Pain and Menthol Use Are Related to Greater Nicotine Dependence Among Black Adults Who Smoke Cigarettes at Wave 5 (2018–2019) of the Population Assessment of Tobacco and Health (PATH) Study

Abstract

Burdens related to pain, smoking/nicotine dependence, and pain-smoking comorbidity disproportionately impact Black Americans, and menthol cigarette use is overrepresented among Black adults who smoke cigarettes. Menthol may increase nicotine exposure, potentially conferring enhanced acute analgesia and driving greater dependence. Therefore, the goal of the current study was to examine associations between pain, menthol cigarette use, and nicotine dependence. Data was drawn from Black adults who were current cigarette smokers (n = 1370) at Wave 5 (2018–2019) of the Population Assessment of Tobacco and Health Study. Nicotine dependence was assessed using the Wisconsin Inventory of Smoking Dependence Motives. ANCOVA revealed that moderate/severe pain (vs. no/low pain) was associated with greater overall nicotine dependence (p < .001) and greater negative reinforcement, cognitive enhancement, and affiliative attachment smoking motives (ps < .001). Menthol smokers with moderate/severe pain also endorsed greater cigarette craving and tolerance, compared to non-menthol smokers with no/low pain (ps < .05). Findings support the notion that among Black individuals who smoke cigarettes, the presence of moderate/severe pain (vs. no/low pain) and menthol use may engender greater physical indices of nicotine dependence relative to non-menthol use. Compared to no/low pain, moderate/severe pain was associated with greater emotional attachment to smoking and greater proclivity to smoke for reducing negative affect and enhancing cognitive function. Clinical implications include the need to address the role of pain and menthol cigarette use in the assessment and treatment of nicotine dependence, particularly among Black adults. These data may help to inform evolving tobacco control policies aimed at regulating or banning menthol tobacco additives.

Pain and cigarette smoking are both highly prevalent and comorbid conditions that engender an economic burden of more than $800 billion in the USA each year [1–3]. Rates of smoking may be up to 45% among persons with pain (vs. 12.5% in the general population) [4–6]. Consistent with established reciprocal pain-smoking interrelations [7–9], smokers with pain (vs. no pain) are substantially more likely to relapse following a quit attempt [10], and nicotine-induced analgesia can be a powerful motivator of smoking urge/behavior [11–13]. There is also evidence that use of nicotine for pain-coping further reinforces smoking behavior [14–16], leading to greater dependence on cigarettes. Indeed, pain and its related constructs (e.g., maladaptive cognitive-affective responses) have consistently been associated with indices of smoking dependence (including diagnostic criteria for nicotine use disorder) [5], self-reported smoking dependence motives [16, 17], and physical indices of cigarette dependence (e.g., time to first cigarette) [18].

Burdens related to pain, smoking/nicotine dependence, and pain-smoking comorbidity disproportionately impact Black Americans. Reports derived from both clinical and nationally representative samples indicate that, among people with pain, Black adults experience higher levels of pain-related interference [19, 20]. Compared to White patients, medical providers have consistently been shown to underestimate pain reports of Black patients [21, 22], who remain undertreated for pain across medical settings [23, 24]. Likewise, Black adults who use cigarettes face numerous structural inequities, including targeted marketing by tobacco companies [25], greater density of tobacco retailers in neighborhoods with higher proportions of Black residents [26], and lower rates of screening for tobacco-related diseases such as lung cancer [27]. Despite smoking at equal or lower rates (along with a greater prevalence of quit attempts) compared to their White counterparts, Black individuals who smoke cigarettes are less likely to successfully quit, experience disproportionate disease burden, and are more likely to die from tobacco-related conditions [28–33]. An emerging literature further suggests that Black adults who use cigarettes experience unique relationships between their smoking and pain. For example, in a sample of smokers with HIV, lower self-efficacy for pain management was associated with lower cessation motivation among Black respondents only [34], and a recent laboratory study demonstrated smoking abstinence–induced pain among Black adults [35]. Taken together, these finding suggest that pain may be a particularly salient motivator of cigarette use and greater dependence among Black adults who smoke cigarettes.

