Nicotine dependence and quitting behaviors among menthol and non-menthol smokers with similar consumptive patterns

Authors

  • Pebbles Fagan,

    Corresponding author
    1. National Cancer Institute, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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  • Eric T. Moolchan,

    1. Alkermes Inc., Cambridge, MA, USA
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  • Alton Hart, Jr.,

    1. Division of Quality Health Care, Department of Internal Medicine, Center on Health Disparities, Virginia Commonwealth University, Richmond, VA, USA
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  • Allison Rose,

    1. Clinical Research Directorate, Clinical Monitoring Research Program, SAIC-Frederick, Inc., National Cancer Institute at Frederick, Frederick, MD, USA
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  • Deirdre Lawrence,

    1. National Cancer Institute, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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  • Vickie L. Shavers,

    1. National Cancer Institute, Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, Bethesda, MD, USA
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  • James Todd Gibson

    1. Information Management Systems, Silver Spring, MD, USA
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Pebbles Fagan, National Cancer Institute, Tobacco Control Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Boulevard, EPN 4034, Bethesda, MD 20892-7337, USA. E-mail: faganp@mail.nih.gov

ABSTRACT

Aims  This study examines the associations between usual cigarette brand (i.e. menthol, non-menthol) and markers for nicotine dependence and quitting behaviors.

Design  The 2003 and 2006/07 Tobacco Use Supplements to the Current Population Surveys were pooled to conduct secondary data analysis.

Setting  National data were collected using in-person and telephone computer-assisted interviews by the United States Census Bureau among civilian, non-institutionalized people aged 15 years and older.

Participants  Data were analyzed among daily current smokers aged 18+ (n = 46 273).

Measurements  The associations between usual cigarette brand and time to first cigarette within 5 and 30 minutes after waking, quit attempts in the past 12 months and length of smoking abstinence in the past 12 months were examined. Bivariate and multivariate logistic regression models were stratified by smoking intensity: ≤5, 6–10, 11–19 and 20+ cigarettes per day.

Findings  Menthol smokers reported a mean of 13.05 compared with 15.01 cigarettes per day among non-menthol smokers (P < 0.001). Multivariate results showed that among smokers consuming 6–10 cigarettes per day, menthol smokers were significantly more likely than non-menthol smokers to consume their first cigarette within 5 minutes after waking (odds ratio = 1.22, 95% confidence interval = 1.05,1.43). The multivariate models did not show significant associations between usual cigarette brand and quit attempts in past 12 months or duration of smoking abstinence >2 weeks in the past 12 months.

Conclusions  Findings from this national survey of daily smokers demonstrate that menthol smokers in the United States who report consuming 6–10 cigarettes per day show greater signs of nicotine dependence than comparable non-menthol smokers.

INTRODUCTION

Any brand or flavor of cigarettes is harmful. Cigarette smoking, the leading cause of preventable deaths world-wide [1], causes cancer, cardiovascular, respiratory, peptic ulcer disease and poor pregnancy outcomes [2]. However, research suggests that menthol-flavored cigarettes may pose additional harm through marketing and taste, and by increasing adolescent smoking risk, tobacco-related diseases, nicotine dependence and smoking maintenance.

Menthol-flavored cigarettes are marketed to youth [3], women [4,5], blacks/African Americans and other minority racial/ethnic groups who suffer from tobacco-related health disparities [6–12]. Consumers may have lower risk perceptions of harm [13,14] or perceive that menthol-flavored cigarettes have medicinal properties [15–17]. Menthol stimulates cold receptors [18,19] to create a cooling effect [15,20] that reduces the harshness of smoke and improves taste [21,22]. The menthol flavor and its sensory qualities have been used to appeal to youth [3] and groups who cannot tolerate the harsh [23] or bitter taste [24] associated with nicotine [25] and cigarettes. Adolescent initiators who have smoked less than 1 year are more likely than adolescents with a longer duration of smoking to smoke menthol cigarettes [26,27]. Menthol cigarette consumption increased among adolescents from 2000 to 2002 [26] and from 2004 to 2008 [27]. Furthermore, menthol cigarettes increase smoking frequency and intensity among adolescents [28].

Menthol cigarettes may elevate the risk for tobacco-related cancers [29–34], impede cardiovascular functioning [35] and mask symptoms of respiratory distress [20]. Menthol cigarettes may contain more carcinogens than non-menthol cigarettes [36], increase the flux of carcinogens and nicotine across tissues [37] and inhibit the detoxification of carcinogens such as N-glucuronidation of the lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) [38]. Menthol cigarette smoking inhibits nicotine metabolism [39], is associated with higher levels of cotinine [40–42] and may increase exposure to carcinogens, as urinary cotinine levels are correlated with exposure to NNAL [43] and NNAL-Gluc [43,44]. Furthermore, menthol cigarettes may pose additional harm by increasing nicotine dependence and quitting difficulty.

Clinic- and population-based studies have examined differences in indicators of nicotine dependence (i.e. time to first cigarette) [45,46]. Clinic-based studies among adults show that menthol smokers are more likely to report shorter time to first cigarette [22,40] and to consume their first cigarette within 30 minutes after waking compared with non-menthol smokers [22]. Among youth, clinic- and population-based studies show that menthol smokers are more likely than non-menthol smokers to show signs of nicotine dependence [26,47]. Among adults in the Community Intervention Trial for Smoking Cessation (COMMIT) population-based trial, no association was found between menthol smoking and indicators of nicotine dependence [48].

The number of cigarettes consumed per day, used on dependence scales because of its correlation with nicotine intake [49], might explain some of the differences observed in nicotine dependence among menthol and non-menthol smokers. This measure has also been used consistently as one indicator of smoking intensity [50–59]. Several studies show that menthol smokers consume fewer cigarettes per day compared with non-menthol smokers [33,60,61], one study among blacks/African Americans did not find differences [62] and another study found that menthol cigarette smokers consumed on average more cigarettes per day [39]. Given the dearth of studies on time to first cigarette and smoking intensity among menthol smokers, it is not clear whether menthol smokers who consume the same number of cigarettes per day as non-menthol smokers are less nicotine-dependent than non-menthol smokers.

Adult menthol smokers who were seeking cessation treatment in clinical settings show lower quit rates compared with non-menthol smokers [22,60,63]. Studies have found that menthol smokers report more recent quit attempts [64] and lower rates of 7-day smoking abstinence than non-menthol smokers [65]. Okuyemi et al. 2007 found that black/African American light menthol smokers report lower abstinence rates at 26 weeks post-treatment compared with light non-menthol smokers [63]. Other studies do not show an association between menthol cigarette smoking and quit attempts [48,61] or smoking abstinence [66]. Studies have found lower quit rates among non-white, but not white adult menthol smokers [67,68].

To increase our understanding of the contribution of smoking intensity in discriminating nicotine dependence and quitting behaviors among menthol and non-menthol smokers, this study used a large national population-based sample to examine the associations between usual cigarette brand and time to first cigarette after waking and quitting behaviors. We hypothesized that daily menthol smokers would report shorter time to first cigarette and duration of smoking abstinence, and fewer quit attempts compared with daily non-menthol smokers with similar smoking intensity (≤5, 6–10, 11–19 and 20 or more cigarettes per day). Findings from this study will inform interventions that aim to reduce nicotine dependence and help smokers quit, provide evidence on the potential harm of menthol-flavored cigarettes and inform regulatory policies regarding brands marketed as menthol cigarettes.

