cigarettes are suggestive only and require further study.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References

Cigarette smoking is the leading cause of premature morbidity and mortality in the United States, accounting for more than 440 000 deaths annually [1,2]. Approximately 90% of adult smokers initiate smoking before the age of 18 years [3]. Along with women and ethnic minority populations, individuals under the age of 18 are among the priority targets for menthol cigarette marketing by tobacco companies [4,5]. Tobacco companies understand that if they target certain brands towards young adults that they are more likely to remain smokers and remain brand-loyal throughout their adult lives. Menthol cigarettes account for approximately 20% of all cigarettes sold in the United States and studies have found that more than 80% of cigarettes purchased by young adult smokers are menthol cigarettes [6–9]. Furthermore, studies have examined menthol cigarettes as a starter product among youth (i.e. 10,11) and found that menthol cigarettes are more common among newer, and younger, smokers and those who smoke menthol cigarettes self-report higher nicotine dependence than non-menthol smokers. In addition to the targeted marketing strategies of tobacco companies towards young smokers, menthol cigarettes may be preferred by younger smokers due to the milder sensation when cigarette smoke is inhaled [12]. While the direct influence of menthol cigarettes on disease and illness is inconclusive, studies suggest indirect effects of menthol cigarette smoking. For example, smoking menthol cigarettes may increase absorption of nicotine and tobacco carcinogens [13]. In addition, studies conducted among adult smokers indicate that menthol cigarette smokers are more nicotine-dependent than non-menthol smokers and may be less likely to quit [14–19].

Tobacco control policy efforts have included cigarette price increases/taxes that reduce the demand for cigarettes, thereby reducing cigarette consumption, reducing initiation of smoking among youth and increasing cessation among youth [20–24]. To counteract these tax and pricing policy efforts the tobacco industry often provides a variety of price-related marketing benefits, including multi-pack discounts [25]. When faced with high cigarette prices, all smokers can potentially control cigarette expenditures by changing their purchasing patterns, including purchasing cigarettes in bulk/carton rather than by the pack [26]. While studies have documented an association between menthol cigarettes and smoking initiation, no research was found that has documented whether menthol smoking status affects cigarette purchasing patterns. This study sought to examine the association of age of smoking initiation and purchasing pattern (pack, carton or pack/carton) on menthol smoking. If positive associations are found, tobacco control policy efforts may need to attend to menthol cigarettes as a unique cigarette product. For example, the Food and Drug Administration (FDA) recently placed certain restrictions on the marketing of ‘flavored’ cigarettes, which are popular starter cigarettes for youth. However, ‘menthol’ cigarettes were excluded from these restrictions because it was not considered a ‘flavor’. In addition, tobacco control policy efforts may need to emphasize interventions that enforce larger excise taxes on menthol cigarettes, to decrease and/or eliminate the smoking of menthol cigarettes as a starter product.

METHODS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References

Design and sample

Data for the analysis were obtained from the 2003 and 2006/07 Tobacco Use Supplement to the Current Population Survey (TUS CPS). The CPS is a national population-based survey that is administered by the Census Bureau for the Bureau of Labor Statistics and the TUS is sponsored by the National Cancer Institute and the Centers for Disease Control. During each of the months the survey was conducted, approximately 50 000 US households were contacted to participate. Multi-stage probability sampling was used and included civilian non-institutionalized individuals aged 18 years and above. Items included on the CPS survey include primarily demographic variables, including employment measures, while the TUS supplement includes a variety of items related to tobacco use.

The design of the study is cross-sectional. Of those who complete the TUS CPS survey, most participate in a telephone survey; the remainder are surveyed during an in-person interview. Overall response rates to the TUS CPS are typically about 80%, but this includes both proxy and self-respondents [27]. However, the results presented here are based on self-responders only. Proxy respondents were excluded from this study because it was assumed that certain items pertaining to smoking, particularly age of initiation of cigarette use, would be less accurate when answered by a proxy respondent. This strategy of including only self-respondents in the analysis of TUS CPS data has been used in two recent studies for which age of initiation was a key variable [28,29]. In the combined 2003 and 2006/07 TUS CPS data set, there were 66 145 current smokers who completed the survey themselves. Of these, 16 294 were menthol smokers and 46 899 smoked non-menthol brands (the remaining 2952 were unresponsive). The binary indicator for menthol cigarette status (i.e. menthol versus non-menthol for the usual brand of cigarette) was the dependent variable in a logistic regression model. Potential predictors included age of initiation and cigarette purchasing type, in addition to demographic and other smoking variables.