Menthol, a flavor additive in cigarettes, has been identified as a key driver of tobacco-related health disparities among Black persons who smoke [28, 36, 37]. Although menthol smoking, itself, may not directly increase risk for cancer or other tobacco-related diseases [38, 39], public health officials have concluded that people who smoke menthol cigarettes can experience greater overall tobacco exposure over time, which can lead to greater disease burden [40, 41]. The cooling effects, which mask aversive physiological sensations from smoking, are believed to promote smoking uptake and progression to regular smoking among youth, and adults who smoke menthol cigarettes are less likely to successfully quit [37]. Consistent with evidence that tobacco companies disproportionately target Black communities for the sale of menthol cigarettes, the proportion of Black smokers who typically smoke menthol cigarettes (77%) is more than three times that of White smokers (25%) [42], and recent estimates indicate that Black Americans accounted for 41% of premature deaths due to menthol smoking, despite constituting only 12% of the population [36]. Although a majority of the literature examining associations between menthol and tobacco dependence has shown no difference in overall dependence as a function of menthol use [38, 39, 43], and considerable heterogeneity in assessment of other indices of dependence (e.g., time to first cigarette) has been observed, a meta-analysis found a small but significant difference in greater likelihood of reporting the shortest time to first cigarette among menthol (vs. non-menthol) smokers [44]. Given such mixed findings, additional research in this area is warranted, and menthol is also of particular importance in the context of pain-smoking interrelations. In addition to conferring acute analgesia [45, 46], menthol has been shown to potentiate analgesic effects of nicotine in rodent models [47]. These data are consistent with a recent study conducted among treatment-seeking smokers, which found that Black individuals who smoke menthol (vs. non-menthol) cigarettes reported lower levels of pain intensity and pain-related interference in daily functioning, with effect sizes that were medium to large in magnitude [48]. Thus, among individuals with pain, greater analgesia derived from menthol cigarettes may reinforce continued smoking and ultimately increase dependence over time. Given well-documented health disparities, there is a particular need to examine pain and menthol smoking in relation to nicotine dependence among Black adults who use cigarettes.

Data from Black adults who endorsed current cigarette smoking at the most recent Wave 5 (2018–2019) of the Population Assessment of Tobacco and Health (PATH) Study was examined to test whether smoking dependence varied as a function of pain and menthol cigarette smoking in a nationally representative sample. Although previous research has demonstrated positive associations between pain and other types of substance use (e.g., alcohol, cannabis, painkillers/sedatives/tranquilizers) in the PATH Study [49], this is the first study to examine pain, menthol cigarette use, and nicotine dependence using this data. First, we tested whether the presence of moderate/severe pain (vs. no/low pain) was associated with higher odds of current menthol cigarette use. Second, we examined whether total nicotine dependence scores were higher among respondents who endorsed moderate/severe pain (vs. no/low pain) and menthol cigarette use (vs. no menthol). Total scores and dimensions of nicotine dependence were assessed via the Wisconsin Inventory of Smoking Dependence Motivates (WISDM), modified for the PATH Study [50, 51]. Finally, pain status by menthol use groups was generated to examine whether menthol smoking plus the presence of moderate/severe pain was associated with greater WISDM total and indices scores.

Method

Data Source and Sample

Data were drawn from the Wave 5 (2018–2019) PATH Study public-use files. Jointly administered by NIDA/NIH, FDA’s Center for Tobacco Products, and Westat, the PATH Study was initiated in 2013 and is an annual, nationally representative cohort study of 45,971 US adults and youth [52]. Each wave of PATH data includes population weights, allowing for representative estimates of the non-institutionalized, civilian US population. All participants provided informed consent and data were de-identified. Data were collected via in-person interviews conducted in English or Spanish at participants’ homes or electronically. Participants were compensated $50 for completing an interview. Further details about the PATH study design and methods are detailed elsewhere [52]. The current analyses included adults aged 18 years or older at Wave 5, who reported their race as Black and were established someday/everyday cigarette smokers, as defined by endorsing at least 100 lifetime cigarettes and reporting smoking cigarettes some days/every day [53].