METHODS

Study design

Cross-sectional data on daily smokers aged 18+ (n = 46 273) were pooled from the 2003 and 2006/07 Tobacco Use Supplements to the Current Population Surveys (TUS CPS) to examine the association between usual cigarette brand and nicotine dependence and quitting behaviors. The Current Population Survey (CPS) is administered by the United States Census Bureau and uses a multi-stage probability design to collect data from about 59 000 households monthly to produce reliable national and state estimates on labor-force characteristics among the civilian, non-institutionalized US population aged 15 years and older. Interviews are conducted in person and by telephone (70%) using computer-assisted interviewing. The Tobacco Use Supplement (TUS) is conducted in conjunction with the CPS every 3 years to collect data on tobacco use and related attitudes and practices. Details of sampling methods for the TUS CPS are reported elsewhere [69–72]. Data collection was approved by the US government institutional review board.

Data from the 2003 Tobacco Use Special Cessation Supplement (TUSCS) and 2006/07 TUS CPS administrations were combined to obtain sufficient sample sizes for subpopulation analyses, enhance the reliability of estimates and increase the power to detect associations among variables. The overall response rate for self-respondents and proxies for the 2003 and 2006/07 TUS were 82.9% and 82.6%, of which 64.6% and 75.1% were self-respondents, respectively.

Measures

Socio-demographics

Gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status and survey year were collected from the CPS. Respondents included age groups 18–30, 31–44, 45–64 and 65 years or older. Race and ethnic groups were categorized as Hispanic and non-Hispanic white, black/African American, American Indian/Alaska Native, Asian/Pacific Islander and two or more races. Of note, 50% of American Indian and Alaska Native respondents reported multiple races, most of whom report their race as white and American Indian and Alaska Native [72]. Marital status was categorized as married, widowed, divorced, separated and never married.

Educational attainment was categorized as 0–8, 9–11, 12 [diploma or general educational development (GED)], 13–15 and 16 or more years of education. Annual family income was categorized as less than $10 000, $10 000–24 999, $25 000–49 999 and greater than $50 000 per year. A combined employment/occupation variable was created to more accurately delineate the ‘not in the labor force’ category, which represents 26% of the sample. Occupation was defined as white-collar, blue-collar and service workers using the standard 2002 Census Bureau industry and classification system [69]. Employment status included the categories employed, unemployed and not in the labor force [69]. Combined employment/occupation categories included: employed: white-collar management, business, financial professional and related; employed: white-collar sales and related; employed: white-collar administrative office support; employed: service; employed: blue-collar; employed: other; unemployed; not in the labor force: retired; not in the labor force: disabled; not in the labor force: taking care of house/family; and not in the labor force: other. The ‘other’ not in the labor force group included people at school or ill. Employed ‘other’ included agriculture and fishery workers. Geographical regions included Northeast, Midwest, South and West. Metropolitan status included respondents who reported that they lived in a metropolitan, non-metropolitan or not identified area.

Smoking behavior

Cigarette smoking status, age of onset of regular smoking, years smoked daily, intensity of smoking, smoking status 12 months ago, usual cigarette brand, nicotine dependence and quitting data were collected using the TUS CPS. All respondents were asked if they had smoked at least 100 cigarettes in their entire life. Those who said ‘yes’ were asked: ‘Do you now smoke cigarettes every day, some days, or not at all?’. Respondents who indicated that they smoked every day were defined as daily current smokers. Age of onset was assessed by asking respondents who had smoked at least 100 cigarettes the age they first started smoking fairly regularly. Respondents were asked about the total number of years they have smoked daily. Smoking intensity was measured by asking daily smokers to report the average number of cigarettes smoked each day [50–59]. Smoking status 12 months ago was used to assess the stability of smoking frequency, as more established daily smokers may be more addicted than daily smokers who reported some days or no smoking in the previous year. It is also possible that smokers who change smoking frequency may have different smoking compensatory behaviors [73]. Respondents were asked: ‘Around this time 12 months ago, were you smoking cigarettes every day, some days, or not at all?’. Usual cigarette brand was assessed by asking respondents: ‘Is your usual brand menthol or non-menthol?’. Response categories were menthol, non-menthol or no usual type.

Nicotine dependence

Time to first cigarette after waking has consistently had high item loadings in confirmatory factor analyses [74–78], and has been recommended [46,76] or used as an indicator for nicotine dependence in other population-based surveys [48]. Respondents were asked: ‘How soon after you wake up do you typically smoke your first cigarette of the day?’ and ‘Would you say you smoke your first cigarette of the day within the first 30 minutes?’. The first question was asked of all smokers and responses were recorded in time (e.g. minutes). Only people who responded that they did not know, refused or said that the time varies received the second question. Respondents who were still unable to respond were categorized as ‘varies’.

Quitting behaviors

Quit attempts were assessed by asking current smokers: ‘How many times during the past 12 months have you stopped smoking for one day or longer because you were trying to quit smoking?’. Period of abstinence was measured among those who had one or more quit attempts and respondents were asked to indicate the longest period of abstinence in the last 12 months because they were trying to quit smoking. Intention to quit was measured by asking respondents if they were planning to quit in the next 30 days (yes or no).

Analysis

Analyses include cross-tabulations and multivariate logistic regression models of self-respondents only. The analysis was conducted using SUDAAN version 9.0.1 to account for the complex sample design and the weights of the respondents [79]. Smoking prevalence estimates were based on weighted self-response variables. χ2 Goodness-of-fit tests were used to determine the statistical significance of the bivariate relationships of the socio-demographic and smoking variables with the outcomes. Independent variables in the bivariate models with P < 0.25 were entered into the final multivariate models [80]. The final multivariate logistic regression models were used to produce odds ratios (ORs) and 95% confidence intervals (CIs). Multivariate logistic regression was conducted to examine the associations of usual brand of cigarette with nicotine dependence and quitting behaviors, while controlling for covariates found to be significant in the bivariate models. The outcome variables included time to first cigarette ≤30 minutes after waking versus >30 minutes; time to first cigarettes ≤5 minutes after waking versus >5 minutes; one or more quit attempts in the past 12 months versus zero; and >2 weeks smoking abstinence versus ≤2 weeks smoking abstinence. Models were run separately for smoking intensity categories (≤5, 6–10, 11–19, 20+). Smokers who reported no usual brand, use of other tobacco such as snuff and never smoked regularly were excluded from the logistic regression analyses.

RESULTS

Socio-demographic characteristics of daily menthol smokers

Seventy-nine per cent of menthol, 81% of non-menthol and 63% of no usual brand type smoked daily. Twenty-seven per cent of daily smokers reported menthol, 70% reported non-menthol and 3% reported no usual type as their usual brand of cigarette (data not shown). Menthol smokers were mainly female, aged 45–64, non-Hispanic white, married, blue-collar workers, smokers who lived in the South and metropolitan areas and who reported having attained a high school diploma or GED (see Table 1).

Table 1.  Socio-demographic characteristics of daily smokers by usual cigarette brand, aged 18+: Tobacco Use Supplements to the Current Population Surveys (TUS CPS), 2003, 2006/07.a
VariableMenthol (n = 11 671)Non-menthol (n = 33 644)No usual type (n = 958)Total (n = 46 273)
n% (95% CI)n% (95% CI)n% (95% CI)n% (95% CI)
  • a

    Denominator excludes people who used other forms of tobacco. The percentages are weighted data and sample number is unweighted. CI: confidence interval; GED: general educational development.

