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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Addict Behav. 2021 Feb 23;118:106880. doi: 10.1016/j.addbeh.2021.106880

The Impact of Menthol Cigarette Use on Quit Attempts and Abstinence Among Smokers with Opioid Use Disorder

Danusha Selva Kumar 1, Meghan Peterson 2, Chenshu Zhang 2, Pebbles Fagan 3, Shadi Nahvi 2
PMCID: PMC8059772  NIHMSID: NIHMS1676608  PMID: 33706070

Abstract

An exceedingly high proportion of persons with opioid use disorder (OUD) smoke cigarettes. Smokers with OUD face multiple barriers to smoking cessation. While menthol cigarette use has been associated with low cessation rates, research has not explored the impact of menthol cigarette use on tobacco use outcomes among smokers with OUD. Participants were current smokers, in methadone treatment for OUD, participating in randomized controlled trials of smoking cessation therapies. We examined the use of menthol cigarettes, and the association between menthol cigarette use and achieving 24-hour quit attempts and seven-day point prevalence abstinence. Of 268 participants, 237 (88.4%) reported menthol use. A similar proportion of menthol and non-menthol smokers achieved a 24-hour quit attempt (83.1% vs. 83.8%, p = 0.92). Though fewer menthol smokers (vs. non-menthol smokers) achieved abstinence (12.7% vs. 22.6%), this did not reach statistical significance (p = 0.14). In this sample of smokers with OUD, menthol smoking was nearly ubiquitous. Menthol smoking was not associated with differences in quit attempts, but was associated with differences in cessation that were not statistically significant. Menthol smoking may contribute to the challenges in achieving abstinence among smokers with OUD.

Keywords: menthol, quit attempts, smoking cessation, tobacco abstinence, opioid use disorder, methadone

Introduction

The prevalence of smoking among individuals with opioid use disorder (OUD) is five to six times higher than among the general population (Weinberger et al., 2018). National data show that 84% to 94% of individuals with OUD smoke compared to 14% of individuals in the general population (Cornelius et al., 2020). Although interest and motivation to quit cigarette smoking among individuals with OUD are comparable to smokers without OUD (Vlad et al., 2020; Richter et al., 2001; Nahvi et al., 2006), rates of smoking cessation with evidence-based treatments are lower among smokers with OUD (Vlad et al., 2020). Smokers with OUD face multiple barriers to smoking cessation, such as challenges establishing initial abstinence and maintaining abstinence long-term (Vlad et al., 2020; de Dios et al., 2014; Nahvi et al., 2014; Shoptaw et al., 2002). However, past research has not evaluated the relationship between menthol cigarette use and smoking cessation outcomes among individuals with OUD.

Extant evidence shows that menthol smokers have greater levels of nicotine dependence compared to non-menthol smokers (Food and Drug Administration, 2013; Fagan et al., 2010). Menthol cigarette use has also been shown to be associated with lower smoking cessation especially among racial and ethnic minority groups (Smith et al., 2020; Trinidad et al., 2010; Okuyemi et al., 2007). Although there are few treatment studies that have compared menthol smokers with non-menthol smokers, Smith et al. (2020) found that even with evidence-based treatments, Black menthol smokers had lower cessation rates than non-menthol smokers. The US Food and Drug Administration (FDA) has the regulatory authority to ban characterizing flavors in tobacco products, including menthol. In 2011, in light of these and other health effects of menthol cigarettes, the Tobacco Products Scientific Advisory Committee advised the FDA that "removal of menthol cigarettes from the marketplace would benefit public health" (Food and Drug Administration, 2011).

There are scant data on how menthol cigarette smoking influences cessation outcomes among smokers with OUD. Among predominantly Black or Latinx smokers with OUD receiving buprenorphine maintenance, 81.5% reported menthol cigarette use (Shah et al., 2017). This prevalence is higher than observed in predominantly white samples of smokers with substance use disorders (between 35.5% to 48.2% of whom had OUD), in which 36.1% to 53.1% of smokers reported menthol use (Gubner et al., 2018; Campbell et al., 2019; Davis et al., 2019). While these findings suggest high use of menthol among smokers with OUD, the impact of menthol use on likelihood of quit attempts or abstinence among smokers with OUD is unknown.