Measures

Pain Status

Past-week pain intensity was assessed using a single item (i.e., “In the past 7 days, how would you rate your pain on average on a scale from 0 to 10, where 0 is no pain and 10 is the worst pain imaginable?”). This item was dichotomized to compare moderate/severe pain (> 4/10) vs. no/low pain (severity ≤ 4/10), using a cut-off commonly utilized in both the clinical and empirical literature. Pain measured over a recent period (e.g., past-week) is well correlated with established measures of pain persistence and severity [54, 55] and has demonstrated relevant associations with measures of smoking heaviness, nicotine dependence, and cessation outcomes [4, 10, 56, 57].

Menthol Cigarette Use

Participants reported whether any of the cigarettes they smoked in the past 30-days were mint or menthol flavored. Consistent with prior work [58], participants who responded “yes” were considered menthol smokers, whereas participants who responded “no” were considered non-menthol smokers.

Nicotine Dependence

Nicotine dependence was assessed via a modified version of the Wisconsin Inventory of Smoking Dependence Motives (WISDM) [51], which was generated for the PATH Study [58]. The full-length WISDM is composed of eight subscales that assess dimensions of smoking dependence motives, in addition to a total score of overall nicotine dependence [50, 51]. The modified WISDM scale for the PATH Study includes a single item from each subscale to represent the eight separate constructs. Items are also summed to generate a total score (range: 5–40). Dimensions of nicotine dependence include craving, tolerance, automaticity, loss of control, negative reinforcement, cognitive enhancement, affiliative enhancement, and social environment. Participants rated each item on a Likert scale ranging from 1 (“Not true of me at all”) to 5 (“Extremely true of me”). Total scores summing these eight nicotine dependence items as well as scores for the individual items were used in analyses.

Sociodemographic Characteristics

Sociodemographic characteristics assessed included gender, ethnicity, age, education, and income. Gender was reported as male or female, and ethnicity was reported as Hispanic or non-Hispanic. Age was reported by the following categories: 18–24, 25–34, 35–44, 45–54, 55–64, and 65 and older. Education levels reported were less than high school, GED, high school graduate, some college or associate’s degree, and bachelor’s or advanced degree. Lastly, past-year annual income was categorized as less than $10,000, $10,000–$24,000, $25,000–$49,000, $50,000–$99,999, and $100,000 or more.

Data Analysis

Analyses were conducted in Stata 17, utilizing population and replicate weights to adjust for complex study design characteristics (e.g., oversampling and non-response) [52]. Estimates were calculated with balanced repeated replication methods using a Fay’s adjustment value of 0.3 [59, 60]. Gender, annual income, education, and Hispanic ethnicity were included as covariates in all models given significant correlations with total nicotine dependence scores (ps < 0.001). All data met assumptions of normality.

First, logistic regression was used to examine whether pain status (no/low pain vs. moderate/severe pain) was associated with higher odds of menthol smoking (yes/no). Second, two separate ANCOVA models were conducted to examine whether total nicotine dependence scores were higher among respondents who reported (a) moderate/severe pain (vs. no/low pain) and (b) menthol cigarette use (vs. no menthol). Third, a four-category pain status/menthol use variable was created and coded as 1 (no/low pain + no menthol use), 2 (no/low pain + menthol use), 3 (moderate/severe pain + no menthol use), 4 (moderate/severe pain + menthol use). A series of ANCOVAS were then conducted, with the four-category pain status/menthol use variable entered as the fixed factor and total nicotine dependence scores and separate indices of dependence entered as the respective dependent variables. Planned comparisons were conducted for each level of the pain status/menthol use factor with no/low pain + no menthol use utilized as the reference group. Benjamini–Hochberg corrections were used to account for multiple comparisons [61].

