Abstract
Background.
Menthol cigarette use among women who smoke cigarettes during pregnancy is high, but little is known about the factors that contribute to preference for menthol cigarette use during pregnancy.
Objective.
This study investigated preferences, perceptions, and intentions to use menthol vs. non-menthol cigarettes in a sample of pregnant women.
Methods.
Pregnant women (N=124, Mage=26.2 years, 50% minorities) completed a study investigating the impact of maternal smoking on biobehavioral markers of fetal risk. During the third trimester, participants self-reported preferences (liking, attractiveness, smoothness, interest), perceptions of harm (general, pregnancy-specific), and intentions to use menthol and non-menthol cigarettes. We examined differences in responses based on whether participants endorsed 1) cigarette use during pregnancy (yes/no) and 2) lifetime cigarette use (yes/no).
Results.
Sixty-two participants endorsed cigarette smoking during pregnancy (85.5% smoked menthol cigarettes), and 94 participants reported lifetime use. Overall, menthol cigarettes were perceived as more likeable and smoother vs. non-menthol (ps<0.001) – even among participants who never smoked cigarettes (ps<0.05). All participants rated both menthol and non-menthol cigarette use as harmful. Compared to participants who did not smoke during pregnancy, participants who smoked during pregnancy rated menthol cigarettes as less harmful for pregnant women (p=0.001), while there were no differences between groups in harm perceptions towards non-menthol cigarettes.
Conclusions.
Menthol may increase cigarettes appeal for pregnant women. Implications for regulation of menthol cigarettes are discussed. Future studies may investigate the role of sensory perception, marketing, and health education in influencing these factors.
Keywords: Smoking, Cigarettes, Menthol, Pregnancy, Perceptions
Introduction
Menthol cigarette (MC) use among smokers continues to increase and disproportionately affect at-risk and vulnerable populations1,2. MC has made up 36% of all sales since 2017 in the U.S. cigarette market – the highest proportion since tobacco companies began reporting rates in 19633. MC use has been linked with increased tobacco dependence and reduced likelihood of smoking cessation compared to non-menthol cigarettes (NMC)4 – potentially contributing to the high proportion of MC use among women who continue to smoke during pregnancy5,6. Although smoking prevalence among pregnant women in the U.S. are decreasing overall, prevalence of women who smoke during pregnancy remain high, especially among many vulnerable and minority populations (e.g., younger women, less educated, American Indian/Alaska Natives)7. Previous work by the authors has shown exceptionally high rates of MC use in two low-income, racially/ethnically diverse cohorts of pregnant smokers, with more than 85% of pregnant women who smoke reporting MC use6. Although specific attitudes and sociocultural factors have been associated with MC use8, little is still known about differing preferences, perceptions, and intentions to use MC specifically in pregnant women. This study investigated differences in the preferences, perceptions, and intention to use MC vs. NMC in a sample of pregnant women based on lifetime and pregnancy smoking history.
Methods
Participants
Participants were recruited from obstetric offices, health centers, and the community in southern New England for a study examining the impact of maternal smoking on fetal biobehavioral markers of risk (5R01DA036999, PI: Stroud). Study eligibility criteria included: singleton pregnancy, between 18–40 years old, and no history of serious gestational medical conditions (e.g., pre-eclampsia). The current study focused on the 124 participants who completed a substudy focused on examining use, preferences, and perceptions of flavorings in tobacco products (5R01DA036999–02S2). Smoking status during pregnancy were categorized by whether participants reported any cigarette use during pregnancy on the Timeline Follow Back (TLFB), which was biochemically verified with a carbon monoxide reading of ≤5 parts per million (ppm). The TLFB is a retrospective calendar-based measure utilized to gather psychometrically-sound information about daily substance use, including cigarette use, ranging up to 12 months prior9. Lifetime smoking status were categorized by whether participants reported ever smoking cigarettes before. All participants provided written informed consent, and all study procedures were approved by local Institutional Review Boards (WIH IRB: 792518).
Study Procedures
Study participants completed the Tobacco Flavors Interview10 during third trimester of pregnancy (Mean (M)=34 weeks gestation, Standard Deviation (SD)=1). The Tobacco Flavors Interview assessed preferences, perceptions, and intentions to use various flavor categories consistent with categories (e.g., menthol/mint, fruit, alcohol) used in the Population Assessment of Tobacco and Health (PATH) Study11 across four tobacco products (cigarettes, e-cigarettes, hookah tobacco, and cigars). Participants were provided with images examples representing each flavor/product using a portable flip chart. Each set of questions used a Likert response scale (e.g., 1–7) with the lowest value indicating lowest appeal/risk and highest indicating highest appeal/risk. The current study focused on questions from the Tobacco Flavors Interview assessing preferences and perceptions of menthol (MC) and tobacco/non-menthol (NMC) flavored cigarettes. Interviewers also assessed demographics, general health, pregnancy-specific information, and administered a TLFB interview assessing daily tobacco and other substance use within the parent study9.