To address this gap, we investigated the use of menthol cigarettes among smokers with OUD and the impact of menthol cigarette use on smoking outcomes. We predicted that compared to individuals who did not report menthol use, individuals who reported menthol use would be less likely to achieve a quit attempt, have fewer quit attempts, and be less likely to achieve abstinence.

Methods

Participants

Participant data were pooled from three randomized controlled trials of smoking cessation therapies among persons with opioid use disorder (OUD): a double-blind, placebo-controlled trial of 12 weeks of varenicline (2009 – 2011, n=112) (Nahvi et al., 2014); a randomized trial of 12 weeks of directly-observed vs. self-administered varenicline (2011 – 2015, n=100) (Nahvi et al., 2021); and an ongoing 2x2 factorial, randomized trial of directly-observed and placebo-controlled, long-term (24 weeks) varenicline (2018 – present, n=60 to date). Four trial participants had missing data for menthol use status and were excluded, bringing the final sample size to 268 participants. We used data from the first 12 weeks for the current study. Participants' sociodemographic characteristics were similar across the three trials.

All study procedures were conducted at the Montefiore Health System's three Division of Substance Abuse (DoSA) clinics in the Bronx, New York, USA. Inclusion criteria in all three trials were: ≥18 years old; receiving methadone treatment for ≥ 3 months; smoking (≥5 cigarettes per day); interested in quitting smoking (ladder of change score 6–8); not pregnant, breastfeeding, or trying to conceive; able to provide informed consent. Exclusion criteria were unstable medical or psychiatric illness.

Measures

Data were collected through interviewer-administered surveys in the varenicline placebo-controlled trial, and through audio computer-assisted self-interview (ACASI) for the subsequent two trials. Research visits were conducted at baseline, and at weeks 2, 4, 8, and 12 (Nahvi et al., 2014); weeks 3, 6, 9, and 12 (Nahvi et al., 2021); or at weeks 4, 8, and 12 (THRIVE trial, ongoing).

Tobacco Use Characteristics

Baseline measures of tobacco use included: (a) number of cigarettes per day; (b) Fagerström Test for Nicotine Dependence score; (c) quit importance, using a 10-point scale; (d) quit confidence, using a 10-point scale; and (e) any past quit attempts.

Mental health and OUD treatment characteristics

Psychiatric measures at baseline included: (a) Diagnostic and Statistical Manual-IV psychiatric diagnoses measured by the Mini-International Neuropsychiatric Interview (Sheehan et al., 1997); and (b) current psychiatric treatment. We measured duration in methadone maintenance treatment and baseline methadone dose using clinical records.

Exposure

Exposure to menthol cigarettes was operationalized as a response of “menthol” to the question “Is your usual cigarette brand menthol or non-menthol?”

Outcomes

We examined the impact of menthol cigarette use on three outcomes: 1) if participants achieved a 24-hour quit attempt at any follow-up timepoint over the 12 week intervention period; 2) total number of 24-hour quit attempts over 12 weeks; and 3) if participants achieved 7-day point prevalence abstinence at any follow-up visit over 12 weeks. Quit attempts are a critical prerequisite to long-term abstinence (Baker et al., 2011). We operationalized having achieved a 24-hour quit attempt as an answer of “Yes” to “[Since the last study visit], have you stopped smoking for one day or longer because you were trying to quit smoking?” at any follow-up timepoint over the 12-week intervention period. We operationalized 7-day point prevalence abstinence as an answer of “No” to the question, “Have you smoked at least part of a cigarette in the past 7 days, even a puff?” at any follow-up visit over the 12 weeks, biochemically verified with CO < 8 parts per million (p.p.m., Bedfont Smokerlyzer). We used a CO threshold of < 8 p.p.m., as used in the parent trials to allow comparison with prior trials of smokers with OUD. We used a pooled measure of 7-day abstinence at any follow-up timepoint because past research has shown negligible rates of long-term abstinence among smokers with OUD who receive evidence-based treatments (Vlad et al., 2020).

