Abstract
This study examines patterns of menthol and nonmenthol cigarette use from 2003 to 2005 in a cohort of smokers, aged 16 to 24 years in the National Youth Smoking Cessation Survey. At follow-up, 15.0% of baseline menthol smokers had switched to nonmentholated cigarettes; by contrast, 6.9% of baseline nonmenthol smokers had switched to mentholated cigarettes. Differences in switching patterns were evident by gender, race/ethnicity, parental education, and smoking frequency. These data support previous evidence that young smokers start with mentholated cigarettes and progress to nonmentholated cigarettes.
Following enactment of the Family Smoking Prevention and Tobacco Control Act in June 2009,1 fruit, candy, and clove characterizing flavorings in cigarettes were banned to reduce youth smoking initiation. Menthol is the only characterizing flavor that was not banned outright by the act. Nationally representative surveys have shown an age gradient in menthol use, with the youngest smokers (aged 12–17 years) most likely to smoke mentholated cigarettes.2,3 Studies of adolescents report that middle school smokers and recent initiates are more likely to use mentholated cigarettes than high school smokers and those smoking longer than 1 year, respectively.4 With other studies,5–7 these results argue that menthol facilitates smoking initiation and that mentholated cigarettes serve as starter tobacco products for youths.4
Although these nationally representative studies document an age gradient in menthol use, they do not address smoking patterns in the same individuals over time and whether there is a disproportionate shift from early use of mentholated cigarettes to nonmentholated cigarette use later on. The current study assesses patterns in menthol and nonmenthol cigarette use over time in young smokers, aged 16 to 24 years.
METHODS
In 2003, the National Youth Smoking Cessation Survey (NYSCS) collected data on tobacco use and quitting practices via a random-digit-dialed computer-assisted telephone survey of 2582 16- to 24-year-old persons who had ever smoked 20 lifetime cigarettes and who had smoked at least once during the previous 30 days.8 The Robert Wood Johnson Foundation funded the survey; Westat conducted the interviewing. Approximately 85 000 households were contacted for study eligibility and the overall screener response rate was 60%. Of these, 21.4% had an age-eligible person in the household; 69.6% of all age-eligible smokers identified participated in the survey. The overall CASRO response rate was 41.8%. After 24 months, 1431 participants responded to the follow-up survey. Of these, 1045 were still smoking and provided information on usual brand and menthol status. There was no difference between 24-month study completers and those lost to follow-up on age, gender, or days smoked per month. Completers were more likely to smoke nonmenthol brands, to be White, and to have parents who went to college.
At baseline and 24 months, smokers were asked, “During the past 30 days, what brand of cigarettes do you usually smoke?” with the subsequent question being, “Is the brand of cigarettes that you usually smoked during the past 30 days menthol or non-menthol?” After adjustment for misclassification of exclusively menthol and nonmenthol brands, smokers were classified as having either switched from a mentholated to a nonmentholated variety or as having switched from a nonmentholated to a mentholated variety. Data were weighted to represent the US population of 16- to 24-year-old smokers, using estimates from the Tobacco Use Supplement to the Current Population Survey.
RESULTS
Table 1 presents data on switching patterns using the 24-month follow-up data from the NYSCS cohort. In this study of 1045 young smokers aged 16 to 24 years, 31.7% (95% CI = 28.44%, 34.96%) reported smoking menthol cigarettes at baseline. After 2 years, proportionately more baseline menthol smokers had switched to nonmenthol cigarettes (15.0%; 95% CI = 10.8%,19.2%) than baseline nonmenthol smokers had switched to menthol brands (6.9%; 95% CI = 4.9%,8.9%). Menthol brand switching had an inverse, though not statistically significant, relationship with age, whereby the youngest menthol smokers (aged 16–18 years at baseline) were the most likely to switch to nonmenthol cigarettes (23.6%), followed by those aged 19 to 20 (20.9%) and those aged 21 to 24 years (10.1%). The differences in switching from menthol at baseline to nonmenthol at follow-up compared with nonmenthol at baseline to menthol at follow-up were especially noticeable in 19- to 20-year-old smokers (20.9% vs 6.7%), non-Hispanic Whites (20.4% vs 5.6%), male smokers (19.2% s 7.2%), those whose parents had at least some college education (16.8% vs 5.1%), and those smoking more than 10 days per month (13.3% vs 6.6%).