Measures

Smoking variables

Current smoking status and smoking frequency were determined with the questions: ‘Have you smoked at least 100 cigarettes in your entire life?’, ‘Do you now smoke cigarettes every day, some days, or not at all?’ and ‘On how many of the past 30 days did you smoke cigarettes?’. Respondents who said they had smoked at least 100 cigarettes in their life-time and who were currently smoking every day or some days (including at least once in the last 30 days) were considered current smokers. Purchasing type was determined with the item ‘Do you USUALLY buy your cigarettes by the pack or by the carton?’. Response categories include ‘pack’ or ‘carton ’ and ‘buy both packs and cartons’. Menthol smoking status was determined with the item: ‘Is your usual cigarette band menthol or non-menthol?’, with responses of ‘menthol’, ‘non-menthol’ and ‘no usual type’. Those who stated that they had no usual type were treated as missing values for the cigarette type variable. Age of initiation of cigarette smoking was assessed with the item: ‘How old were you when you first started smoking cigarettes FAIRLY REGULARLY?’, and the participant responded with age in years.

Demographic variables

The demographic items included in this analysis were gender, race/ethnicity, age, education and annual family income. The four categories for race/ethnicity were white non-Hispanic, black, Hispanic and Other, including American Indian/Alaska Native and Asian/Pacific Islander. Age was coded into four categories: 18–24, 25–44, 45–64 and 65 years and above. The categories for education were less than high school, high school graduate and at least some post-secondary education. Income was collected as a 14-category variable; this measured the combined family income during the last 12 months. Income was recoded into a smaller number of categories prior to analysis: <$15 000; $15 000–39 999; $40 000–74 999; or at least $75 000 [30]. These categories were chosen so that the distribution of respondents was roughly equal in the lowest and highest categories. Age of initiation of smoking was categorized as <18 years and ≥18 years for the descriptive summary, but was left in terms of years of age for inclusion in the multivariable regression analysis.

Data analysis

The study data were summarized descriptively with frequency distributions, means and standard deviations. Binary logistic regression was used to assess the influence of age of initiation and other smoking variables in addition to demographic characteristics on menthol use status. All data analysis was performed using SUDAAN (release 9.0.3; Research Triangle Institute, Research Triangle Park, NC, NC). For the univariate and multivariable analyses, observations were weighted to adjust for the probability of selection using replicate weights.

RESULTS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References

Demographic and smoking characteristics stratified by menthol status

Frequency distributions for each of the demographic and study variables were determined for the entire sample of current smokers and were stratified by menthol status (Table 1). In the full sample of current smokers, slightly more than one-fourth smoked menthol cigarettes. In the full sample and in the non-menthol subgroup the majority of current smokers were male; females were the majority among all menthol smokers. Most of the groups (full sample, menthol, non-menthol) were white non-Hispanic, while the percentage of black participants in the menthol group was much higher (29%) than in either of the other two groups. Most were between the ages of 25 and 64; most had at least a high school education and an annual income of less than $40 000. The majority smoked every day when compared to only some days. About four-fifths in each of the groups smoked every day, and most purchased their cigarettes by the pack. While about one-third of smokers in the full and non-menthol groups purchased cigarettes by the carton, only about one-fourth of menthol smokers did so. In all three groups of current smokers, most initiated smoking prior to age 18, although this percentage was slightly smaller in the menthol group relative to the others.

Table 1.  Demographic characteristics and smoking indicators of current smokers, for the full sample and by menthol status, who participated in Tobacco Use Supplement to the Current Population Survey (TUS CPS) (2003 and 2006/07).
Demographic characteristicCurrent smokers (n = 66 145)Menthol smokers (n = 16 294)Non-menthol smokers (n = 46 899)
Sample sizePercentage (95% CI)Sample sizePercentage (95% CI)Sample sizePercentage (95% CI)
  1. CI: confidence interval; TUS CPS: Tobacco Use Supplements to the Current Population Survey.