Study Measures
Preferences
Four separate questions assessed participants preferences for MC and NMC using Likert-scales: (1) how much they would like cigarettes that taste like menthol/tobacco (1=extremely dislike to 7=extremely like); (2) how attractive are cigarettes that taste like menthol/tobacco (1=very unattractive to 7=very attractive); (3) whether cigarettes that taste like menthol/tobacco are harsh or smooth on the throat (1=harsh, 2=neither harsh/smooth, 3=smooth); and (4) how interested they would be in smoking MC or NMC (1=not at all interested to 7=very interested).
Postpartum Intentions to Use
Participants rated their intentions to use MC and NMC after their baby was born on a 7-point Likert scale (1=extremely unlikely to 7=very likely).
Perceptions of Harm
Participants rated their perceptions of harm of MC and NMC on 7-point Likert scales regarding their perceptions of general harm (harmful for your health) and pregnancy-related harm (harmful for pregnant women to use, harmful to the fetus) (1=not at all harmful to 7=very harmful).
Statistical Analysis
All statistical analyses were conducted using IBM SPSS Statistical Version 27. Differences in demographic variables by groups were examined using chi-squares and one-way analysis of variances. Two-sample Mann-Whitney U tests were used to compare self-reported perceptions of MC and NMC for each Tobacco Flavors Interview measure. A non-parametric test was chosen due to the ordinal measurement scale used. Separate between-group analyses were conducted to examine differences in perception ratings: first based on lifetime cigarette use (n=30 never smokers vs. n=94 lifetime cigarette smokers), and then based on cigarette use during pregnancy in lifetime smokers only (n=62 prenatal smokers vs. n=32 did not smoke during pregnancy).
Results
The sample included 124 pregnant women (M age=26.2 years, SD=4.2), of whom 34.7% identified as Latina, and 49.2% as a racial minority; 49.2% had ≤high school education; 61.3% had <$30,000 annual household income; and 34.7% were unemployed (Table 1).
Table 1.
Participant characteristics overall and by smoking history
| Overall | No Lifetime Cigarette Use | Lifetime Cigarette Use | Prenatal Cigarette Use | F or X2 | p | |
|---|---|---|---|---|---|---|
| (N=124) | (n=30) | (n=32) | (n=62) | |||
| Age, in years (mean, SD) | 26.2 (4.5) | 23.6 (3.5) | 26.7 (4.4) | 27.2 (4.6) | 7.38 | .001 |
| Ethnicity (% Latina) | 34.7% | 60.0% | 40.6% | 19.4% | 15.42 | <.001 |
| Race (% racial minority) | 49.2% | 63.3% | 46.9% | 43.5% | 3.26 | .196 |
| % American Indian/Alaskan Native | 4.8% | 3.3% | 0.0% | 8.1% | ||
| % Asian | 3.2% | 3.3% | 3.1% | 3.2% | ||
| % Native Hawaiian or Other Pacific Islander | 0.8% | 0.0% | 0.0% | 1.6% | ||
| % Black or African American | 29.0% | 20.0% | 28.1% | 33.9% | ||
| % White | 50.8% | 36.7% | 53.1% | 56.5% | ||
| % Other | 24.2% | 43.3% | 25.0% | 14.5% | ||
| Education (% high school or less) | 49.2% | 46.7% | 37.5% | 56.5% | 3.13 | .209 |
| Income (% less than 30,000/year) | 61.3% | 76.7% | 40.6% | 64.5% | 9.02 | .011 |
| Employment (% unemployed) | 34.7% | 16.7% | 21.9% | 50.0% | 13.04 | .001 |
| Gravida (mean, SD) | 2.8 (1.9) | 2.0 (1.3) | 2.2 (1.4) | 3.4 (2.2) | 8.47 | <.001 |
| Parity (mean, SD) | 0.9 (1.1) | 0.6 (0.7) | 0.47 (1.0) | 1.2 (1.2) | .001 |
Notes: p values denote differences between groups using independent t-tests and chi square analyses
Perceptions and intentions based on lifetime cigarette use (Figure 1)
Figure 1. Mean (±SEM) for preferences, intentions to use, and perceptions of harm of menthol and non-menthol cigarettes based on whether participants ever used cigarettes.
