Use of mentholated cigarettes: what can we learn from national data sets?

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This Supplement, entitled ‘Mentholated cigarettes: usage patterns, cessation behaviors, policy protection and health profiles’, marks the second Addiction supplement and fifth journal supplement and/or special journal issue published by the Tobacco Research Network on Disparities (TReND) with a focus on tobacco's detrimental influence on populations that experience tobacco-related inequalities. Approximately one-fourth of all cigarettes sold in the United States are mentholated [1]. Menthol cigarettes are used commonly by new, young smokers of all racial/ethnic groups with the overwhelming majority of African American smokers (∼80%) smoking mentholated cigarettes [2,3]. In addition, some studies have suggested that mentholated cigarettes are more addictive and that smoking cessation treatments are less effective for mentholated cigarettes smokers [4–7]. Despite the widespread use of mentholated cigarettes and the disproportionate burden of tobacco-related morbidity experienced by populations who predominantly smoke mentholated cigarettes, there are significant gaps in scientific knowledge about the role of mentholated cigarettes in smoking initiation, nicotine dependence and smoking cessation, including relapse and morbidity.

In 2002, the National Cancer Institute (NCI) and Centers for Disease Control and Prevention (CDC) collaborated to host the First Conference on Menthol Cigarettes: Setting the Research Agenda. This 2-day meeting was developed to investigate systematically the potential hazards of menthol cigarettes by examining the current evidence base and laying the groundwork for future research on this topic. The meeting agenda focused on the sociology, marketing, epidemiology, smoking initiation, biochemistry and the physiological impact of menthol. The results from the meeting were published in two key documents: (1) NCI's Executive Summary of the meeting (cancercontrol.cancer.gov/tcrb/MentholExecSumRprt4-10-16.pdf—09-25-2006); and (2) a special journal issue entitled: ‘Menthol cigarettes—setting the research agenda’, published in 2004 by Nicotine & Tobacco Research (vol. 6, Suppl. 1). Since the 2002 Conference on Menthol Cigarettes, there has been little progress to increase our understanding of menthol's role in cancer and other tobacco-related diseases. As a result, TReND commissioned papers to take advantage of two nationally representative surveys sponsored by the NCI and CDC, the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) and the National Health Interview Survey Cancer Control Supplement (NHIS-CCS). These two surveys were chosen because they are nationally representative, have sample sizes large enough to address the research questions of interest and they both contain the same survey items to assess the use of mentholated cigarettes. This journal supplement responded to the need to understand more clearly the smoking of mentholated cigarettes by various socio-demographic groups at the national level. We anticipate that these data will inform intervention studies that prevent the use of menthol cigarette smoking.

The 11 original papers in this supplemental issue of Addiction include quantitative secondary data analyses of national survey data in the United States. The manuscripts were commissioned to address four categories of questions responsive to the priority research agenda outlined as a part of the 2002 Conference on Menthol Cigarettes. These questions include: (1) what is the role of mentholated cigarettes in smoking initiation and progression; what is the role of mentholated cigarettes in tobacco addiction and reinforcement; (2) how do mentholated cigarettes affect the smoking cessation processes; (3) to what extent are the higher prevalence rates of mentholated cigarettes preference/use among specific groups influenced by health beliefs and/or neighborhood, social, cultural, economic or other policy-level factors; and (4) do any of these factors operate in combination to exert a synergistic effect on the occurrence of these higher prevalence rates? It is important to note that the papers in this supplement were not intended to address questions related to the morbidity or mortality attributable to use of menthol cigarettes.

In ‘National patterns and correlates of mentholated cigarette use in the United States’, based on the TUS-CPS 2003 and 2006–07 data, Lawrence et al. used gender- and race/ethnicity-stratified multivariate logistic regression models to examine the associations between socio-demographic and smoking variables predicting current use of mentholated cigarettes. Due to the large sample size of the data used (66 000+), the authors were able to examine variables within and across multiple racial/ethnic groups. Their research showed that correlates and patterns of use of mentholated cigarettes exist beyond the African American population. With the exception of American Indian/Aleut/Eskimo smokers, non-white smokers were significantly more likely to smoke mentholated cigarettes than were white smokers. Additional significant factors associated with mentholated cigarette smoking included being unmarried, divorced/separated, being born in a US territory, living in a non-metropolitan area, being unemployed and lower levels of education. Race/ethnicity stratified analyses showed that women were more likely than men to smoke mentholated cigarettes, and among black smokers young adults (aged 18–24 years) were more likely to smoke mentholated cigarettes compared with individuals 65 years or older. Their paper uniquely highlights the need to not limit research about mentholated cigarettes to African Americans. There is clearly a need for more research to understand more clearly the motivations for using menthol cigarettes in these other socio-demographic groups and develop effective interventions to reduce initiation and enhance cessation of tobacco use. This paper also sets the stage for socio-demographic variables of interest regarding use of mentholated cigarettes for the rest of the supplement.