TABLE 1—
Menthol Brand Switching Among Youth and Young Adult Smokers (n = 1045): United States, National Youth Smoking Cessation Survey, 2003–2005
| Baseline (2003) |
Follow-Up (2005) |
|||
| No. | % (95% CI)a | Switched, No. | Switched, % (95% CI)a | |
| Overall | ||||
| Menthol | 360 | 31.7 (28.44, 34.96) | 58 | 15.0 (10.83, 19.17)b |
| Nonmenthol | 685 | 68.3 (65.04, 71.56) | 55 | 6.9 (4.9, 8.9)b |
| Age at baseline, y | ||||
| 16–18 | ||||
| Menthol | 116 | 39.5 (33.42, 45.63) | 29 | 23.6 (15.29, 31.98) |
| Nonmenthol | 177 | 60.5 (54.37, 66.58) | 21 | 12.5 (7.23, 17.83) |
| 19–20 | ||||
| Menthol | 83 | 28.9 (22.93, 34.78) | 16 | 20.9 (11.3, 30.42)b |
| Nonmenthol | 192 | 71.1 (65.22, 77.07) | 16 | 6.7 (3.21, 10.21)b |
| 21–24 | ||||
| Menthol | 161 | 30.4 (25.94, 34.91) | 13 | 10.1 (4.7, 15.42) |
| Nonmenthol | 316 | 69.6 (65.10, 74.06) | 18 | 5.6 (2.97, 8.21) |
| Race/ethnicity | ||||
| White, non-Hispanic | ||||
| Menthol | 228 | 24.6 (21.35, 27.89) | 53 | 20.4 (14.63, 26.09)b |
| Nonmenthol | 612 | 75.4 (72.11, 78.66) | 40 | 5.6 (3.66, 7.48)b |
| Black, non-Hispanic | ||||
| Menthol | 100 | 93.6 (88.19, 98.98) | 3 | … |
| Nonmenthol | 6 | … | 3 | … |
| Hispanic | ||||
| Menthol | 32 | 29.2 (18.69, 39.80) | 2 | … |
| Nonmenthol | 67 | 70.8 (60.20, 81.31) | 12 | 17.6 (7.06, 28.13) |
| Gender | ||||
| Female | ||||
| Menthol | 185 | 34.6 (29.92, 39.34) | 24 | 10.9 (6.28, 15.51) |
| Nonmenthol | 326 | 65.4 (60.66, 70.08) | 25 | 6.6 (3.69, 9.41) |
| Male | ||||
| Menthol | 175 | 29.2 (24.83, 33.55) | 34 | 19.2 (12.44, 25.91)b |
| Nonmenthol | 359 | 70.8 (66.45, 75.17) | 30 | 7.2 (4.36, 10.00)b |
| Parental education | ||||
| No HS diploma/HS diploma, no college | ||||
| Menthol | 158 | 35.7 (30.22, 41.22) | 20 | 12.2 (6.25, 18.23) |
| Nonmenthol | 233 | 64.3 (58.78, 69.78) | 24 | 10.6 (6.22, 15.06) |
| Some college/college graduate | ||||
| Menthol | 202 | 29.5 (25.51, 33.54) | 38 | 16.8 (11.12, 22.49)b |
| Nonmenthol | 452 | 70.5 (66.46, 74.49) | 31 | 5.1 (3.07, 7.04)b |
| Smoking, d/mo | ||||
| 1–9 | ||||
| Menthol | 50 | 29.1 (21.31, 36.82) | 15 | 26.3 (13.42, 39.27) |
| Nonmenthol | 111 | 70.9 (63.18, 78.69) | 10 | 8.6 (2.87, 14.37) |
| 10–30 | ||||
| Menthol | 310 | 32.1 (28.59, 35.70) | 43 | 13.3 (8.9, 17.65)b |
| Nonmenthol | 574 | 67.9 (64.30, 71.42) | 45 | 6.6 (4.48, 8.72)b |
Note. CI = confidence interval; HS = high school. Ellipses indicate insufficient precision to report.
