Menthol Cigarette Smoking Trends among United States Adults, 2003-2019

Knowledge and Use of Menthol-Mimicking Cigarettes Among Adults in the US

Importance

Cigarette companies have been introducing synthetic cooling agent menthol-mimicking cigarettes into the US marketplace as menthol cigarette bans are implemented. These cigarettes may reduce the public health benefits of menthol cigarette bans.

Objective

To examine the epidemiology of the use of synthetic cooling agent menthol-mimicking cigarettes among adults in the US.

Design, Setting, and Participants

This population-based cross-sectional survey study of adults in the US (≥21 years) with oversampling of Asian, American Indian or Alaska Native, Black or African American, and Hispanic or Latino peoples was conducted from March to May 2024. Participants were recruited from an online panel using a sample-matching approach to achieve national representation. Data were weighted to be nationally representative. Descriptive statistics were used to summarize the population characteristics. Weighted prevalence of awareness of, ever use (among those aware), current use (among ever used), susceptibility (among noncurrent use), and likely to switch to synthetic cooling agent menthol-mimicking cigarettes were estimated overall and by covariate. Sequential weighted logistic regression models were used to estimate the associations between covariates and synthetic cooling agent menthol-mimicking-related outcomes (awareness, ever use, current use, susceptibility). Statistical analysis was performed from July to September 2024.

Exposures

Demographics, state menthol cigarette ban, cigarette smoking, and disclosure of synthetic cooling agent.

Main Outcomes and Measures

Awareness of, susceptibility to, ever and currently using synthetic cooling agent menthol-mimicking cigarettes and intention to switch to these cigarettes if a nationwide menthol cigarette ban were enacted.

Results

The study population included 3200 US adults (47.4% men; 0.8% American Indian or Alaska Native, 5.9% Asian, 12.0% Black or African American, 16.0% Hispanic or Latino, 63.6% White, and 1.9% other race; 34.8% with a college degree; and 36.7% with annual household income of ≥$75 000). Overall, 29.1% (95% CI, 27.0%-31.1%) of US adults were aware of synthetic cooling agent menthol-mimicking cigarettes, 36.9% (95% CI, 33.1%-40.8%) of those aware ever used these cigarettes, 24.7% (95% CI, 20.1%-29.3%) of those who ever used reported currently using these cigarettes, and 37.5% (95% CI, 33.4%-41.6%) of those not currently using were susceptible to using them. Black or African American (vs White), men (vs women), adults aged 60 years or younger (vs adults aged ≥61 years), adults who used menthol and nonmenthol cigarettes (vs adults who did not smoke cigarettes), and those who lived in states with a menthol cigarette ban (vs those who lived in states with no ban) had higher odds of awareness, ever use, current use, and/or susceptibility to these cigarettes. Considering a national menthol cigarette ban, 50.8% (95% CI, 42.8%-58.7%) of adults who smoked menthol cigarettes and were aware of menthol-mimicking cigarettes with a synthetic cooling agent reported likely to switch to these cigarettes. Ever using these cigarettes was associated with the likelihood of switching (adjusted odds ratio, 2.61 [95% CI, 1.20-5.68]).

Conclusions and Relevance

In this survey study of US adults, a substantial proportion were aware of and had already experimented with synthetic cooling agent menthol-mimicking cigarettes. These products may serve as a substitute for menthol cigarettes and reduce the public health benefits of a menthol cigarette ban in promoting smoking cessation.

Evaluation of pancreatic iodine uptake and related influential factors in multiphase dual-energy CT

OBJECTIVES

To establish normative values and identify potential factors influencing pancreatic iodine uptake using dual-energy CT (DECT).

MATERIALS AND METHODS

This retrospective study included participants without pancreatic diseases undergoing DECT at two institutions with different platforms. Their protocols both included arterial phase (AP), portal venous phase (PP), and equilibrium phase (EP), defined as 35 s-40 s, 60 s-70 s, and 150 s-180 s after injection of contrast agent, respectively. Both iodine concentration (IC) and normalised IC (NIC) were measured. Demographic features, local measurements of the pancreas and visceral fat area (VFA) were considered as potential factors influencing iodine uptake using multivariate linear regression analyses.

RESULTS

A total of 562 participants (median age 58 years [interquartile range: 47-67], with 282 men) were evaluated. The mean IC differed significantly between two institutions (all p < 0.001) across three contrast-enhanced phases, while the mean NIC showed no significant differences (all p > 0.05). The mean values of NIC were 0.22 at AP, 0.43 at PP and 0.45 at EP. NICAP was independently affected by VFA (β = 0.362, p < 0.001), smoking (β = -0.240, p = 0.001), and type-II diabetes (β = -0.449, p < 0.001); NICPP by VFA (β = -0.301, p = 0.017) and smoking (β = -0.291, p < 0.001); and NICEP by smoking (β = -0.154, p = 0.10) and alcohol consumption (β = -0.350, p < 0.001) with statistical power values over 0.81.

CONCLUSION

NIC values were consistent across institutions. Abdominal obesity, smoking, alcohol consumption, and diabetes are independent factors influencing pancreatic iodine uptake.