Notes: *p<0.05, **p<0.01, ***p<0.001 indicate significance for between-group comparisons based on lifetime use (yes vs. no); a MC were rated significantly higher than NMC in never smokers (p<.05), b MC were rated significantly higher than NMC in lifetime smokers (p<.05); All preferences and perception scales are 1–7 Likert scales (other than smoothness which is a 1–3 scale), with 1 being lowest appeal or risk; MC = menthol cigarettes, NMC = non-menthol/tobacco cigarettes.
Across all participants, 75.8% (n=94) identified as ever smoking cigarettes of which 91.4% (n=86) had ever tried MC in their lifetime. Compared to those who had never smoked, participants who had ever smoked in their lifetime were more likely to be younger (p<.001), unemployed (p=.017), and higher gravida (i.e., total number of pregnancies; p=.010), but were less likely to have <$30,000 income (p=.047) or identify as Latina (p<.001). There were no significant differences between groups in race, education, or parity (i.e., total number of pregnancies reaching viable gestational age) (ps>.08).
Within each group (MC vs. NMC)
Among participants who have ever smoked cigarettes (n=94), MC were rated as more likeable, attractive, and smoother compared to NMC (ps<0.001). Participants who ever smoked also reported greater interest in using MC and intentions to use MC postpartum compared to NMC (ps<0.001). Among participants who have never smoked (n=30), MC were rated as more likeable (p=0.04) and smoother (p=0.03) compared to NMC. Among participants who never smoked, there were no differences between MC and NMC in reported interest in or intention to use postpartum (ps>.30). There were no significant differences in general or pregnancy-specific harm perceptions comparing MC and NMC in either group (ps>.30).
Between groups (Lifetime users vs. Never users)
Participants who have ever smoked rated both MC and NMC as more likeable (ps<0.01) and attractive (ps<0.02) than did participants who never smoked (Figure 2). Participants who have ever smoked also rated MC as smoother than did participants who never smoked (p=0.01), but not NMC (p=0.75). Participants who have ever smoked reported greater interest in using both MC (p<.001) and NMC (p=.005) than did participants who never smoked. Participants who have ever smoked also reported greater intentions to use MC postpartum than did participants who never smoked (p<0.001), while no statistically significant differences emerged between groups for intentions to use NMC postpartum (p=0.07). No statistically significant differences for MC and NMC were found between participants who have ever vs. never smoked regarding general health risks or risk for pregnant women to use (ps>0.50), with both groups rating both MC and NMC as very harmful. No statistically significant differences were found between participants who have ever vs. never smoked regarding the risk of MC on fetal health (p>0.05); however, participants who never smoked rated NMC significantly higher in fetal-specific risk than did participants who have ever smoked (p=0.03).
Figure 2. Mean (±SEM) for preferences, intentions to use, and perceptions of harm of menthol and non-menthol cigarettes based on whether participants reported cigarette use during pregnancy.
Notes: *p<0.05, **p<0.01, ***p<0.001 indicate significance for between-group comparisons based on prenatal use (yes vs. no); a MC were rated significantly higher than NMC in individuals who did not smoke during pregnancy (p<.05), b MC were rated significantly higher than NMC in prenatal smokers (p<.05); All preferences and perception scales are 1–7 Likert scales (other than smoothness which is a 1–3 scale), with 1 being lowest appeal or risk; MC = menthol cigarettes, NMC = non-menthol/tobacco cigarettes.
Perceptions and intentions based on cigarette use during pregnancy in lifetime smokers (Figure 2)
Among lifetime smokers (n=94), 62 (70.0%) participants endorsed cigarette use during pregnancy of which 53 (85.5%) participants reported currently using MC during pregnancy. Compared to those who did not smoke during pregnancy, participants who smoked during pregnancy were more likely to identify as Latina (p=.027), have a yearly income of <$30,000 (p=.027), be unemployed (p=0.008), and have greater gravidity (p=.005) and parity (p=.002). There were no significant differences between groups in age, race, or education (ps>.08).
Within each group (MC vs. NMC)
Among participants who smoked during pregnancy, MC were rated as more likeable, attractive, and smoother compared to NMC (ps<0.001). Participants who smoked during pregnancy also reported greater interest in using MC and intentions to use MC postpartum compared to NMC (ps<0.001). Participants who did not smoke during pregnancy (n=32) rated MC as more likeable (p=0.038) and smoother (p=0.008) compared to NMC. Among participants who did not smoke during pregnancy, there were no differences between MC and NMC in reported interest in or intention to use postpartum (ps>.10). There were no significant differences between MC and NMC in general or pregnancy-specific harm perceptions for either group (ps>.40).
