Abstract
This study compares respondents’ planned behavior before the 2017 menthol cigarette ban in Ontario with actual behavior 1 month after the ban.
The province of Ontario, Canada, implemented a full menthol cigarette ban on January 1, 2017. To date, there has been no population-wide, systematic evaluation of the association of the implementation of a menthol ban with smoker behavior. Assessments of perceived behavioral responses to hypothetical menthol flavor bans are useful1; however, there is no guarantee that individuals will follow through with their planned behaviors. This study compares respondents’ planned behavior before the ban with actual behavior 1 month after the ban.
Methods
Eligible participants were residents of Ontario 16 years or older who had smoked at least 1 menthol cigarette in the past year and were past-month smokers. A total of 325 participants were recruited using random-digit dialing of residential telephone numbers from September 12 through December 31, 2016. Participation rate for the random-digit dialing was 44.1%, with a 6.7% refusal rate among known eligible participants, consistent with an established provincial health monitoring survey. Participants were contacted for follow-up beginning 1 month (February 1, 2017) after the implementation of the ban (January 1, 2017) through an online survey (206 recontacted [63.4%]). Those who were unavailable for follow-up did not differ by level of menthol smoking, age, sex, income, educational level, or smoking characteristics. Planned reaction to the ban, actual behavior at 1 month after the ban, and planned future reaction beyond 1 month after the ban were compared. Oral consent was obtained from all participants, and the analytic data set was deidentified. This study was approved by the research ethics board of the University of Toronto, Toronto, Ontario, Canada.
Results
A total of 325 participants participated in the study (181 [55.7%] male; 143 [44.0%] female; mean [SD] age, 47.1 [0.9] years). Before the ban, most menthol smokers (123 [59.7%]) said that they would switch to or only use nonmenthol cigarettes, but only 51 (28.2%) had done so at follow-up (Table). In contrast, a larger proportion (60 [29.1%]) attempted to quit compared with only 30 (14.5%) who said they would do so. Similarly, a larger proportion (60 [29.1%]) reported using other flavored tobacco or e-cigarette products (menthol was not banned in e-cigarette products) compared with their preban plans (12 [5.8%]). After the ban, participants were less likely to anticipate using other flavored products. Of those who made a quit attempt, 16 (80.0%; 95% CI, 56.3%-92.5%) of those who primarily smoked menthol cigarettes at baseline suggested that the ban affected their decision to quit at least a little compared with 10 (25.6%; (95% CI, 14.1%-41.0%) of those who smoked menthol cigarettes only occasionally. Before the ban, 1 individual (0.3%) suggested trying to switch to marijuana and 4 (1.2%) suggested adding menthol to cigarettes separately using flavor cards, oils, or papers as substitutes for the lack of menthol, but none reported planning to use these substitutes in the future.
Table. Expected, Short-term Actual, and Long-term Planned Reactions to the Ban on Menthol in Tobacco, Ontario, Canada.
| Reaction | No. (%; 95% CI) (n = 206) | ||
|---|---|---|---|
| Expected Reaction Before Ban | Actual Short-term Reactiona | Long-term Planned Reaction | |
| Use of nonmenthol cigarettes onlyb | 123 (59.7; 52.8-66.2) | 51 (28.2; 22.0-35.2) | 102 (49.5; 42.7-56.4) |
| Quit | 30 (14.5; 10.3-20.1) | 60 (29.1; 23.3-35.8)c | 35 (17.0; 12.4-22.3) |
| Use of alternative flavored products (e-cigarettes, cigars, and other flavored tobacco products) | 12 (5.8; 3.3-10.2) | 60 (29.1; 23.3-35.8) | 6 (2.9; 1.3-6.4) |
| Use of contraband menthol | 23 (11.2; 7.5-16.3) | 29 (14.1; 10.0-19.6)d | 34 (16.5; 12.0-22.3) |
| Adding menthol or other reaction | 4 (1.9; 0.7-5.1) | 29 (14.1; 10.0-19.6) | NR |
| Don’t know | 14 (6.8; 4.1-11.2) | 6 (2.9; 1.3-6.4) | 29 (14.1; 10.0-19.6) |
Abbreviation: NR, not reported.
Column does not total 100% because actual behaviors were not mutually exclusive.
Continued or new users of nonmenthol cigarettes who did not try to quit, use any menthol product, use any other flavored product, or add flavor to nonmenthol cigarettes.
Quit or made serious quit attempt. The number (percentage) not currently smoking by follow-up was 25 (12.1%; 95% CI, 8.3%-17.4%).
Purchasing menthol cigarettes from a First Nations reserve, other province, other country, or online. Does not include stockpiled cigarettes, cigarettes bought from existing stocks that enforcement allowed stores to sell out, or those provided by friends. A total of 72 individuals (35.1%; 95% CI, 28.9%-42.0%) used menthol from all sources in the past month.
Discussion
This study is, to our knowledge, the first evaluation of the immediate association of a menthol cigarette ban with behavior change. Actual behaviors contrast sharply with planned behaviors. Although a substantial decrease in menthol cigarette use was observed, there was a considerable increase in use of flavored e-cigarettes and cigars. Furthermore, 29.1% of menthol smokers attempted to quit smoking shortly after ban implementation. Because previous studies2,3 have found an expected rate of 0.5 quit attempts and a 7.7% abstinence rate during a 6-month period in this population, this finding suggests that the ban substantially increased quit attempts. Few smokers used aftermarket additive flavorings, and there was no increase in the use of contraband tobacco. Limitations of this study include the unique demographics of menthol cigarette smokers in Canada, where menthol cigarettes comprise 5% of cigarette sales4,5 compared with 30% in the United States6 and use is not concentrated among black Canadians.5 The initial results suggest that removing menthol tobacco from the market is a feasible strategy that may influence cessation behavior, although differences between menthol users in Ontario, Canada, and other jurisdictions may affect the potential influence of a ban.
References
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