Results

The total sample was comprised 1370 adult Black smokers, of which 73.63% reported use of menthol cigarettes in the past 30 days. The sample was evenly distributed by self-reported gender (51.61% female), the age category with the highest percentage of participants was 25–35 years (24.51%), and almost 35% reported a past-year annual income of less than US$10,000. Approximately 47% of the sample endorsed moderate/severe pain. On average, respondents smoked 11 cigarettes per day (M = 11.44; SE = 0.26) and endorsed a total nicotine dependence score of 20.66 (SE = 0.25). Additional sociodemographic data are presented in Table 1.

Table 1.

Unweighted sample characteristics of Black adults who smoke cigarettes at Wave 5 of the PATH Study (N = 1370)

	n (%)
Gender
Male	663 (48.39%)
Female	707 (51.61%)
Ethnicity
Hispanic	70 (5.27%)
Age
18–24	122 (8.90%)
25–34	336 (24.51%)
35–44	254 (18.53%)
45–54	236 (17.21%)
55–64	294 (21.44%)
65 and older	129 (9.41%)
Education level
Less than high school	292 (21.55%)
GED	176 (12.99%)
High school graduate	402 (29.67%)
Some college or associate degree	396 (29.23%)
Bachelor’s degree or advanced degree	89 (6.57%)
Past-year annual income
Less than $10,000	453 (34.82%)
$10,000–$24,000	400 (30.75%)
$25,000–$49,000	286 (21.98%)
$50,000–$99,999	127 (9.76%)
$100,000 or more	35 (2.69%)
Menthol cigarette use	983 (73.63%)
Moderate/severe pain (> 4)	639 (47.02%)

Participants included Black, adult (aged 18 or older), established cigarette smokers who provided data at Wave 5 (2018–2019) of the PATH Study

Association of Pain Status with Menthol Cigarette Use and Nicotine Dependence

ANCOVA revealed that moderate/severe pain (vs. no/low pain) was associated with greater overall nicotine dependence (F(5, 66) = 2.74, p < 0.001). Specifically, Black respondents with moderate/severe pain scored higher on the WISDM than those with no/low pain (M = 22.11, SE = 0.29 vs. M = 19.41, SE = 0.32). Pain status was not associated with odds of menthol use in the sample (p = 0.601).

Association of Menthol Use with Nicotine Dependence

There was no difference in overall WISDM total scores as a function of menthol cigarette use (F(5, 64) = 0.69, p = 0.271). Specifically, nicotine dependence scores among menthol smokers (M = 20.83, SE = 0.28) were similar to those among non-menthol smokers (M = 20.63, SE = 0.45).

Association of Pain Status and Menthol Use with Nicotine Dependence

ANCOVA models further showed that associations with WISDM indices differed across pain status/menthol use groups. As seen in Tables 2 and 3, menthol users with moderate/severe pain reported significantly greater cigarette craving (F(7, 62) = 0.32, p = 0.033; M = 3.16, SE = 0.07) and tolerance (F(7, 68) = 0.33, p = 0.035; M = 3.28, SE = 0.06) than non-menthol smokers with no/low pain (craving: M = 2.93, SE = 0.12; tolerance: M = 3.03, SE = 0.13). Menthol users with no/low pain endorsed significantly greater automaticity and loss of control (ps = 0.001) relative to non-menthol users with no/low pain. Furthermore, in comparison to non-menthol users with no/low pain, participants with moderate/severe pain (regardless of menthol use status) endorsed greater scores on the following WISDM dependence indices: negative reinforcement (F(7, 62) = 0.32, p = 0.033), cognitive enhancement (F(7, 62) = 0.32, p = 0.033), and affiliative attachment (F(7, 62) = 0.32, p = 0.033) dependence scores. All group comparisons are presented in Table 3.

Table 2.