Data Analysis

We first compared demographic and clinical characteristics between menthol and non-menthol smokers. We tested the association between menthol use and the outcomes of achieving a 24-hour quit attempt, number of quit attempts, and achieving 7-day point prevalence abstinence. We conducted bivariate analyses using chi-square and Wilcoxon tests as appropriate. We then conducted multivariate logistic or linear regression analyses to evaluate the association between menthol cigarette smoking and achieving quit attempts, number of quit attempts, and achieving abstinence, controlling for the demographic and clinical variables which had a p-value of less than .10 in relation to menthol smoking (race/ethnicity, stable housing, duration of methadone treatment, methadone dose), as well as treatment condition (varenicline or placebo).

Results

Sociodemographic and clinical characteristics.

In this sample of 268 smokers with OUD, 50.4% identified as Latinx, 33.2% as Black, 50.8% as male; the median age was 50; and 88.4% reported use of menthol cigarettes. Compared to non-menthol smokers, menthol smokers were more likely to be Black (35.7% vs. 12.9%, p < .001), had fewer median years in methadone treatment (8.9 vs. 11.1, p = 0.03) and a lower median methadone dose (95 vs. 130 mg, p < .001) (Table 1).

Table 1.

Baseline Characteristics

Sociodemographic characteristics Uses menthol
cigarettes (n=237)		 Does not use
menthol
cigarettes (n=31)		 p-value
Age, median (IQR) 50 (45-55) 49 (46-56) 0.68
Male sex, n (%) 117 (49.4) 19 (61.3) 0.21
Race/ethnicity, n (%) <.001
Latinx 119 (50.2) 16 (51.6)
Non-Hispanic Black 85 (35.7) 4 (12.9)
Non-Hispanic white 19 (8) 10 (32.3)
≤High school education, n (%) 188 (79.3) 23 (74.2) 0.51
Employed, n (%) 57 (24.1) 8 (25.8) 0.83
Unstable housing, n (%) 90 (38) 7 (25.6) 0.09
Uninsured or publically insured, n (%) 209 (88.2) 28 (90.3) 0.87
Tobacco use characteristics
Cigarettes/day, median (IQR) 11 (9-20) 15 (7-20) 0.75
Fagerström Test of Nicotine 5 (3-6) 4 (3-6) 0.91
Dependence score, median (IQR)
Quit importance, median (IQR) 10 (8-10) 10 (7-10) 0.27
Quit confidence, median (IQR) 8 (5-10) 7 (5-9) 0.39
Any past quit attempts, n (%) 178 (75.1) 25 (80.7) 0.50
Psychiatric comorbidity
Lifetime major depressive disorder, n (%) 49 (20.7) 6 (19.4) 0.86
Currently receiving psychiatric treatment, n (%) 95 (40.1) 13 (41.9) 0.84
Median duration of methadone treatment, years (IQR) 8.9 (4-12) 11.1 (4-24.4) 0.03
Median methadone dose, mg (IQR) 95 (60-130) 130 (100-190) <.001
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Quitting behaviors among menthol and non-menthol cigarette smokers.

There was no difference in the proportion of menthol vs. non-menthol smokers achieving a 24-hour quit attempt at any timepoint (83.1% vs. 83.8%, p = 0.92); for both groups, the median number of 24-hour quit attempts over 12 weeks was two. Despite similar rates of quit attempts, only 12.7% of smokers who used menthol cigarettes achieved 7-day point prevalence abstinence at any timepoint over the 12 weeks compared to 22.6% of smokers who did not use menthol cigarettes, X2 (1, N = 268) = 2.20, p = 0.14. The relationship between menthol cigarette use and achieving a 7-day point prevalence abstinence at any timepoint over the 12 weeks (OR = 0.50, 95% CI = 0.20, 1.25, p = 0.14) was unchanged in the multivariate logistic regression model adjusting for race/ethnicity, housing status, duration of methadone treatment, methadone dose, and treatment condition (OR = 0.59, 95% CI = 0.20, 1.73, p = 0.34).