Gender66 145 16 294 46 899 
 Male 53.8 (±0.4) 45.2 (±0.9) 56.3 (±0.5)
 Female 46.2 (±0.4) 54.8 (±0.9) 43.7 (±0.5)
Race/ethnicity66 145 16 294 46 899 
 White non-Hispanic 75.2 (±0.4) 58.0 (±1.0) 82.6 (±0.5)
 Black 11.0 (±0.3) 28.7 (±0.9) 3.9 (±0.3)
 Hispanic 8.9 (±0.3) 8.7 (±0.6) 8.6 (±0.4)
 Asian/Other 4.9 (±0.2) 4.6 (±0.5) 4.9 (±0.3)
Age (years)66 145 16 294 46 899 
 18–24 15.0 (±0.4) 17.3 (±0.8) 14.1 (±0.4)
 25–44 42.7 (±0.4) 40.6 (±0.9) 43.7 (±0.5)
 45–64 35.2 (±0.4) 36.4 (±0.9) 34.7 (±0.5)
 65+ 7.1 (±0.2) 5.7 (±0.4) 7.5 (±0.2)
Education66 145 16 294 46 899 
 Less than high school 18.8 (±0.4) 19.9 (±0.8) 18.0 (±0.5)
 High school 39.5 (±0.5) 40.7 (±1.0) 39.1 (±0.5)
 Some post-secondary 41.7 (±0.5) 39.4 (±0.9) 42.9 (±0.6)
Income59 688 14 739 42 644 
 <$15 000 20.5 (±0.5) 24.3 (±1.0) 18.7 (±0.6)
 $15 000–<40 000 36.0 (±0.5) 36.2 (±1.0) 35.9 (±0.6)
 $40 000–<75 000 27.6 (±0.5) 25.4 (±1.0) 28.7 (±0.6)
 $75 000+ 15.9 (±0.4) 14.1 (±0.7) 16.7 (±0.5)
Smoking frequency66 145 16 294 46 899 
 Every day 80.3 (±0.4) 79.6 (±0.8) 81.4 (±0.4)
 Some days 19.7 (±0.4) 20.4 (±0.8) 18.6 (±0.4)
Purchase type61 737 15 524 44 464 
 Pack 62.1 (±0.5) 68.8 (±0.9) 59.2 (±0.6)
 Carton 31.4 (±0.5) 25.1 (±0.8) 34.3 (±0.6)
 Buy pack/carton 6.5 (±0.3) 6.1 (±0.5) 6.5 (±0.3)
Age of initiation63 741 15 851 45 626 
 <18 55.3 (±0.5) 53.2 (±0.9) 56.2 (±0.6)
 ≥18 44.7 (±0.5) 46.8 (±0.9) 43.8 (±0.6)
Menthol status63 193     
 Menthol 27.6 (±0.5)  
 Non-menthol 72.4 (±0.5)  

Predictors of menthol status

The logistic model with menthol status as the dependent variable included age of initiation of smoking and purchasing type as predictors, along with demographic characteristics as covariates. In this model males were less likely than females to smoke menthol cigarettes (OR = 0.58, 95% CI: 0.55–0.61; see Table 2). Blacks, Hispanics and other minorities were more likely to smoke menthol cigarettes, compared with white non-Hispanics (ORs = 11.10, 1.55 and 1.35, respectively; 95% CIs: 10.01–12.31, 1.40–1.71, and 1.19–1.54, respectively). Current smokers who were younger were more likely to smoke menthol cigarettes (OR = 1.66, 95% CI: 1.47–1.88 for the 18–24 age group relative to those aged 65 and above; OR = 1.20, 95% CI: 1.07–1.34 for the 25–44 age group relative to those aged 65 and above; and OR = 1.36, 95% CI: 1.22–1.51 for 45–64 age group relative to those aged 65 and above). Compared to those with some post-secondary education, current smokers with only a high school diploma were more likely to smoke menthol cigarettes (OR = 1.11, 95% CI: 1.05–1.18), but there was no difference in the likelihood of smoking menthol cigarettes when comparing those with less than a high school education and those with post-secondary schooling. Smokers with incomes less than $15 000/year were less likely to smoke menthol cigarettes compared to smokers with incomes of $75 000 or more (OR = 0.88, 95% CI: 0.81–0.97).