Gender        
 Male4 18142.05 (40.94, 43.16)15 89752.73 (52.17, 53.29)56165.67 (62.27, 68.93)20 63950.17 (49.64, 50.71)
 Female7 49057.95 (56.95, 59.06)17 74747.27 (46.71, 47.83)39734.33 (31/07, 37.73)25 63449.83 (49.29, 50.36)
Age (years)        
 18–302 56227.39 (26.33, 28.48)6 75524.17 (23.59, 24.77)21528.42 (24.83, 32.32)9 53225.14 (24.65, 25.62)
 31–443 40428.77 (27.83, 29.74)10 74130.90 (30.32, 31.48)26227.00 (23.93, 30.31)14 40730.24 (29.77, 30.72)
 45–644 85738.11 (37.07, 39.16)13 07437.12 (36.49, 37.77)35834.23 (30.56, 38.10)18 28937.32 (36.80, 37.84)
 65+8485.73 (5.30, 6.19)3 0747.80 (7.52, 8.09)12310.35 (8.42, 12.65)4 0457.31 (7.08, 7.54)
Race/ethnicity        
 Non-Hispanic white7 82361.34 (60.21, 62.47)29 41585.05 (84.50, 85.58)70467.39 (63.51, 71.06)37 94278.29 (77.80, 78.77)
 Non-Hispanic black/African American2 50926.91 (25.86, 27.98)8833.48 (3.21, 3.78)9512.68 (10.18, 15.69)3 4879.97 (9.60, 10.34)
 Hispanic6887.56 (6.97, 8.18)1 6436.81 (6.46, 7.18)9313.38 (10.71, 16.60)2 4247.17 (6.87, 7.47)
 Non-Hispanic American Indian/Alaska Native1090.62 (0.48, 0.81)5000.84 (0.72, 0.97)130.22 (0.09, 0.51)6220.77 (0.67, 0.88)
 Non-Hispanic Asian American/Pacific Islander2711.92 (1.60, 2.31))5192.12 (1.90, 2.35)375.36 (3.61,7.88)8272.14 (1.96, 2.34)
 Non-Hispanic two or more races2711.65 (1.43, 1.89)6841.70 (1.53, 1.90)160.97 (0.53, 1.76)9711.67 (1.53, 1.83)
Marital status        
 Married4 85438.85 (37.73, 39.99)16 09546.66 (45.86, 47.45)38639.65 (36.09, 43.32)21 33544.40 (43.76, 45.05)
 Widowed6204.45 (4.06, 4.88)1 8074.62 (4.37, 4.87)665.72 (4.33, 7.51)2 4934.60 (4.40, 4.81)
 Divorced2 32518.44 (17.63, 19.28)7 11019.68 (19.13, 20.25)19117.77 (15.50, 20.29)9 62619.30 (18.83, 19.79)
 Separated5725.34 (4.86, 5.87)1 2113.75 (3.52, 4.00)413.89 (2.58, 5.82)1 8234.18 (3.96, 4.41)
 Never married3 30032.92 (31.77, 34.10)7 42125.29 (24.71, 25.89)27432.98 (29.54, 36.61)10 99527.52 (27.04, 28.00)
Educational attainment (years)        
 <93222.71 (2.37, 3.08)1 3264.16 (3.91, 4.42)818.74 (6.71, 11.32)1 7293.88 (3.68, 4.09)
 9–111 83217.15 (16.35, 17.98)4 65514.48 (13.98, 14.99)18520.05 (17.22, 23.22)6 67215.32 (14.91,15.75)
 12 (diploma or GED)4 91342.17 (41.00, 43.34)14 19341.28 (40.62, 41.93)38239.56 (35.73, 43.52)19 48841.47 (40.88, 42.07)
 13–153 43528.51 (27.56, 29.48)9 77728.84 (28.22, 29.48)22622.51 (19.39, 25.98)13 43828.61 (28.09, 29.13)
 16+1 1699.46 (8.82, 10.15)3 69311.25 (10.85, 11.65)849.13 (7.10, 11.66)4 94610.72 (10.35, 11.09)
Annual family income        
 <$10 0001 42212.97 (12.12, 13.88)3339.57 (9.15, 10.01)14513.98 (11.54, 16.85)4 90010.59 (10.20, 10.99)
 $10 000–24 9992 47621.11 (20.15, 22.11)7 18320.56 (19.99, 21.14)24726.56 (23.14, 30.29)9 90620.85 (20.34, 21.36)
 $25 000–49 9993 37528.44 (27.36, 29.55)10 14929.93 (29.26, 30.60)23324.74 (21.51, 28.28)13 75729.41 (28.83, 29.99)
 $50 000+3 30927.75 (26.74, 28.78)10 01330.74 (30.05, 31.44)19220.63 (17.78, 23.79)13 51429.70 (29.08, 30.33)
 Unknown1 0899.73 (9.00, 10.50)2 9629.19 (8.73, 9.66)14114.09 (11.69, 16.89)4 1929.45 (9.01, 9.90)
Employment/occupational status        
 Employed: white-collar management, business, finance professional and related1 70013.90 (13.15, 14.68)4 98214.89 (14.45, 15.34)10410.42 (8.42, 12.82)6 78614.52 (14.13, 14.92)
 Employed: white-collar sales and related8577.42 (6.85, 8.04)2 5107.51 (7.19, 7.86)707.52 (5.65, 9.94)3 4377.49 (7.20, 7.79)
 Employed: white-collar administrative and office1 36910.92 (10.26, 11.62)3 2699.28 (8.92, 9.66)606.09 (4.55, 8.12)4 6989.65 (9.32, 9.99)
 Employed: service1 68713.91 (13.15, 14.71)4 20212.20 (11.76, 12.66)949.73 (7.75, 12.15)5 98312.60 (12.22, 12.99)
 Employed: blue-collar1 88317.85 (17.06, 18.67)6 88122.29 (21.74, 22.86)20824.00 (21.06, 27.20)8 97221.15 (20.67, 21.63)
 Employed: other440.37 (0.26, 0.54)1980.55 (0.46, 0.66)61.01 (0.37, 2.77)2480.51 (0.43, 0.61)
 Unemployed8288.66 (8.01, 9.36)1 9476.22 (5.87, 6.59)647.16 (5.35, 9.53)2 8396.90 (6.59, 7.21)
 Not in labor force: retired1 0267.26 (6.80, 7.75)3 5629.36 (9.04, 9.70)13611.83 (9.75, 14.29)4 7248.86 (8.59, 9.14)
 Not in labor force: disabled1 1119.26 (8.64, 9.93)3 1498.76 (8.42, 9.12)11511.37 (9.21, 13.97)4 3758.96 (8.65, 9.28)
 Not in labor force: taking care of house/family8327.02 (6.48, 7.60)2 1156.24 (5.92, 6.58)686.69 (5.03, 8.84)3 0156.46 (6.18, 6.75)
 Not in labor force: all others3343.42 (2.94, 3.97)8292.67 (2.46, 2.91)334.18 (2.90, 5.98)1 1962.91 (2.68, 3.15)
Region        
 Northeast48421.84 (20.83, 22.88)6 17515.87 (15.34, 16.41)19922.13 (18.68, 26.01)8 85817.61 (17.15, 18.90)
 Midwest3 34328.30 (27.19, 29.44)9 40626.13 (25.47, 26.79)21018.47 (15.77, 21.50)12 95926.53 (25.99, 27.07)
 South4 03538.50 (37.31, 39.70)10 45138.34 (37.62, 39.07)31438.10 (34.21, 42.14)14 80038.38 (37.77, 38.99)