WISDM total scores and indices as a function of pain status and menthol use

	No/low pain + no menthol	No/low pain + menthol	Moderate/severe pain + no menthol	Moderate/severe pain + menthol
	Weighted mean (95% CI)	Weighted mean (95% CI)	Weighted mean (95% CI)	Weighted mean (95% CI)
Craving I frequently crave cigarettes	2.93 (2.70–3.16)	2.70 (2.58–2.82)	3.10 (2.91–3.29)	3.16* (3.03–3.29)
Tolerance I usually want to smoke a cigarette right after I wake up	3.03 (2.77–3.30)	2.99 (2.86–3.12)	3.08 (2.81–3.36)	3.28* (3.12–3.43)
Automaticity I find myself reaching for cigarettes without thinking about it	2.35 (2.14–2.55)	2.56* (2.44–2.70)	2.83** (2.60–3.05)	2.97** (2.82–3.14)
Loss of control My cigarette use is out of control	2.03 (1.86–2.21)	2.30* (2.18–2.43)	2.75** (2.53–2.97)	2.52** (2.38–2.66)
Negative reinforcement Smoking helps me feel better if I’ve been feeling down	2.34 (2.16–2.53)	2.49 (2.37–2.61)	2.86** (2.66–3.07)	2.82** (2.70–2.93)
Cognitive enhancement Smoking cigarettes helps me think better	1.88 (1.71–2.06)	2.04 (1.09–2.20)	2.39 ** (2.18–2.60)	2.31 ** (2.20–2.42)
Affiliative attachment I would feel alone without my cigarettes	1.75 (1.57–1.94)	1.88 (1.75–2.01)	2.40 ** (2.17–2.58)	2.20 ** (2.06–2.32)
Social environment Most of the people I spend time with smoke cigarettes	2.81 (2.49–3.11)	2.67 (2.53–2.82)	2.83 (2.51–3.14)	2.97 (2.81–3.13)
WISDM total score	19.17 (17.93–20.41)	19.61 (18.92–20.31)	22.24 ** (20.96–23.52)	22.22 ** (21.56–22.90)

Weighted means and standard errors of WISDM scores and indices. No/Low Pain + No Menthol Use utilized as the comparison group for ANCOVA models

^*p significant at 0.05 after Benjamini-Hochberg correction;

^**p < 0.001

Table 3.

ANCOVA models comparing WISDM total scores and indices as a function of pain and menthol use

	No/low pain + menthol		Moderate/severe pain + no menthol		Moderate/severe pain + menthol
	Weighted beta (95% CI)	P	Weighted beta (95% CI)	P	Weighted beta (95% CI)	P
Craving	− 0.21 (− 0.44 to 0.02)	0.069	0.22 (− 0.10 to 0.54)	0.180	0.32 (0.03–0.61)	0.033*
Tolerance	0.06 (− 0.03 to 0.38)	0.699	0.17 (− 0.22 to 0.56)	0.398	0.33 (0.02–0.64)	0.035*
Automaticity	0.28 (0.07–0.49)	0.011*	0.57 (0.27–0.87)	< 0.001**	0.73 (0.51–0.95)	< 0.001**
Loss of control	0.37 (0.16–0.58)	0.001*	0.80 (0.50–1.10)	< 0.001**	0.59 (0.36–0.83)	< 0.001**
Negative reinforcement	0.14 (− 0.08 to 0.36)	0.225	0.51 (0.26–0.75)	< 0.001**	0.47 (0.23–0.70)	< 0.001**
Cognitive enhancement	0.24 (− 0.01 to 0.49)	0.060	0.56 (0.31–0.86)	< 0.001**	0.50 (0.27–0.72)	< 0.001**
Affiliative attachment	0.22 (− 0.02 to 0.47)	0.067	0.62 (0.32–0.93)	< 0.001**	0.49 (0.28–0.71)	< 0.001**
Social environment	− 0.03 (− 0.34 to 0.28)	0.843	− 0.04 (− 0.43 to 0.34)	0.811	0.20 (− 0.17 to 0.57)	0.281
Total score	1.11 (− 0.33 to 2.60)	0.136	3.46 (1.84–5.07)	< 0.001**	3.63 (2.15–5.11)	< 0.001**