Discussion

In this sample of smokers with OUD, 88.4% were menthol smokers, and the proportion of menthol smokers who achieved 7-day point prevalence abstinence was nearly half that of non-menthol smokers. We observed no difference in 24-hour quit attempts between smokers who did and did not smoke menthol cigarettes. However, only 12.7% of menthol smokers achieved abstinence, compared to 22.6% among non-menthol smokers. Though this difference was not statistically significantly different, it raises questions about whether menthol smoking contributes to the low rate of cessation seen among smokers with OUD.

Nearly 90% of participants reported use of menthol cigarettes. This may be attributable to our sample and recruitment setting. First, among smokers with mental illness, 58% report using menthol cigarettes (Brunette et al., 2019), and many smokers with OUD also struggle with mental illness (Stein et al., 2013). Second, this low SES sample, of whom half identified as Latinx, and one-third as Black, is vulnerable to structural racism and corporate determinants of health (Maani et al., 2020). Menthol cigarettes are disproportionately marketed in racial / ethnic minority communities (Mills et al., 2018; Gardiner & Clark. 2010). In addition to these social and structural factors, it is possible that menthol impacts the complex interplay between nicotine and opioids among smokers with OUD (Vlad et al., 2020).

The finding that menthol smokers are equally as likely to make a quit attempt as non-menthol smokers is consistent with previous research that has found no difference in the likelihood of a past-year quit attempt (Gubner et al., 2018). Concordant with prior research that has linked menthol use with lower cessation among racial and ethnic minority groups (Smith et al., 2020), we found that fewer menthol smokers achieved tobacco abstinence; this difference was not statistically significant. One possibility is that menthol use did not adversely impact smoking cessation in this sample. Another possibility is that we did not have sufficient power to detect a statistically significant difference: our sample of 268 participants yields 54% power to detect the 10% difference in cessation outcomes that we observed. Research shows that since menthol-flavored tobacco products were banned in Ontario, quit rates among menthol smokers have increased (Chaiton et al., 2020). If menthol use is found to predict lower cessation success among smokers with OUD, this could inform strategies to tailor treatments and inform the FDA in regulating and banning menthol products.

Limitations

There are several limitations to this study. This study included smokers who were receiving treatment for OUD, and thus may not generalize to smokers with OUD who were not receiving treatment. We did not measure brand of menthol cigarettes used, duration of menthol smoking, or structural determinants of menthol use such as retail outlet density and neighborhood advertising. Only 31 participants did not use menthol cigarettes, and smoking cessation was rare, making it challenging to detect differences in outcomes. Additionally, this study investigates the association between menthol cigarette use and smoking cessation outcomes, and we are unable to infer causation.

Conclusion

In this sample of smokers with OUD, we found that menthol cigarette use was nearly ubiquitous. While we did not find statistically significant differences in outcomes, we found that menthol users had similar quit attempt rates compared to non-menthol users, but lower abstinence rates. Future research is needed to determine if menthol smoking contributes to the challenges in achieving smoking cessation among smokers with OUD.

Highlights.

  • There was near-ubiquitous use of menthol cigarettes among smokers with OUD.

  • Menthol and non-menthol cigarette users were equally likely to make a quit attempt.

  • Fewer menthol smokers achieved abstinence than non-menthol smokers.

Acknowledgements

The authors thank Amy Cheng and Kea Edwards for assistance with trial administration, and acknowledge the contributions of Division of Substance Abuse patients and staff.

Financial Support

This project was supported by the National Institutes of Health National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA grant KL2 TR002558, and National Institute on Drug Abuse grants K23DA025736 and R01DA042813. The funding sources had no role in the study design; data collection, analysis and interpretation; writing the manuscript; or the decision to submit the manuscript for publication.

Footnotes

Conflicts of Interest

Dr. Nahvi receives investigator-initiated grant support from Pfizer.

Ethical Standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

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