 West1 80911.36 (10.61, 12.15)7 61219.66 (19.13, 20.20)23521.31 (18.17, 24.83)9 65617.48 (17.04, 17.92)
Metropolitan status        
 Metropolitan8 85881.41 (80.16, 82.60)22 95576.01 (74.62, 77.35)72082.65 (79.67, 85.28)32 53377.62 (76.38, 78.81)
 Non-metropolitan2 74718.11 (16.95, 19.34)10 42423.37 (22.05, 24.75)23016.74 (14.18, 19.67)13 40121.81 (20.63, 23.03)
 Not identified660.48 (0.31, 0.73)2650.62 (0.41, 0.93)80.60 (0.27, 1.33)3390.58 (0.39, 0.86)
Survey year        
 20036 27250.75 (49.56, 51.94)17 79650.30 (49.54, 51.05)52752.14 (48.21, 56.05)24 59550.46 (49.84, 51.08)
 2006/075 39949.25 (48.06, 50.44)15 84849.70 (48.95, 50.46)43147.86 (43.95, 51.79)21 67849.54 (48.92, 50.16)
Age of onset (years)        
 <152 10917.94 (17.04, 18.88)6 75819.65 (19.09, 20.21)22021.94 (19.13, 25.03)9 08719.24 (18.75, 19.74)
 15–174 16736.71 (35.64, 37.80)12 75338.54 (37.84, 39.24)34836.98 (33.55, 40.55)17 26838.01 (37.45, 38.58)
 18+5 26544.15 (43.08, 45.23)13 85040.92 (40.21, 41.64)36037.85 (34.43, 41.40)19 47541.72 (41.12, 42.32)
Total years smoked daily        
 0–102 86930.03 (28.95, 31.13)6 90924.48 (23.88, 25.09)23929.53 (25.93, 33.40)10 01726.09 (25.55, 26.62)
 11–202 73223.11 (22.25, 24.00)8 39024.51 (23.94, 25.10)20822.10 (19.14, 25.36)11 33024.08 (23.61, 24.56)
 21–302 86423.22 (22.38, 23.08)7 87522.34 (21.83, 22.85)21620.40 (17.52, 23.61)10 95522.53 (22.09, 22.97)
 31+2 94421.46 (20.65, 22.30)9 91626.94 (26.37, 27.51)25423.49 (20.33, 26.97)13 11425.39 (24.94, 25.85)
 Unknown2622.17 (1.87, 2.52)5541.73 (1.54, 1.94)414.48 (3.24, 6.18)8571.91 (1.74, 2.10)
Cigarettes per day        
 ≤51 16810.75 (10.10, 11.43)2 3737.83 (7.48, 8.19)12714.12 (11.73, 16.90)3 6688.76 (8.46,9.06)
 6–103 69332.41 (31.42, 33.42)8 18024.52 (23.98, 25.06)27529.36 (26.00,32.96)12 14826.74 (26.27, 27.22)
 11–191 64913.82 (13.05, 14.61)4 75613.89 (13.46, 14.33)10910.14 (8.16, 12.52)6 51413.78 (13.41, 14.16)
 20+5 16143.03 (41.88, 44.19)18 33553.76 (53.07, 54.46)44746.38 (42.28, 50.53)23 94350.72 (50.14, 51.30)
First cigarette within 30 minutes after waking        
 Yes4 91642.21 (41.10, 43.32)14 91743.09 (42.44, 43.74)34234.39 (30.62, 38.37)20 17542.65 (42.06, 43.23)
 No6 48455.28 (54.16, 56.39)18 03454.62 (53.97, 55.27)50454.17 (50.12, 58.16)25 02254.79 (54.21, 55.36)
 Varies2712.51 (2.12, 2.98)6932.29 (1.98, 2.65)11211.44 (9.08, 14.32)1 0762.57 (2.30, 2.87)
Time to first cigarette (minutes)        
 0–52 56222.27 (21.30, 23.27)7 70422.17 (21.57, 22.79)15615.26 (12.60, 18.37)10 42222.04 (21.51, 22.57)
 6–101 0669.11 (8.49, 9.76)3 2749.51 (9.12, 9.92)819.08 (7.03, 11.65)4 4219.39 (9.04, 9.76)
 11–158427.03 (6.50, 7.59)2 5997.50 (7.15, 7.86)666.34 (4.80, 8.35)3 5077.34 (7.05, 7.65)
 16+6 93059.09 (57.97, 60.19)19 37458.52 (57.89, 59.16)54357.88 (53.72, 61.92)26 84758.66 (58.09, 59.22)
 Varies2712.51 (2.12, 2.98)6932.29 (1.98, 2.65)11211.44 (9.08, 14.32)1 0762.57 (2.30, 2.87)
Smoking status 12 months ago        
 Every day10 61690.71 (90.00, 91.37)31 19292.47 (92.13, 92.80)84287.08 (84.08, 89.60)42 65091.87 (91.57, 92.17)
 Some days6445.88 (5.34, 6.48)1 3294.19 (3.92, 4.48)667.39 (5.62, 9.67)2 0394.72 (4.47, 4.98)
 Not at all4023.36 (2.98, 3.78)1 1053.28 (3.07, 3.50)505.53 (3.90, 7.80)1 5573.35 (3.17, 3.55)
Quit attempt 1 day or longer in past 12 months        
 Yes3 82533.79 (32.67, 34.92)10 84831.94 (31.34, 32.54)21720.38 (17.57, 23.51)14 89032.16 (31.62, 32.71)
 No7 84666.21 (65.08, 67.88)22 79668.06 (67.46, 68.66)74179.62 (76.49, 82.43)31 38367.84 (67.29, 68.38)
Number of quit attempts one day or longer in past 12 months        
 07 84666.21 (65.08, 67.33)22 79668.06 (67.46, 68.66)74179.62 (76.49, 82.43)31 38367.84 (67.29, 68.38)
 1–33 25325.88 (24.87, 26.91)8 48624.85 (24.28, 25.43)15314.22 (11.87, 16.94)11 59224.88 (24.35, 25.41)
 4+8727.91 (7.33, 8.53)2 3627.09 (6.76, 7.43)646.16 (4.45, 8.48)3 2987.28 (7.01, 7.57)
Longest quit attempt in past 12 months        
 ≤2 weeks2 56167.55 (65.56, 69.47)7 31167.20 (66.10, 68.28)13561.58 (53.68, 68.90)10 00767.21 (66.28, 68.13)
 >2 weeks–<1 month2726.61 (5.89, 7.63)8057.25 (6.72, 7.81)102.77 (1.22, 6.1701 0877.03 (6.58, 7.51)
 1–3 months60615.92 (14.49, 17.4701 69015.60 (14.70, 16.53)4017.77 (12.79, 24.1702 33615.72 (14.98, 16.49)
 >3–6 months1874.51 (3.75, 5.42)5585.14 (4.67, 5.65)199.85 (5.79, 16.27)7645.03 (4.64, 5.47)
 >6 months1995.31 (4.48, 6.27)4844.81 (4.35, 5.32)138.02 (4.53, 13.81)6965.00 (4.60, 5.43)
Intention to quit in next 30 days        
 Yes1 52113.33 (12.61, 14.09)4 40712.98 (12.51, 13.46)10910.82 (8.67, 13.43)6 03713.02 (12.63, 13.42)
 No9 65082.15 (81.34, 82.92)27 88582.91 (82.36, 83.45)80384.11 (81.37, 86.50)38 33882.73 (82.27, 83.19)
 Unknown5004.52 (4.10, 4.98)1 3524.12 (3.85, 4.40)465.08 (3.59, 7.12)1 8984.25 (4.01, 4.50)