All percentages and 95% confidence intervals weighted to represent the national population of 16–24-year-old smokers.
Nonoverlapping 95% confidence intervals in those switching from a menthol brand at baseline to nonmenthol at follow-up compared with those switching from a nonmenthol brand at baseline to menthol at follow-up.
DISCUSSION
This study documents the temporal relationship of brand switching between mentholated and nonmentholated cigarettes in young smokers. It shows that young smokers are more likely to progress from mentholated products to nonmentholated varieties in a short period of time and lends further credence to evidence on mentholated cigarettes as a starter product for young smokers. Age, gender, race/ethnicity, parental education and smoking frequency might also influence the switch from mentholated to nonmentholated cigarettes.
Menthol may act as a starter product for a relatively large number of smokers by facilitating experimentation and subsequent addiction.2,4 Later in the uptake process, the smoker may switch to non menthol brands. The lack of switching in Black participants may reflect the predominance of menthol brands in Black communities throughout the life span and limitations in power resulting from the small sample size. Reviews of tobacco industry documents show that menthol levels in cigarettes have been tailored to attract young people to smoking.7,9 Banning menthol in cigarettes could prevent some significant proportion of youth smoking initiation and truncate smoking careers by disrupting the progression from experimentation to regular smoking.
Acknowledgments
This study was funded by the Schroeder Institute for Tobacco Research and Policy Studies at Legacy. The National Youth Smoking Cessation Survey was funded by the Robert Wood Johnson Foundation.
Human Participant Protection
The protocol of the National Youth Smoking Cessation Survey was approved by the institutional review boards of the Roswell Park Cancer Institute and Westat, Inc.
References
- 1. Family Smoking Prevention and Tobacco Control Act. H.R. 1256, 111th Cong. § 1 (2009)
- 2. The NSDUH Report: Use of Menthol Cigarettes. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2009.
- 3.Rock VJ, Davis SP, Thorne SL, Asman KJ, Caraballo RS. Menthol cigarette use among racial and ethnic groups in the United States, 2004-2008. Nicotine Tob Res. 2010;12(suppl 2):S117–S124 [DOI] [PubMed] [Google Scholar]
- 4.Hersey JC, Ng SW, Nonnemaker JMet al. Are menthol cigarettes a starter product for youth? Nicotine Tob Res. 2006;8(3):403–413 [DOI] [PubMed] [Google Scholar]
- 5.Ferris Wayne G, Connolly GN. Application, function, and effects of menthol in cigarettes: a survey of tobacco industry documents. Nicotine Tob Res. 2004;6(suppl 1):S43–S54 [DOI] [PubMed] [Google Scholar]
- 6.Kreslake JM, Wayne GF, Connolly GN. The menthol smoker: tobacco industry research on consumer sensory perception of menthol cigarettes and its role in smoking behavior. Nicotine Tob Res. 2008;10(4):705–715 [DOI] [PubMed] [Google Scholar]
- 7.Klausner K. Menthol cigarettes and smoking initiation: a tobacco industry perspective. Tob Control. 2011;20(suppl 2):ii12–ii19 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Barker DC, Giovino GA, Gable J, Tworek C, Orleans CT, Malarcher A. The use of smoking cessation methods among smokers aged 16-24 years—United States, 2003. MMWR Morb Mortal Wkly Rep. 2006;55(50):1351–1354 [PubMed] [Google Scholar]
- 9.Kreslake JM, Wayne GF, Alpert HR, Koh HK, Connolly GN. Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults. Am J Public Health. 2008;98(9):1685–1692 [DOI] [PMC free article] [PubMed] [Google Scholar]