In ‘Menthol and non-menthol smoking: the impact of prices and smoke-free air laws’, Tauras and colleagues examine how menthol and non-menthol prices and smoke-free air laws affect the choice between menthol and non-menthol cigarettes among current smokers. Authors used a regression model to estimate the probability of being a menthol smoker conditional on being a current smoker who had a distinct preference for either non-menthol or menthol cigarettes. The paper reported that smokers did not find menthol and non-menthol cigarettes to be close substitutes for one another. Non-menthol cigarettes were found to be less of a substitute for menthol cigarettes than vice versa. In addition, young adults and African Americans were less responsive to prices with respect to switching between menthol and non-menthol cigarettes than were older adults and non-African Americans, respectively. This is the first study that provides evidence on the degree of substitutability that exists between menthol and non-menthol cigarettes, and could inform policy decisions about whether or not to ban menthol cigarettes.

Cubbin et al. presented findings on the differences in smoking behaviors by menthol status stratified by gender and ethnicity. This paper is interesting because it addressed the intricate race–gender interaction in the use of mentholated cigarettes. In addition to a higher prevalence of menthol use among black men and women, they also found that across all races, female smokers used mentholated cigarettes at much higher rates than their male counterparts. These findings are consistent with those reported by Lawrence and colleagues in this supplement.

Ahijevych and colleagues examined effects of menthol brand preference, socio-demographic factors and state tobacco control policies on smoking intensity behaviors among young adult daily and some-days smokers. Dependent variables of smoking intensity were operationalized as the average time to the first cigarette (TTF) smoked and the average number of cigarettes smoked per day (cpd). Independent variables examined included preference for mentholated cigarettes and socio-demographic variables. In their final model for daily smokers, there were no significant associations between menthol brand preference and TTF or cpd. However, lower educational attainment, not being in the labor force and the lack of home smoking rules were associated positively with shorter TTF, while lower educational attainment, being white and state excise taxes were associated positively with higher cpd. Among non-daily smokers, menthol brand preference was associated positively with shorter TTF, but associations did not vary with state tobacco control policies. The finding that mentholated cigarettes smokers have a shorter time to first cigarette of the day is consistent with findings by Fagan et al. in this supplement. Although no significant interactions were found between state tobacco control policies and smoking of mentholated cigarettes, the authors in this paper highlight the need to continue to evaluate potential effects of state-level tobacco control policies on cigarette brand preferences.

Fagan et al. examined the associations between menthol cigarette smoking status and nicotine dependence and quitting behaviors among daily smokers using data from the 2003 and 2006/07 TUS-CPS. The paper reports that menthol smokers on average smoked fewer cigarettes per day compared to non-menthol smokers. However, despite smoking fewer cigarettes per day, menthol smokers seem to be more nicotine-dependent, as indicated by their being more likely to smoke their first cigarette of the day within 5 minutes of awakening, a finding that is consistent with that of Ahijevych et al. in this supplement. These interesting findings underscore the fact that the number of cigarettes smoked per day may not be a good measure of nicotine dependence, especially for menthol smokers.

Stahre and her colleagues examined the relationship between menthol cigarette smoking and the population quit ratio and whether menthol smokers differ in utilization of evidence-based smoking cessation aids among a nationally representative sample of US adult smokers.

Their analysis, which was based on the 2005 NHIS-CCS, revealed significant differences in the population quit ratio for menthol versus non-menthol among African American smokers but not among whites. Their multiple logistic regression analysis showed a significant interaction between race and menthol smoking status, in that African American menthol smokers were significantly less likely than white non-menthol smokers to have quit smoking after controlling for age group, sex, marital status, region and average number of cigarettes smoked per day. Menthol smoking status was not associated with differences in utilization of quit aids. Future research is warranted to examine why there was no association between menthol cigarettes smoking and cessation among whites.

Trinidad et al. present some interesting and unique findings in the paper: ‘Menthol cigarettes and smoking cessation among racial/ethnic groups in the United States’, based on the 2003 and 2006/07 TUS-CPS data. The paper examined the relationship between the use of mentholated cigarettes and measures of smoking cessation among African American, Asian American/Pacific Islander, Hispanic/Latino, Native American and non-Hispanic white adults in the United States. The large sample size of the data set utilized presented the authors with a unique opportunity to examine the menthol–cessation relation across multiple racial/ethnic groups, which is often not possible due to limited sample sizes of other data sets. The researchers used adjusted logistic regression models to predict successful smoking cessation (cessation greater than 6 months) among former smokers, stratified by racial/ethnic group. Results showed that those who smoked mentholated cigarettes were significantly less likely to have quit successfully for at least 6 months, for all racial/ethnic groups except Native Americans/Alaska Natives. This was despite the fact that greater proportions of African American and Latino menthol smokers thought that they would probably succeed in quitting. Therefore, the higher confidence for quitting reported by menthol smokers may be negated by the poorer success in quitting. This area warrants further research. The finding of a negative association between use of menthol cigarettes and cessation is consistent with the study by Stahre et al. in this supplement, despite the fact that the latter study used quit ratio to operationalize cessation.