Smoking characteristics of daily menthol smokers

Forty-four per cent of menthol smokers began smoking regularly at age 18 or older and 30% smoked daily for 0–10 years (see Table 1). Forty-three per cent of menthol smokers reported smoking 20 or more cigarettes per day; 42% had their first cigarette within 30 minutes and 22% had their cigarette within the first 5 minutes after waking. Ninety per cent of menthol smokers reported daily smoking 12 months ago. Sixty-six per cent of menthol smokers reported no quit attempts in the past 12 months. Sixty-seven per cent of menthol smokers reported smoking abstinence ≤ 2 weeks in the past 12 months and 82% had no intention to quit in the next 30 days.

Mean smoking characteristics by usual cigarette brand

Mean cigarettes smoked per day was significantly lower (13.05 versus 15.01 cigarettes per day) and mean quit attempts significantly higher among menthol smokers compared with non-menthol smokers (see Table 2). Mean time to first cigarette was significantly higher among white and black/African American menthol smokers compared with white and black/African American non-menthol smokers.

Table 2.  Geometric mean of smoking characteristics among daily smokers by usual cigarette brand, aged 18+: Tobacco Use Supplements to the Current Population Surveys (TUS CPS), 2003, 2006/07.
 Menthol (n = 11 671)95% CINon-menthol (n = 33 644)95% CINo usual type (n = 958)95% CITotal (n = 46 273)95% CI
Mean (SE)Mean (SE)Mean (SE)Mean (SE)
  • a

    Menthol versus non-menthol; *P-value <0.001; **P-valu e<0.01; ***P-value <0.05.

  • b

    Menthol versus no usual type *P-value <0.001; **P-value <0.01; ***P-value <0.05.

  • c

    Non-menthol versus no usual type *P-value <0.001; **P-value <0.01; ***P-value <0.05; n: unweighted sample size. Means are weighted. CI: confidence interval; SE: standard error.

Cigarettes per day13.05a* (0.09)12.86, 13.2315.01c* (0.06)14.88, 15.1412.53 (0.38)11.81, 13.3114.40 (0.05)14.29, 14.50
Time to first cigarette after waking (minutes)22.46 (0.40)21.69, 23.2521.77c** (0.23)21.32, 22.2227.07b** (1.86)23.63, 30.9922.05 (0.20)21.66, 22.45
 Non-Hispanic white21.47a*** (0.44)20.62, 22.3420.34 (0.22)19.90, 20.7723.03 (1.89)19.60, 27.0720.62 (0.20)20.22, 21.02
 Non-Hispanic black/African American20.86a*** (0.77)19.41, 22.4324.64 (1.60)21.67, 28.0122.23 (4.22)15.33, 32.2521.77 (0.70)20.44, 23.19
 Hispanic39.19 (2.79)34.06, 45.0944.13 (2.14)40.10, 48.5659.80b*** (11.15)41.42, 86.3143.22 (1.66)40.06, 46.62
 Non-Hispanic American Indian/Alaska Native25.28 (4.79)17.41, 36.6920.46 (2.14)16.67, 25.1136.84 (14.01)17.47, 77.6921.51 (1.99)17.93, 25.81
 Non-Hispanic Asian American/Pacific Islander30.60 (3.28)24.79, 37.7838.17 (2.87)32.94, 44.2536.01 (9.04)22.00, 58.9236.09 (2.26)31.90, 40.82
 Non-Hispanic two or more races20.93 (2.67)16.29, 26.8916.50 (1.21)14.27, 19.0836.47 (15.81)15.12, 87.9317.71 (1.14)15.59, 20.12
Quit attempts 1 day or longer in past 12 months among those who made a quit attempt2.23a*** (0.04)2.16, 2.302.14 (0.02)2.10, 2.182.25 (0.17)1.93, 2.612.16 (0.02)2.13, 2.20
Longest length of abstinence in past 12 months among smokers who made a quit attempt (months)0.32 (0.01)0.30, 0.340.32c*** (0.01)0.31, 0.330.46b*** (0.07)0.34, 0.620.32 (0.00)0.31, 0.33

Bivariate and multivariate logistic regression of first cigarette within 30 and 5 minutes after waking

The bivariate data showed that compared with non-menthol smokers, menthol smokers had significantly higher odds of having their cigarette within the first 30 minutes after waking among smokers consuming fewer than five (OR = 1.35; 95% CI = 1.12, 1.61) and six to 10 cigarettes per day (OR = 1.25; 95% CI = 1.13, 1.38); the relationship was not significant among smokers consuming 11–19 and 20 or more cigarettes per day (data not shown). After controlling for the covariates in each multivariate model, the differences between menthol and non-menthol smokers were no longer statistically significant for smokers consuming fewer than five or six to 10 cigarettes per day (see Table 3).

Table 3.  Multivariate logistic regression of time to first cigarette and quitting behaviors among daily smokers by smoking intensity, aged 18+: Tobacco Use Supplements to the Current Population Surveys (TUS CPS), 2003, 2006/07.
Usual cigarette brandTime to first cigarette within 30 minutes after waking versus >30 minutes
5 cpd1c6–10 cpd211–19 cpd320+cpd4
OR 95% CIOR 95% CIOR 95% CIOR 95% CI
  • *

    P-value <0.001;

  • **

    P-value <0.01;

  • ***

    P-value <0.05.

  • b

    b Because of small sample sizes, American Indians/Alaska Natives were not included in some analyses.

  • c

    c Because of small sample sizes, employed: other was not included in some analyses.

  • 1,5

    1,5 The covariates age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, age of onset, total years smoked daily and smoking status 12 months ago were included in the multivariate model.

  • 2

    2 The covariates gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, survey year, age of onset, total years smoked daily and smoking status 12 months ago were included in the multivariate model.

  • 3,8

    3,8 The covariates gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in the next 30 days were included in the multivariate model.

  • 4

    4 The covariates age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in the next 30 days were included in the multivariate model.

  • 6

    6 The covariates gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, age of onset, total years smoked daily and smoking status 12 months ago were included in the multivariate model.

  • The covariates gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, age of onset, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 9

    9 The covariates age, race/ethnicity, marital status, employment/occupational status, region, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 10

    10 The covariates age, marital status, educational attainment, annual family income, employment/occupational status, region, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 11

    11 The covariates gender, age, marital status, educational attainment, annual family income, employment/occupational status, region, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 12

    12 The covariates gender, age, race/ethnicity, marital status, educational attainment, annual family income, employment/occupational status, region, metropolitan status, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 13

    13 The covariates age, marital status, employment/occupational status, region, survey year, age of onset, total years smoked daily, smoking status 12 months ago and intention to quit in 30 days were included in the multivariate model.

  • 14

    14 The covariates employment/occupational status, region, metropolitan status, total years smoked daily and smoking status 12 months ago were included in the multivariate model.

  • 15

    15 The covariates age, annual family income, region, metropolitan status and smoking status 12 and months ago were included in the multivariate model.

  • 16

    16 The covariates age, marital status, educational attainment, annual family income, employment/occupation, survey year, total years smoked daily and smoking status 12 and months ago, and intention to quit in 30 days were included in the multivariate model. CI: confidence interval; cpd: cigarettes per day; OR: odds ratio.

Menthol1.20 (0.96, 1.50)1.09 (0.97, 1.22)0.98 (0.84, 1.14)1.05 (0.95, 1.16)
Non-menthol1.001.001.001.00
Time to first cigarette within 5 minutes after waking versus >5 minutes
≤5 cpd5bc6–10 cpd6c11–19 cpd7c20+ cpd8c
OR 95% CIOR 95% CIOR 95% CIOR 95% CI
Menthol0.94 (0.60, 1.47)1.22 (1.05, 1.43)***1.18 (0.97, 1.45)1.03 (0.95, 1.13)
Non-menthol1.001.001.001.00
Quit attempt 1 day or longer in the past 12 months versus none
≤5 cpd96–10 cpd1011–19 cpd1120+ cpd12
OR 95% CIOR 95% CIOR 95% CIOR 95% CI
Menthol1.10 (0.91, 1.34)0.92 (0.83, 1.02)0.99 (0.85, 1.16)0.97 (0.88, 1.07)
Non-menthol1.001.001.001.00
Length of smoking abstinence >2 weeks versus ≤2 weeks
≤5 cpd136–10 cpd1411–19 cpd1520+ cpd16
OR 95% CIOR 95% CIOR 95% CIOR 95% CI
Menthol1.03 (0.78, 1.36)0.97 (0.82, 1.14)1.05 (0.82, 1.36)0.93 (0.79, 1.12)
Non-menthol1.001.001.001.00
Table 3.  Multivariate logistic regression of time to first cigarette after waking among daily smokers by smoking intensity: Tobacco Use Supplements to the Current Population Surveys (TUS CPS): confidence interval CPS, 2003, 2006/07.
VariablesTime to first cigarette within 30 minutes after waking versus >30 minutesTime to first cigarette within 5 minutes after waking versus >5 minutes
5 cpd6–10 cpd11–19 cpd20+ cpd5 cpd6–10 cpd11–19 cpd20+ cpd
OR 95% CIOR 95% CIOR 95% CIOR 95% CIOR 95% CIOR 95% CIOR 95% CIOR 95% CI
  1. * P-value <0.001; ** P-value <0.01; *** P-value <0.05. a Because of small sample sizes, American Indians/Alaska Natives and Employed: other were not included some analyses. NS: not significant in the bivariate model; CI: confidence interval; cpd: cigarettes per day; GED: general educational development; OR: odds ratio.