Between groups (Smoked during pregnancy vs. Did not smoke during pregnancy)
Participants who smoked during pregnancy rated MC only as more likeable, attractive, and smoother (ps≤.001), but only rated NMC as more attractive (p=0.005), compared to participants who did not smoke during pregnancy. Participants who smoked during pregnancy had greater interest in smoking MC and NMC (ps<.001), but intentions to use MC only postpartum (p<.001), compared to participants who did not smoke during pregnancy. Participants who smoked during pregnancy also rated both MC (p=.003) and NMC (p=.006) as generally less harmful to health than did participants who did not smoke. There were no between group differences for pregnancy or fetal-specific harm for MC or NMC (ps>.071).
Discussion
The current study examined preferences, perceptions, and intentions to use MC and NMC. To our knowledge, this is the first study to investigate perceptions of MC vs. NMC in a sample of pregnant women. The current study replicated previous findings by the authors showing very high rates of MC use in pregnant smokers (86% in the current study vs. 85% and 87% in other prenatal cohorts)6. Overall, pregnant women had more positive perceptions of, interest in, and greater intention to use MC postpartum compared to NMC. Notably, all pregnant women rated MC as more likeable and smoother compared to NMC – regardless of lifetime use or use during pregnancy. Women who have ever smoked or smoked during pregnancy also rated MC higher in attractiveness, interest, and postpartum intentions to use compared to NMC. These findings also complement prior studies by the authors showing increased use and stronger preference for menthol/mint flavors compared to tobacco flavor in both electronic cigarettes and hookah tobacco in pregnant women12,13. While all participants rated both MC and NMC highly in terms of being harmful for themselves and their pregnancy, participants who smoked during pregnancy specifically rated MC and NMC as significantly less harmful to use in general compared to participants who did not smoke during pregnancy.
Flavorings in tobacco products remain a regulatory target due to their widespread use among vulnerable populations – including those who disproportionately bear the burden of tobacco-related morbidity and mortality – and to their contribution to smoking initiation and persistence through sensory processes. Yet menthol had often previously been excluded from flavoring regulations. The current study found that even pregnant women who never smoked perceived MC as more appealing than NMC. Pregnant women may be uniquely susceptible to the appeal of flavorings in tobacco products due to the alterations in taste, cravings, and nausea during pregnancy14,15. MC-preferring pregnant smokers have been shown to have a genetic predisposition for heighted bitter taste perceptions16, which may strengthen the appeal of MC. Studies have suggested that not only are MC users are more likely to struggle with staying abstinent during pregnancy6, prepartum MC use may also increase postpartum smoking relapse among those able to quit smoking17. Together with prior findings by the authors regarding preference for mint/menthol flavorings in e-cigarettes and hookah tobacco12,13, there remains a continue to call attention to the high use and preference for menthol/mint flavorings in pregnant women across tobacco products.
Overall, the current study suggests that menthol increases the appeal of cigarettes while decreasing perceptions of harm of cigarette smoking for pregnant women – potentially explaining increased use of menthol cigarettes among pregnant women who smoke. Results should be considered in the context of limitations. Although our sample was racially/ethnically diverse and included predominantly low-income women, national and international generalizability may be limited due to the cross-sectional design examining pregnant women in one Northeast U.S. region. Furthermore, including only English-speaking women may have limited generalizability of findings to non-English speaking, pregnant women. Additionally, due to most participants endorsing MC use, we were unable to examine differences in perceptions based on cigarette type preferences among smokers. Our findings emphasize that the impact of regulating menthol in cigarettes could potentially be extremely significant for pregnant populations. While MC bans have been implemented domestically in various state jurisdictions (e.g., California, Minnesota, Illinois), there has yet to be any national-level MC bans implemented in the U.S. – although the FDA recently announced in April 2021 their intention to ban menthol as a characterizing flavor in cigarettes18. While a MC ban may reduce cigarette use in pregnant women, there is also the possibility that cigarette users who prefer flavored smoking products may switch to alternative smoking products. Studies examining menthol flavoring use across tobacco products among pregnant women, especially internationally where national MC bans have been implemented (e.g., Canada, Brazil, European Union), are increasingly necessary to support national flavored-tobacco product regulations in the U.S. Future research would also benefit from investigating how perceptions of menthol and flavored products may change across pregnancy (e.g., preconception, postpartum) and whether other sociocultural factors may also contribute to cigarette use during pregnancy.
Acknowledgements
We are grateful to the pregnant women who contributed to this study. We also thank the Maternal-Infant Studies Laboratory staff for their assistance with data collection.