Alexander et al. sought to understand an important question about whether or not there is a relationship between the existence of smoking cessation programs in the work-place and menthol preference, as well as quitting behaviors and occupational status, using data from the 2006–07 TUS-CPS. Although researchers did not find any differences in quitting behaviors by menthol status, their findings are consistent with existing research in showing that menthol smokers were younger [1,3], from the northeast region of the United States [1] and more likely to be service workers compared to non-menthol smokers [4]. The paper also found that white-collar workers were more likely to have a work-place clean indoor air policy and an employer-sponsored cessation program compared to blue-collar and service workers. Blue-collar workers were also less likely to quit compared to white-collar workers.

In the first of two papers, Fernander and her colleagues examined the relationship between age of smoking initiation, purchasing patterns and menthol smoking status using data from the 2003 and 2006/07 TUS-CPS. Some of the findings from this paper confirm existing research while others do not. Results showing associations between menthol smoking and female gender, racial/ethnic minority status, younger age, higher income and completing a high school education are also reported by other researchers [3], as well as Lawrence et al. and Cubbin et al. in this supplement. Their multivariate logistic model revealed that age of smoking initiation predicted menthol smoking; that is, the longer the delay of initiation the more likely it was that an individual smoked menthol cigarettes. The finding that the longer the delay of smoking initiation, the more likely an individual smoked menthol cigarettes, does not support the notion that menthol promotes early smoking initiation. However, this finding may be confounded by the fact that menthol cigarettes are smoked predominantly by African Americans who in general have a later onset of smoking initiation compared to whites.

In their second paper, Fernander and colleagues examined interesting questions about whether menthol cigarette smoking is related to exposure to smoke-free home and work-place policies, availability of cessation services at work and knowledge of cessation resources among current smokers. The authors found that menthol smokers were less likely to have a smoke-free policy at both work and home. Menthol smoking was not related to availability of cessation services offered at work or knowledge of cessation services. Their study finding that menthol cigarette smoking was a risk factor for lack of home or work-place smoke-free policies has not been reported previously and warrants further study.

‘Health profile differences for menthol and non-menthol smokers: findings from the National Health Interview Survey’, by Mendiondo and colleagues, presents new and intriguing findings from their analyses that looked at differences between self-reported health characteristics for menthol and non-menthol smokers. The value of this study is its attempt to look beyond what has been reported previously about menthol smoking by advancing the discussion about potential health effects of mentholated cigarettes beyond cancer and cardiovascular diseases. After controlling for sex, age and race, the mean number of cigarettes smoked per day by current smokers is significantly lower for menthol smokers when compared to non-menthol smokers (odds ratio = 0.99; 95% confidence interval = 0.98, 1.00). Also, former menthol smokers had higher body mass indices (BMIs) and were more likely to have visited the emergency room due to asthma. Because the topic of health effects of menthol cigarettes is not well understood, this paper makes an important contribution and also highlights the need for more research in this area, especially those examining possible biological mechanisms.

Taken together, the papers in this supplement present exciting findings, drawing on large national data sets to examine further the role of menthol smoking patterns, nicotine dependence, smoke-free policies, smoking cessation and short-term health effects. There was a fair degree of consistency across the studies showing that mentholated cigarette smokers tend to be female and racial/ethnic minorities, have poorer cessation success, have less protection from work-place tobacco-free policies and are more likely to have a higher BMI. As a result, menthol smokers could be at higher risk from tobacco and other life-style-related diseases. Also, menthol and non-menthol cigarettes may not be close substitutes for one another. The papers in this supplement have created a synergistic body of population-based empirical evidence that researchers can build upon for designing future research addressing the mechanisms underlying the role of menthol and the development of effective cessation interventions for menthol smokers. Future research is warranted to examine if the negative health behavior risk profile (e.g. shorter time to first cigarette of the day, poorer cessation outcomes, less protection from work-place tobacco-free policies and higher BMI) associated with smoking of mentholated cigarettes leads to worse tobacco-related morbidity for mentholated cigarette smokers. Research in this direction has potential for significant contributions for reducing tobacco-related health disparities related especially to the use of mentholated cigarettes.

Declarations of interest

Dr Lawrence is currently an employee of Pinney Associates, Inc., a scientific consulting company that provides services to pharmaceutical companies.

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