Usual cigarette brand        
 Menthol1.20 (0.96, 1.50)1.09 (0.97, 1.22)0.98 (0.84, 1.14)1.05 (0.95, 1.16)0.94 (0.60, 1.47)1.23 (1.05, 1.43)***1.18 (0.97, 1.45)1.03 (0.95, 1.13)
 Non-menthol1.001.001.001.001.001.001.001.00
GenderNS  NSNS   
 Male1.001.001.001.001.00
 Female1.03 (0.93, 1.15)1.11 (0.96, 1.28)1.32 (1.12, 1.56)**1.27 (1.07, 1.50)**1.07 (0.99, 1.16)
Age (years)        
 18–300.56 (0.29, 1.07)0.92 (0.66, 1.26)1.00 (0.65, 1.54)1.34 (1.05, 1.72)***1.18 (0.38, 3.65)1.64 (0.98, 2.73)1.52 (0.89, 2.60)1.99 (1.56, 2.54)*
 31–440.65 (0.36, 1.18)0.92 (0.69, 1.22)0.86 (0.58, 1.25)1.39 (1.12, 1.72)**2.53 (1.00, 6.40)***1.54 (0.96, 2.48)1.54 (0.90, 2.62)1.71 (1.40, 2.08)*
 45–640.72 (0.44, 1.17)0.98 (0.76, 1.26)0.86 (0.63, 1.19)1.23 (1.02, 1.47)***1.46 (0.64, 3.32)1.24 (1.24, 1.89)1.31 (0.78, 2.20)1.28 (1.07, 1.52)**
 65+1.001.001.001.001.001.001.001.00
Race/ethnicity        
 Non-Hispanic white1.001.001.001.001.001.001.001.00
 Non-Hispanic black/African American1.32 (0.99, 1.77)1.37 (1.17, 1.60)*1.16 (0.88, 1.54)1.07 (0.88, 1.29)1.73 (1.04, 2.86)***1.58 (1.25, 1.99)*1.77 (1.29, 2.42)*1.25 (1.07, 1.45)**
 Hispanic0.57 (0.39, 0.83)**0.65 (0.54, 0.78)*0.68 (0.50, 0.91)***0.73 (0.58, 0.92)**0.65 (0.35–1.22)0.82 (0.61, 1.09)0.66 (0.43, 1.02)0.81 (0.65, 1.02)
 Non-Hispanic American Indian/Alaska Nativea0.32 (0.13, 0.82)1.28 (0.85, 1.94)0.88 (0.45, 1.72)1.07 (0.63, 1.82)0.92 (0.49, 1.76)2.54 (1.23, 5.25)***1.39 (0.98, 1.96)
 Non-Hispanic Asian American/Pacific Islander1.65 (0.97, 2.81)1.07 (0.80, 1.42)1.41 (0.86, 2.32)1.04 (0.69, 1.56)2.99 (1.51–5.95)**1.02 (0.61, 1.69)1.30 (0.68, 2.49)0.92 (0.60, 1.41)
 Non-Hispanic two or more races0.95 (0.47, 1.91)1.26 (0.91, 1.74)0.98 (0.62, 1.55)1.12 (0.83, 1.50)1.95 (0.75–5.10)1.39 (0.89, 2.18)1.28 (.070, 2.34)1.20 (0.94, 1.53)
Marital status        
 Married1.001.001.001.001.001.001.001.00
 Widowed1.20 (0.78, 1.86)0.85 (0.69, 1.05)0.76 (0.55, 1.03)0.89 (0.74, 1.06)0.86 (0.40, 1.85)0.73 (0.51, 1.04)0.80 (0.48, 1.32)0.98 (0.83, 1.15)
 Divorced1.29 (0.98, 1.69)0.93 (0.80, 1.07)0.97 (0.83, 1.15)1.07 (0.96, 1.19)2.09 (1.35, 3.25)**0.89 (0.73, 1.09)0.98 (0.77, 1.24)1.13 (1.03, 1.24)**
 Separated1.63 (1.01, 2.62)***1.45 (1.13, 1.85)**1.37 (0.94, 1.98)1.19 (0.96, 1.48)1.04 (0.44, 2.48)1.35 (0.99, 1.85)1.24 (0.81, 1.91)1.13 (0.96, 1.34)
 Never married0.89 (0.65, 1.22)0.92 (0.81, 1.05)0.91 (0.77, 1.09)1.08 (0.96, 1.21)1.33 (0.82, 2.16)0.94 (0.77, 1.15)0.98 (0.77, 1.24)1.00 (0.90, 1.11)
Educational attainment (years)        
 <91.48 (0.81, 2.72)1.59 (1.21, 2.08)*1.24 (0.77, 1.99)1.29 (0.99, 1.67)2.43 (0.85, 7.01)2.49 (1.60, 3.87)*1.32 (0.72, 2.43)1.47 (1.18, 1.83)*
 9–111.31 (0.82, 2.08)1.58 (1.28, 1.94)*1.34 (1.00, 1.79)***1.37 (1.16, 1.63)*1.73 (0.73, 4.12)1.90 (1.38, 2.62)*1.50 (1.00, 2.25)***1.34 (1.16, 1.55)*
 12 (diploma or GED)1.56 (1.06, 2.28)***1.33 (1.13, 1.57)*1.11 (0.89, 1.38)1.29 (1.12, 1.48)*2.08 (0.95, 4.56)1.60 (1.19, 2.14)**0.95 (0.68, 1.33)1.20 (1.06, 1.37)**
 13–151.21 (0.84, 1.74)1.11 (0.94, 1.32)1.02 (0.82, 1.26)1.12 (0.97, 1.29)1.49 (0.71, 3.15)1.23 (0.93, 1.65)0.90 (0.65, 1.24)1.03 (0.90, 1.17)
 16+1.001.001.001.001.001.001.001.00
Annual family income        
 <$10 0001.68 (1.17, 2.42)**1.62 (1.35, 1.93)*1.33 (0.99, 1.77)1.32 (1.12, 1.55)*2.69 (1.35, 5.38)**1.76 (1.35, 2.30)*1.75 (1.23, 2.49)**1.54 (1.34, 1.77)*
 $10 000–24 9991.32 (0.95, 1.84)1.21 (1.05, 1.39)**1.30 (1.07, 1.59)**1.26 (1.11, 1.42)*1.69 (0.88, 3.25)1.40 (1.09, 1.79)**1.61 (1.21, 2.13)**1.28 (1.15, 1.43)*
 $25 000–49 9991.43 (1.06, 1.93)***1.11 (0.99, 1.27)0.98 (0.84, 1.15)1.12 (1.02, 1.23)***1.18 (0.63, 2.21)1.13 (0.91, 1.39)1.28 (1.01, 1.63)***1.13 (1.03, 1.23)**
 $50 000+1.001.001.001.001.001.001.001.00
 Unknown1.40 (0.92, 2.13)0.99 (0.84, 1.17)1.21 (0.93, 1.59)1.23 (1.03, 1.48)***2.21 (1.06, 4.64)***1.13 (0.85, 1.50)1.86 (1.33, 2.59)*1.12 (0.96, 1.30)
Employment/occupational status        
 Employed: white-collar management, business, finance professional and related1.001.001.001.001.001.001.001.00