Table 2.  Predictors of menthol smoking status for current smokers who participated in the Tobacco Use Supplement to the Current Population Survey (TUS CPS), 2003 and 2006/07 (n = 61 447).
VariableOdds ratio (95% CIa)
  • a

    Confidence interval (CI).

  • *

    *Odds ratio significant at the 0.05 level. TUS CPS: Tobacco Use Supplements to the Current Population Survey

Gender 
 Male0.58* (0.55,0.61)
 Female1.00
Race/ethnicity 
 Black11.10* (10.01,12.31)
 Hispanic1.55* (1.40,1.71)
 Other1.35* (1.19,1.54)
 White non-Hispanic1.00
Age (years) 
 18–241.66* (1.47,1.88)
 25–441.20* (1.07,1.34)
 45–641.36* (1.22,1.51)
 65+1.00
Education 
 Less than high school1.02 (0.94,1.10)
 High school1.11* (1.05,1.18)
 Some post-secondary1.00
Income 
 <$15 0000.88* (0.81,0.97)
 $15 000–<40 0000.93 (0.86,1.00)
 $40 000–<75 0000.95 (0.88,1.03)
 $75 000+1.00
Smoking frequency 
 Every day1.06 (0.99,1.14)
 Some days1.00
Purchase type 
 Carton0.86* (0.81,0.91)
 Both pack and carton0.92 (0.82,1.04)
 Pack1.00
Age of initiation (years)1.01* (1.00,1.01)

Among all current smokers, there were no differences in prevalence of menthol use between every-day and some-days smokers. Compared with those who typically purchased their cigarettes in packs, those who bought cartons of cigarettes were less likely to use menthol cigarettes (OR = 0.86, 95% CI: 0.81–0.91). There was no difference in the likelihood of using menthol cigarettes when comparing pack purchasers with those who bought both packs and cartons.

With all the demographic and other smoking variables in the model, age of initiation was only a marginally significant predictor of menthol status. The OR for the effect of age of initiation in the logistic model was 1.01 (95% CI: 1.00–1.01; P = 0.0007). This finding is suggestive that delayed initiation of smoking is a risk factor for using menthol cigarettes.

DISCUSSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References

The purpose of the study was to examine the relationship between age of cigarette smoking initiation and purchasing patterns on use of menthol cigarettes among a nationally representative sample of current smokers. Risk factors for menthol smoking identified in the logistic regression were being female, being an ethnic minority, being younger, having less education and lower family income and purchasing cigarettes by the pack. While only marginally significant, the multivariate logistic model was suggestive that the longer the delay of initiation, the more likely an individual smoked menthol cigarettes.

Consistent with what is commonly known regarding smoking initiation, the average age of smoking initiation in this study was between 17 and 18 years. Hersey and colleagues examined data from a national survey of youth in grades 6–12 (the National Youth Tobacco Survey) and suggested that menthol cigarettes are a starter product for youth smokers [10]. It is important to note that the study by Hersey and colleagues did not query age of smoking initiation, but rather concluded that because those who had been smoking for less than 1 year were more likely to smoke menthol cigarettes, menthol cigarettes may be a starter product for youth. Furthermore, age of cigarette smoking initiation is operationalized differently across studies. The TUS CPS queries age of cigarette smoking initiation by asking: ‘How old were you when you first started smoking cigarettes fairly regularly?’, and the participant provides an age in years. This is in contrast to other studies that query age of cigarette smoking initiation by asking respondents: ‘How old were you when you first started smoking?’. Respondents may simply respond to the question by indicating the age at which they smoked their first cigarette(s). However, developing the habit of regular smoking typically follows a somewhat slow trajectory, so there is often a notable time lapse between the first cigarette and becoming a regular smoker [31]. Thus, the finding that if people delay smoking onset they are also more likely to smoke menthol cigarettes is not contradictory. Rather, it may suggest that smokers often start off smoking menthol cigarettes (hence greater prevalence among younger smokers) but presumably switch to non-menthols later on, whereas smokers who start smoking later and also start off smoking mentholated cigarettes may be more likely to continue to smoke menthol cigarettes (hence the positive association with age of smoking initiation and menthol smoking). This current study's findings requires further investigation.