Funding and Support
Funding for this study and manuscript preparation was supported by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) and the Center for Tobacco Products (CTP) of the U.S. Food and Drug Administration (FDA) under grant 5R01DA036999 and 5R01DA036999-02S2 to LRS. NCJ was supported by National Heart, Lung, and Blood Institute (NHLBI) T32HL076134, NAS was supported by National Institute on Alcohol Abuse and Alcoholism (NIAAA) T3211007459, and CVL was supported by NIDA K08DA045935. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or FDA. NIDA, CTP, and FDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Footnotes
Conflict of Interest Statement: The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or FDA. NIDA, CTP, and FDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Authors have no other potential conflicts of interest.
References
- 1.Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults - United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(45):1013–1019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Schneller LM, Bansal-Travers M, Mahoney MC, McCann SE, O’Connor RJ. Menthol Cigarettes and Smoking Cessation among Adult Smokers in the US. Am J Health Behav. 2020;44(2):252–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.U.S. Federal Trade Commission. Federal Trade Commission Cigarette Report for 2018. 2019.
- 4.Villanti AC, Collins LK, Niaura RS, Gagosian SY, Abrams DB. Menthol cigarettes and the public health standard: a systematic review. BMC Public Health. 2017;17(1):983. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Delnevo CD, Ganz O, Goodwin RD. Banning Menthol Cigarettes: A Social Justice Issue Long Overdue. Nicotine Tob Res. 2020;22(10):1673–1675. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Stroud LR, Vergara-Lopez C, McCallum M, Gaffey AE, Corey A, Niaura R. High Rates of Menthol Cigarette Use Among Pregnant Smokers: Preliminary Findings and Call for Future Research. Nicotine Tob Res. 2020;22(10):1711–1717. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Azagba S, Manzione L, Shan L, King J. Trends in smoking during pregnancy by socioeconomic characteristics in the United States, 2010–2017. BMC Pregnancy Childbirth. 2020;20(1):52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Glasser AM, Barton A, Rath J, et al. Perceptions of Use Patterns and Health Consequences Associated With Mentholated Cigarettes Among U.S. Adults. Health Educ Behav. 2020;47(2):284–292. [DOI] [PubMed] [Google Scholar]
- 9.Robinson SM, Sobell LC, Sobell MB, Leo GI. Reliability of the Timeline Followback for cocaine, cannabis, and cigarette use. Psychol Addict Behav. 2014;28(1):154–162. [DOI] [PubMed] [Google Scholar]
- 10.Scott-Sheldon LAJ, Stroud LR. Preferences and Perceptions of Flavored Hookah Tobacco among US Women. Am J Health Behav. 2018;42(3):37–46. [DOI] [PubMed] [Google Scholar]
- 11.United States Department of Health Human Services, National Institutes of Health, National Institute on Drug Abuse, United States Department of Health Human Services, Food Drug Administration, Center for Tobacco Products. Population Assessment of Tobacco and Health (PATH) Study [United States] Restricted-Use Files. In: Inter-university Consortium for Political and Social Research [distributor]; 2021. [Google Scholar]
- 12.Stroud LR, Papandonatos GD, Borba K, Kehoe T, Scott-Sheldon LAJ. Flavored electronic cigarette use, preferences, and perceptions in pregnant mothers: A correspondence analysis approach. Addict Behav. 2019;91:21–29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Stroud L, Werner E, Matteson K, et al. Waterpipe (hookah) tobacco use in pregnancy: use, preferences and perceptions of flavours. Tob Control. 2020;29(Suppl 2):s62–s71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Choo E, Dando R. The Impact of Pregnancy on Taste Function. Chem Senses. 2017;42(4):279–286. [DOI] [PubMed] [Google Scholar]
- 15.Pletsch PK, Kratz AT. Why do women stop smoking during pregnancy? Cigarettes taste and smell bad. Health Care Women Int. 2004;25(7):671–679. [DOI] [PubMed] [Google Scholar]
- 16.Oncken C, Feinn R, Covault J, et al. Genetic Vulnerability to Menthol Cigarette Preference in Women. Nicotine Tob Res. 2015;17(12):1416–1420. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Reitzel LR, Nguyen N, Cao Y, et al. Race/ethnicity moderates the effect of prepartum menthol cigarette use on postpartum smoking abstinence. Nicotine Tob Res. 2011;13(12):1305–1310. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.FDA Commits to Evidence-Based Actions Aimed at Saving Lives and Preventing Future Generations of Smokers [press release]. April 29, 2021. 2021. [Google Scholar]