 Employed: white-collar sales and related0.93 (0.55, 1.57)0.87 (0.69, 1.10)1.04 (0.79, 1.36)1.02 (0.85, 1.21)0.48 (0.14, 1.60)0.84 (0.58, 1.20)1.00 (0.69, 1.44)0.91 (0.77, 1.08)
 Employed: white-collar administrative and office0.70 (0.45, 1.09)0.97 (0.82, 1.15)1.22 (0.96, 1.55)1.03 (0.87, 1.22)0.71 (0.28, 1.77)0.94 (0.70, 1.27)1.35 (0.98, 1.86)1.10 (0.96, 1.26)
 Employed: service1.31 (0.88, 1.94)0.95 (0.79, 1.14)0.85 (0.68, 1.05)0.92 (0.79, 1.07)1.53 (0.74, 3.15)0.97 (0.73, 1.28)0.94 (0.69, 1.27)1.04 (0.92, 1.19)
 Employed: blue-collar1.42 (0.90, 2.24)1.00 (0.83, 1.21)1.05 (0.84, 1.33)0.98 (0.86, 1.12)1.85 (0.80, 4.26)1.06 (0.79, 1.40)0.95 (0.70, 1.29)1.05 (0.92, 1.19)
 Employed: othera2.12 (1.00, 4.47)***1.61 (0.49, 5.31)0.98 (0.59, 1.64)
 Unemployed1.49 (0.88, 2.49)1.18 (0.95, 1.46)1.23 (0.91, 1.65)1.02 (0.84, 1.24)1.66 (0.71, 3.90)1.33 (0.97, 1.84)0.85 (0.54, 1.33)1.11 (0.94, 1.32)
 Not in labor force: retired1.00 (0.53, 1.89)0.91 (0.71, 1.17)0.83 (0.59, 1.17)0.97 (0.79, 1.19)2.37 (0.83, 6.79)0.94 (0.62, 1.42)0.98 (0.59, 1.63)0.86 (0.72, 1.02)
 Not in labor force: disabled1.88 (1.15, 3.06)***1.28 (1.04, 1.58)***1.18 (0.86, 1.63)1.12 (0.93, 1.36)2.24 (0.98, 5.13)1.45 (1.07, 1.96)***1.12 (0.74, 1.69)1.20 (1.05, 1.39)**
 Not in labor force: taking care of house/family1.54 (0.89, 2.67)1.43 (1.17, 1.75)*1.27 (0.93, 1.76)1.17 (0.95, 1.43)1.58 (0.68, 3.67)1.10 (0.78, 1.54)1.28 (0.83, 1.97)1.11 (0.94, 1.33)
 Not in labor force: all others1.69 (0.93, 3.05)1.27 (0.93, 1.73)1.04 (0.66, 1.63)0.83 (0.62, 1.11)1.96 (0.74, 5.21)1.11 (0.67, 1.83)0.97 (0.49, 1.94)1.02 (0.81, 1.27)
RegionNS   NS   
 Northeast1.11 (0.94, 1.30)1.03 (0.83, 1.27)1.05 (0.90, 1.21)0.86 (0.67, 1.10)0.88 (0.66, 1.16)0.93 (0.82, 1.05)
 Midwest1.12 (0.97, 1.29)1.22 (1.01, 1.46)***0.99 (0.88, 1.12)0.94 (0.76, 1.17)1.11 (0.86, 1.42)1.06 (0.95, 1.18)
 South1.22 (1.05, 1.42)**1.04 (0.86, 1.25)1.12 (0.99, 1.27)1.05 (0.84, 1.30)0.98 (0.76, 1.25)1.12 (1.01, 1.24)***
 West1.001.001.001.001.001.00
Metropolitan statusNS   NS   
 Metropolitan0.95 (0.85, 1.07)0.97 (0.84, 1.12)0.79 (0.72, 0.87)*0.91 (0.77, 1.07)0.91 (0.74, 1.14)0.95 (0.87, 1.04)
 Non-metropolitan1.001.001.001.001.001.00
 Not identified 0.97 (0.59, 1.60)0.55 (0.19, 1.62)0.87 (0.61, 1.24)1.06 (0.28, 4.07)0.23 (0.06, 0.85)***1.20 (0.84, 1.72)
Survey yearNS NS NSNSNSNS
 20031.001.00
 2006/071.09 (0.99, 1.20)1.12 (1.03, 1.21)**
Age of onset (years)        
 <151.001.001.001.001.001.001.001.00
 15–170.87 (0.63, 1.19)0.71 (0.62, 0.81)*0.82 (0.68, 0.99)***0.76 (0.67, 0.86)*0.83 (0.53, 1.30)0.60 (0.49, 0.72)*0.59 (0.47, 0.74)*0.60 (0.55, 0.65)*
 18+0.74 (0.55, 0.99)***0.61 (0.53, 0.70)*0.60 (0.50, 0.73)*0.56 (0.49, 0.62)*0.75 (0.48, 1.16)0.48 (0.40, 0.58)*0.45 (0.36, 0.57)*0.52 (0.47, 0.57)*
Total years smoked daily      NS 
 0–100.79 (0.52, 1.23)0.62 (0.49, 0.77)*0.46 (0.34, 0.62)*0.41 (0.34, 0.49)*1.00 (0.46, 2.16)0.72 (0.51, 1.00)***0.48 (0.40, 0.57)*
 11–200.97 (0.65, 1.44)0.75 (0.62, 0.89)**0.60 (0.47, 0.77)*0.57 (0.50, 0.65)*0.82 (0.43, 1.56)0.82 (0.61, 1.11)0.63 (0.55, 0.72)*
 21–300.99 (0.69, 1.44)0.91 (0.78, 1.06)0.77 (0.63, 0.95)***0.79 (0.71, 0.89)*1.07 (0.60, 1.91)1.13 (0.88, 1.44)0.79 (0.71, 0.88)*
 31+1.001.001.001.001.001.001.00
 Unknown0.49 (0.23, 1.00)***0.64 (0.45, 0.91)***0.67 (0.38, 1.18)0.52 (0.35, 0.77)*0.66 (0.21, 2.11)0.92 (0.53, 1.58)0.68 (0.47, 0.98)***
Smoking status 12 months ago        
 Every day1.001.001.001.001.001.001.001.00
 Some days0.66 (0.48, 0.91)***0.48 (0.40, 0.58)*0.61 (0.44, 0.85)**0.41 (0.31, 0.53)*0.78 (0.46, 1.33)0.74 (0.56, 1.00)***0.50 (0.29, 0.87)***0.52 (0.38, 0.72)*
 Not at all0.56 (0.37, 0.86)**0.84 (0.68, 1.04)0.59 (0.42, 0.83)**0.59 (0.47, 0.75)*0.49 (0.21, 1.17)0.86 (0.59, 1.26)0.71 (0.43, 1.18)0.70 (0.54, 0.90)**
Intention to quit in next 30 daysNSNS  NSNS  
 Yes0.96 (0.80, 1.16)0.91 (0.81, 1.02)1.13 (0.89, 1.44)0.97 (0.86, 1.08)
 No1.001.001.001.00
 Unknown0.80 (0.59, 1.09)0.91 (0.73, 1.10)0.49 (0.29, 0.82)**0.89 (0.75, 1.06)