No/low pain + no menthol use utilized as the comparison group. All models covaried for gender, annual income, education, and Hispanic ethnicity

^*p significant at 0.05 after Benjamini-Hochberg correction;

^**p < 0.001

Discussion

Previous research has shown that pain status is associated with greater cigarette smoking, higher nicotine dependence scores, and poorer cessation outcomes [4, 5, 10, 62]. However, we are not aware of any prior studies that extended this work to Black adults who smoke cigarettes or in the context of menthol cigarette use. Utilizing the most recent Wave 5 (2018–2019) of the PATH Study, results indicated that regardless of menthol cigarette use, the presence of moderate/severe pain (vs. no/low pain) was associated with greater WISDM total nicotine dependence scores, and with greater scores on several WISDM subscales, including indices reflecting negative reinforcement, cognitive enhancement, and affiliative attachment. Consistent with prior research [38, 39, 43], we observed no difference in nicotine dependence scores as a function of menthol use status alone. However, an interesting pattern emerged in which menthol smokers with moderate/severe pain reported greater cigarette craving and tolerance, when compared to non-menthol smokers with no/low pain. Results indicate that among Black adults who smoke, pain is uniquely associated with greater nicotine dependence, which in some cases may be further enhanced by menthol cigarette smoking.

Negative reinforcement frameworks are commonly invoked when conceptualizing pain-smoking relations [7–9, 63]. Smokers often report using cigarettes to cope with pain [15, 16, 64], in part due to the acute analgesic properties of nicotine [13]. Pain also negatively impacts cognitive functioning [65], nicotine has been shown to confer acute improvements in memory and cognition [66], and smokers with pain may be more motivated to use nicotine in an effort to mitigate pain-related cognitive impairments. In addition to negative reinforcement and cognitive coping, these findings indicate that participants with moderate/severe pain (vs. no/low pain) reported greater affiliative attachment to smoking, indicating a strong emotional attachment and more positive feelings towards cigarette smoking [67]. These findings build upon prior literature which has shown that pain engenders greater dependence on cigarettes [5, 18] and extend this work among Black adults who smoke by demonstrating differences in indices of nicotine dependence as a function of moderate/severe pain. Greater overall nicotine dependence among smokers with pain may ultimately impact the incidence of tobacco-induced diseases, which is consistent with greater rates of cigarette use among pain populations (vs. the general population) [4–6].

The present results suggest that menthol smoking plus the presence of moderate/severe pain may be associated with cigarette craving and tolerance indices, in comparison to non-menthol smoking no/low pain. Cigarette craving and tolerance are considered primary dependence motives that relate most closely to physical symptoms of nicotine dependence [68]. Earlier time to first cigarette in the morning (approximately assessed via the WISDM tolerance item) has specifically demonstrated utility as a robust and reliable indicator of nicotine dependence [69]. Consistent with an established literature [38, 39, 43], the current findings did not demonstrate differences in overall nicotine dependence as a function of menthol use alone. Although the literature is inconclusive in this area, some findings have shown higher cotinine/cigarette ratios among menthol smokers compared to non-menthol smokers [70, 71], and a meta-analysis found menthol smokers may be more likely than non-menthol smokers to smoke their first cigarette within 5 min of waking [44]. Shorter latency to resume smoking after overnight abstinence may be particularly relevant in the context of pain [35], and the experience of acute pain has been shown to reduce latency to smoke [12, 72]. Menthol also has pain-relieving properties [45, 46] and may enhance nicotine-induced analgesia [47, 73]. This may be due, in part, to prolonged nicotine exposure resulting from menthol inhibiting nicotine metabolism [74, 75] and/or upregulation of α4β2 nicotinic acetylcholine receptors (nAChRs) which may increase reward derived from nicotine [76]. Thus, smokers with pain may use menthol cigarettes as a way to enhance overall nicotine exposure and increase analgesic properties of nicotine [48], leading to stronger craving and greater tolerance over time. In addition, menthol use (regardless of pain status) was associated with greater automaticity and loss of control smoking motives, which have been linked to greater all dependence [77]; however, we are unaware of prior research which has shown differences in these indices among menthol vs. non-menthol smokers. Given the high prevalence of menthol smoking (73%) and moderate/severe pain (47%) in the present sample, these findings are relevant to a large group of smokers at risk for greater dependence and poorer cessation outcomes.