CLINICAL RELEVANCE STATEMENT

This study has provided reference normative values, influential factors and effective normalisation methods of pancreatic iodine uptake in multiphase dual-energy CT for future studies in this area as a new biological marker.

KEY POINTS

Evaluation of pancreatic iodine uptake measured by dual-energy CT is a promising method for future studies. Abdominal obesity, smoking, alcohol consumption, diabetes, and sex are independent factors influencing pancreatic iodine uptake. Utility of normalised iodine concentration is necessary to ensure the consistency across different institutions.

The influence of sociodemographic, tobacco use, and mental health characteristics on treatment adherence among adults enrolled in a community-based tobacco cessation program

Background

While counseling and pharmacological interventions are known to facilitate smoking cessation, poor adherence can impact their effectiveness. Therefore, this study aimed to identify personal and clinical factors that influenced adherence to smoking cessation treatment among socioeconomically disadvantaged adult Oklahomans enrolled in a publicly available tobacco treatment program and observational research study.

Methods

Adult participants (N = 442) were enrolled in a community-based tobacco treatment program. Logistic regression models identified sociodemographic, mental health, and substance use characteristics associated with treatment adherence. Adherence was measured by counseling session attendance and weeks of moderate/high medication adherence assessed via the Medication Adherence Questionnaire. Analyses were conducted using SAS 9.4 with p < 0.05.

Results

Participants (mean age of 53, 55 % female, and 42.3 % racially minoritized), smoked 16 (SD = 10) cigarettes/day for 30 years on average (SD = 15), and 44.8 % reported depression (Center for Epidemiological Studies Depression Scale [CESD] score ≥ 10). Self-efficacy, White race, increasing age, and years of smoking were positively associated with counseling adherence, while menthol use, being uninsured, and depression predicted lower counseling adherence. Medication adherence was lower among individuals who used menthol cigarettes, lived with someone who smoked, and had higher levels of expired carbon monoxide.

Conclusions

This study highlights key factors that influenced adherence to smoking cessation treatment in a socioeconomically disadvantaged population. Tailored interventions are needed to address social, behavioral, and environmental factors, such as living situations and mental health, in smoking cessation interventions to enhance treatment outcomes for underserved populations. Future tobacco cessation programs should consider these factors to improve adherence and, ultimately, success rates.

Association of Use of Menthol- Versus Tobacco-Flavored ENDS with Switching Completely Away from Cigarettes and Differences by Menthol Cigarette Smoking

INTRODUCTION

Menthol cigarettes and menthol-flavored electronic nicotine delivery systems (ENDS) are a current focus of US regulatory policy considerations. Informed policy requires understanding how ENDS flavor may influence smoking behavior, and whether this association varies by preferred cigarette flavor.

MATERIALS AND METHODS

The analytic sample included 8,428 US adults who smoked cigarettes (AWS) in the Adult JUUL Switching and Smoking Trajectories Study and used tobacco- or menthol-flavored JUUL products. Repeated-measures logistic regressions assessed the time-varying association between primary JUUL flavor (menthol vs. tobacco) and switching (no past-30-day smoking) across four follow-ups in year 2 of the study, adjusting for sociodemographics and baseline smoking history. Analyses also examined interactions with cigarette flavor preference (menthol vs. non-menthol).

RESULTS

AWS smoking menthol cigarettes predominantly used menthol-flavored JUUL (∼70% of follow-ups) and had significantly higher switch rates (aOR[95%CI] = 1.30[1.09-1.55]). AWS primarily using menthol-flavored (vs. tobacco-flavored) JUUL had higher odds of switching (aOR = 1.24[1.08-1.43]). The association varied by preferred cigarette flavor: AWS who smoked non-menthol cigarettes had higher odds of switching when using menthol- (vs. tobacco-flavored) JUUL aOR = 1.21[1.05-1.40]). Among AWS who smoked menthol cigarettes, the difference in switching was not significant, but trended in the opposite direction (aOR = 0.94[0.79-1.11] for menthol- vs. tobacco-flavored JUUL). More generally, AWS who used cigarette-incongruent JUUL flavors (especially non-menthol cigarettes and Menthol-flavored JUUL) had higher odds of switching (aOR = 1.16[1.04-1.29]).

DISCUSSION

Some menthol-flavored ENDS may promote complete switching beyond that facilitated by tobacco-flavored ENDS. Cigarette-incongruent ENDS flavors, especially menthol-flavored ENDS among people who smoke non-menthol cigarettes, may facilitate increased switching.

Behavior change, health, and health disparities 2024: Smoking and other tobacco use among women and girls

This Special Issue (SI) of Preventive Medicine is the 11th in an annual series on behavior change, health, and health disparities. The theme of this 2024 issue is Smoking and Other Tobacco Use among Women and Girls. Cigarette smoking remains the single most preventable cause of death in the U.S., causing the premature death of more than 200,000 U.S. women annually, a mortality rate that far exceeds levels from conditions more commonly associated with premature death in women (e.g., breast cancer). Of course, cigarette smoking among women and girls is also a well-known cause of intergenerational adverse health effects. Women and girls are also using e-cigarettes and many other tobacco products that are flooding the U.S. tobacco marketplace. This SI includes eleven peer-reviewed articles that advance knowledge across a wide range of topics on disproportionate adverse effects, prevalence, and risk factors for cigarette smoking and other tobacco use in women and girls.