The bivariate data showed that compared with non-menthol smokers, menthol smokers had significantly higher odds of having their cigarettes within 5 minutes after waking among smokers consuming six to 10 (OR = 1.51; 95% CI = 1.31, 1.74) and 11–19 cigarettes per day (OR = 1.35; 95% CI = 1.10, 1.64); the relationship was not significant among smokers consuming fewer than five or 20 or more cigarettes per day (data not shown). After controlling for covariates in each multivariate model, the relationship remained significant only for menthol smokers consuming six to 10 cigarettes per day (OR = 1.22; 95% CI = 1.05, 1.43) (see Table 3). The ORs for time to first cigarette after waking did not increase as smoking intensity increased for menthol smokers; the relationship was non-linear.

Bivariate and multivariate logistic regression of one or more quit attempts in past 12 months and smoking abstinence >2 weeks

Bivariate and multivariate analyses did not show a statistically significant relationship between usual cigarette brand and having a quit attempt for 1 day or longer in the past 12 months or length of abstinence from smoking (see Table 3).

DISCUSSION

This is the first study to show that, among adults, daily menthol smokers consuming six to 10 cigarettes per day were more likely than non-menthol smokers consuming six to 10 cigarettes per day to smoke their cigarette within the first 5 minutes after waking. Our findings are consistent with Collins & Moolchan [47], who found that among adolescents, menthol cigarette smokers were significantly more likely than non-menthol smokers to consume their first cigarette within the first 5 minutes. Mean cigarettes smoked per day and the Fagerstrom Test for Nicotine Dependence (FTND) scores did not differ significantly for menthol and non-menthol smokers [47]. These studies suggest that menthol-flavored cigarettes may affect nicotine dependence differentially among light smokers. Studies suggest that menthol may enhance the absorption of nicotine [37,41,81–84] and result in more efficient nicotine absorption among smokers. Menthol cigarettes may allow smokers to consume fewer cigarettes per day while maintaining the desired level of nicotine in the body [39]. Menthol cigarettes may prompt deeper inhalation [85] among light smokers, resulting in greater nicotine intake than observed among light non-menthol smokers. In high concentrations menthol may be irritating [86], and therefore do not prompt deeper inhalation among heavy menthol smokers.

Time to first cigarette within the first 5 minutes after waking appears to be a more sensitive measure of nicotine dependence than other categorical measures (i.e. within 30, 60 minutes) [45] and may be critical to understanding dependence among light smokers. Time to first cigarette is associated significantly with cotinine levels and has higher predictability of nicotine uptake within the first 5 minutes after waking than other categorical measures. Future laboratory studies may consider examining time to first cigarette and its association with cotinine among menthol and non-menthol smokers with different smoking consumption patterns to increase our understanding of nicotine uptake.

These data do not support the hypothesis that menthol smokers experience greater quitting difficulty. Our results are similar to other studies that showed no differences in quit attempts among light menthol and non-menthol smokers [63], quit attempts or duration of quit attempts [64] or 7-day smoking abstinence following treatment [66]. One study found that light menthol smokers were less likely than non-menthol smokers to maintain long-term smoking abstinence (26 weeks) compared with non-menthol smokers, but this difference was not observed at 8 weeks post-treatment [63]. Our study examined smoking abstinence >2 weeks because 67% of smokers reported smoking abstinence less than or equal to 2 weeks, and we expected that menthol smokers might have higher relapse during this critical time-period. Findings from additional analyses did not show differences in smoking abstinence at 1, 3 and 6 months between menthol and non-menthol smokers at different levels of consumption (data not shown). Although under-reporting of quitting behavior is possible with self-report data [87], there is no literature suggesting that menthol smokers would have differential bias in self-report of quit attempts or duration of abstinence compared with non-menthol smokers. Future research should investigate multiple measures of smoking abstinence, differences in unaided and assisted quitting between menthol and non-menthol smokers and other factors that contribute to quitting success.

Limitations

Cross-sectional data limit the ability to determine the directionality of the relationships and measure the dynamic processes of quitting and nicotine dependence across the smoking life-span. These data are self-reported and biochemical measures of quitting are not measured in the TUS CPS. The TUS CPS does not collect data on smoking topography, menthol concentrations, longevity of menthol smoking, brand-switching, external cues and other factors that may influence quitting behaviors. Menthol concentrations vary by cigarette [15,88], and exact concentrations in brands of cigarettes are unknown. Therefore, it is difficult to quantify exposure to menthol in cigarettes over time, which may provide more precise information on disease risk. Little is known about brand-switching. Non-menthol smokers have reported higher switching rates to mentholated cigarettes than vice versa [60], and black/African American smokers felt that switching to non-menthol cigarettes may help menthol smokers to quit smoking [14]. External cues such as social–environmental factors, stress and coping [89], advertising and measures that affect mood regulation may prompt smoking maintenance.

CONCLUSIONS

These findings add to the body of evidence that suggests potentially more harmful effects of menthol on nicotine dependence, but show clearly that the association may be strongest among light smokers who may perceive lower harm. The data show that menthol smokers tend to be lighter smokers, but light smoking is common among minority racial/ethnic groups [8]. The mean number of cigarettes consumed per day has decreased over the years [49,90], and social and tobacco control policies coupled with cessation treatments have reduced smoking consumptive patterns. The prevalence of and trends towards light smoking prompt the need for studies that examine the relationships between menthol, nicotine dependence, exposure to carcinogens and disease risk among light smokers. Native Hawaiians and black/African American smokers who consume fewer than 10 cigarettes per day have an elevated risk of lung cancer compared with white, Latino and Japanese light smokers, but this difference is not observed among heavy smokers [91]. Little is known about the role of menthol, puffing behavior [92] and how these factors increase risk for exposure to toxins such as NNAL [38] among light menthol smokers.

It is also important to understand other areas of the potential harm of menthol cigarettes. Genetic studies suggest that tasters and supertasters [93], who perceive oral stimuli as more bitter, salty, sweet or irritating and perceive more burn [93], are less likely to be heavy smokers compared with non-tasters [24,94,95]. Blacks/African Americans have a higher proportion of tasters and supertasters who are less likely to smoke and be nicotine-dependent, and European Americans have a higher proportion of non-tasters, who are more likely to smoke and be nicotine-dependent [24]. Menthol may make cigarettes palatable to groups who have an aversion to the taste of non-menthol cigarettes or nicotine [25]. Finally, studies are needed to examine how policies at multiple levels, including the 2009 Family Smoking Prevention and Tobacco Control Act, impact smoking behaviors and brand choice, the consumption of mentholated cigarettes, the design and delivery of menthol cigarettes, concentration of menthol and nicotine in cigarettes and marketing practices.

Declarations of interest

Drs Fagan, Hart and Shavers and Mr Gibson and Ms Rose have no conflicts of interest to declare. Dr Moolchan is an employee of Alkermes Inc., a pharmaceutical company. Dr Lawrence is currently an employee of Pinney Associates, Inc., a scientific consulting company that provides services to pharmaceutical companies. This work was done while Dr Lawrence was at the National Cancer Institute, prior to employment at Pinney Associates.

Acknowledgements

We thank Drs Cathy Backinger and William Klein for reviewing this manuscript. We also thank Anne Hartman and Dennis Buckman for their advice on using the Tobacco Use Supplement to the Current Population Survey and conducting the analyses. Support for these analyses was provided by the National Cancer Institute. Drs Fagan, Lawrence and Shavers and Mr Gibson were funded by the National Cancer Institute at the time of the analyses. Allison Rose was funded by the National Cancer Institute under contract no. HHSN261200800001E to SAIC Frederick. Dr Hart was funded by Virginia Commonwealth University and the Massey Cancer Center. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does the mention of trade names, commercial products or organizations imply endorsement by the US Government.

Human participant protection

The research was determined to be exempt from IRB review at the National Institutes of Health.

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