Structural racism, including inequalities in healthcare access [23, 24], tailored tobacco marketing [25, 26], provider bias [21], and discrimination [22], contributes to disproportionate burdens in both pain and cigarette smoking morbidity and mortality among Black adults. In light of this and the current findings, several implications warrant discussion. First, clinicians and researchers should be educated regarding the detrimental effects of pain and menthol use on nicotine dependence trajectories, and these factors should be assessed over the course of smoking cessation. Second, these findings are consistent with a growing literature that indicates communities in which menthol cigarette smoking is overrepresented experience disproportionate tobacco-related disparities in cessation rates and overall mortality [40, 41], which may help to inform tobacco control policies. Although results from Canada’s menthol ban suggest that a US menthol ban would lead an additional 1,337,988 smokers to quit, including 381,272 Black adults [78], a federal menthol ban has yet to be implemented in the USA. Third, there is a scarcity of tailored smoking cessation interventions for Black adults who use cigarettes [79–82], despite evidence that they tend to experience greater difficulty quitting than their White counterparts [30, 31], and that menthol use specifically has been linked to greater risk of cessation failure [83].

Integrated cessation interventions that address the role of pain and menthol use among Black adults who smoke are sorely needed. Components of such an intervention could include increasing self-efficacy for managing pain symptoms in the absence of smoking [34], providing education on how cigarette smoking is incongruent with goals for pain management [8], and modifying beliefs that menthol has medicinal/healing properties [84]. Menthol smokers with cooccurring pain may especially benefit from pharmacotherapy (e.g., varenicline) [85–87], motivational interviewing [88], and from learning adaptive strategies for managing craving (e.g., acceptance, focusing on long-term consequences, urge surfing) [89–92] and pain (e.g., progressive muscle relaxation, distraction, mindfulness) [93, 94] in the absence of cigarette smoking. Integrated pain-smoking interventions should also be culturally tailored, which may include use of narrative communication, peer experiences, incorporation of cultural values, and culturally specific vignettes/images [79–81, 88, 95, 96]. It is also imperative that such interventions aim for high scalability and reduced barriers to access (e.g., low cost, telehealth, health literacy).

Several study limitations warrant noting. First, pain assessment in the PATH study was limited to a single variable (i.e., past-week pain intensity). Although previous research has demonstrated clinically relevant associations between past-week pain and indices of cigarette smoking [56] and chronic pain severity [54], future work should examine menthol smoking and nicotine dependence in relation to more detailed assessments of pain (e.g., impairment, duration, location). Second, menthol smoking was assessed via past 30-day use of menthol/mint cigarettes, with no indication of frequency or intensity. However, it is notable that prevalence of menthol use in the sample was 73%, which is consistent with other nationally representative estimates among Black smokers [97]. Third, although observed between-group differences in WISDM total scores and indices were relatively small in magnitude (range WISDM total scores: 19.17–22.22), the modified version of the WISDM for the PATH study utilizes a smaller response range (1–5) than the original measure (1–7) [51]. Indeed, the distribution of scores in this study is consistent with prior research using the modified WISDM [58]. Other abbreviated versions of the WISDM (e.g., Brief WISDM) have also demonstrated excellent validity/reliability [98], including high test–retest reliability [67] and sensitivity in differentiating across race/ethnicity [99]. Finally, future research would benefit from explicating the role of social determinants of health (e.g., healthcare access, perceived discrimination, attitudes, and self-efficacy) in associations between pain, menthol smoking, and nicotine dependence among Black persons who smoke [34, 84, 100, 101].