This is the first study that we know of to examine whether purchasing pattern is associated with menthol cigarette use. Smokers who purchased cigarettes by the pack were more likely to be menthol smokers. This finding is consistent with other studies that indicate that menthol smokers typically smoke fewer cigarettes than non-menthol smokers [8,10]. This may also be a function of the lower income level of menthol smokers. While lower consumption may appear to be one positive aspect of menthol smoking, it is important to note that even when controlling for number of cigarettes per day, studies have indicated that menthol cigarette smokers appear to suffer similar or even greater tobacco health outcomes as those who smoke non-menthol brands [13].

The finding that one-quarter of the population surveyed were menthol cigarette smokers is consistent with a study which found that one-quarter of all cigarettes sold in the United States are mentholated [7], although recent Federal Trade Commission (FTC) results place that figure as one-fifth of the population [6]. Other studies have examined characteristics of menthol cigarette use and, consistent with the current study, have found that menthol smokers are more likely to be racial/ethnic minorities, younger and female [8–12].

Finally, the univariate analysis revealed that the household incomes of those who smoked menthol cigarettes tended to be lower than the incomes of those who smoked non-menthol brands. Similarly, menthol smokers tended to have lower educational attainment compared to non-menthol smokers. In apparent contrast to these observations, the logistic model revealed that those with incomes less than $15 000 were less likely to smoke menthol cigarettes when compared to those with incomes of $75 000 or more, controlling for other demographic factors. In the same model, while those with a high school education were at increased odds to smoke menthol cigarettes (relative to those with post-secondary education), there was no difference in the odds of menthol cigarette smoking between those with less than a high school education and those with post-secondary education.

While it is well established that there is an inverse relationship between smoking prevalence and socio-economic status, it is not as clear how menthol smoking and socio-economic status are related, particularly when other demographic factors (including gender, race, age, smoking frequency, purchasing type and age of initiation) are included as controls in a multivariate model. The current study findings, that the lowest income group was least likely to smoke menthol cigarettes, is similar to previous studies that have found higher prevalence of menthol smoking among high socio-economic status individuals when compared to those of lower socio-economic status (i.e. education and employment status; 8,32). It is possible that there may be potential confounding of age of smoking initiation and socio-economic indices across studies, due to critical periods in the smoking trajectory. In the current study, age of smoking initiation was found to be between 17 and 18 years, which is also the typical age of transition from high school to college (resulting in a subsequent potentially significant increase in income and employment status) when many smokers are exposed to cigarette brand promotional marketing and socio-cultural influences to smoke (particularly, mentholated branded cigarettes; 32–34). Future studies may need to examine the influence of menthol cigarette marketing and other socio-cultural influences on the trajectory of menthol cigarette use. Additional research in this area would also benefit from assessing nicotine dependence so that this personal indicator may be included as a covariate in models that determine risk factors for menthol smoking.

While the study findings have important implications, limitations regarding the cross-sectional nature of the data must be considered. An additional limitation of the survey format is the fact that smoking status, age of smoking initiation and menthol cigarette use were measured by self-report only. However, it is duly noted that numerous national population-based surveys have relied on self-report smoking characteristics. The lack of a nicotine dependence measure is an additional limitation; inclusion of this potential confounder as a control variable in the multivariate logistic model may have provided a clearer assessment of the relationships of age of initiation and purchasing type with menthol cigarette use.

The study has important implications for clinical practice and policy development. While the tobacco industry's marketing of menthol cigarettes to youth is increasingly becoming the focus among anti-tobacco advocates, it is also important to continue to focus on racial/ethnic minorities and female menthol smokers for prevention and cessation efforts of all ages (particularly among those who may delay smoking). Furthermore, if menthol smokers typically smoke less (more likely to purchase their cigarettes by the pack than by the carton) and still suffer the same smoking-related health consequences, it could be postulated that menthol cigarettes may be more harmful to the smoker on a per-cigarette basis. Consequently, tobacco control efforts may need to attend to menthol cigarettes as a unique cigarette product.

References

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. Declarations of interest
  8. References
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