Cigarette smoking and prostate cancer aggressiveness among African and European American men

PURPOSE

Smoking is a modifiable lifestyle factor that has not been established as a prostate cancer risk factor, nor emphasized in prostate cancer prevention. Studies have shown that African American (AA) smokers have a poorer cancer prognosis than European Americans (EAs), while having a lower prevalence of heavy smoking. We examined the relationship between cigarette smoking and prostate cancer aggressiveness and assessed racial differences in smoking habits on the probability of high-aggressive prostate cancer.

METHODS

Using data from the North Carolina-Louisiana Prostate Cancer Project (n = 1,279), prostate cancer aggressiveness was defined as high or low based on Gleason scores, serum prostate-specific antigen levels, and tumor stage. Cigarette smoking was categorized as current, former, or never smokers. Multivariable logistic regression was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Self-reported current (OR = 1.99; 95% CI 1.30-3.06) smoking was associated with high-aggressive prostate cancer relative to never smokers. When stratified by self-reported race, the odds of having high-aggressive cancer increased among AA current (OR = 3.58; 95% CI 2.04-6.28) and former smokers (OR = 2.21; 95% CI 1.38-3.53) compared to AA never smokers, but the odds were diminished among the EA stratum (Pself-reported race x smoking status = 0.003).

CONCLUSION

Cigarette smoking is associated with prostate cancer aggressiveness, a relationship modulated by self-reported race. Future research is needed to investigate types of cigarettes smoked and metabolic differences that may be contributing to the racial disparities observed.

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: findings from the International Tobacco Control (ITC) project

BACKGROUND

Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020.

METHODS

Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS).

RESULTS

Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%).

CONCLUSIONS

Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Effects of mint, menthol, and tobacco-flavored e-cigarettes on tobacco withdrawal symptoms in adults who smoke menthol cigarettes: A laboratory pilot study

BACKGROUND

Menthol cigarette smoking has remained stable or increased in certain groups, despite an overall decline in cigarette smoking rates in the U.S. Understanding whether e-cigarettes alter patterns of menthol cigarette use is critical to informing efforts for reducing the public health burden of menthol cigarette smoking. This 2019-2020 laboratory pilot study evaluated whether self-administration of mint-, menthol-, or tobacco-flavored e-cigarettes would differentially impact tobacco withdrawal symptoms in e-cigarette-naïve adults who smoke menthol cigarettes daily.

METHODS

Participants (N=17; 35.3% Female; mean age=51.8) attended three laboratory sessions after 16-hours of tobacco abstinence. Participants self-administered a study-provided JUUL e-cigarette (0.7mL with 5% nicotine by weight) at each session in which flavor was manipulated (mint vs. menthol vs. tobacco; order randomized). Participants completed pre- and post-e-cigarette administration self-report assessments on smoking urges, nicotine withdrawal, and positive and negative affect states. Multilevel linear regression models tested differences between the three flavor conditions for individual study outcomes.

RESULTS

Following overnight tobacco abstinence, vaping either a mint or menthol (vs. tobacco) flavored e-cigarette led to significantly greater reductions in smoking urges over time; menthol (vs. tobacco) flavored e-cigarettes also suppressed urges to smoke for pleasure. Notably, no differences in nicotine withdrawal, positive affect, or negative affect were observed.

CONCLUSIONS

In this laboratory pilot study, mint and menthol (vs. tobacco) flavored e-cigarettes provided some negative reinforcement effects via acute reductions in smoking urges during tobacco abstinence, yet only menthol flavored e-cigarettes demonstrated suppressive effects on smoking urges for pleasure in adults who smoke menthol cigarettes daily.

Testing Alpha-1 Antitrypsin Deficiency in Black Populations

Alpha-1 antitrypsin (AAT) deficiency (AATD) is an under-recognized hereditary disorder and a significant cause of chronic obstructive pulmonary disease (COPD), a disease that contributes to global mortality. AAT is encoded by the SERPINA1 gene, and severe mutation variants of this gene increase the risk of developing COPD. AATD is more frequently screened for in non-Hispanic White populations. However, AATD is also observed in other ethnic groups and very few studies have documented the mutation frequency in these other ethnic populations. Here, we review the current literature on AATD and allele frequency primarily in Black populations and discuss the possible clinical outcomes of low screening rates in a population that experiences poor health outcomes and whether the low frequency of AATD is related to a lack of screening in this population or a truly low frequency of mutations causing AATD. This review also outlines the harmful SERPINA1 variants, the current epidemiology knowledge of AATD, health inequity in Black populations, AATD prevalence in Black populations, the clinical implications of low screening of AATD in this population, and the possible dangers of not diagnosing or treating AATD.

Smoking cessation prevalence by menthol cigarette use and select demographics among adults in the United States, TUS-CPS, 2003-2019

People who smoke menthol cigarettes, particularly those who are non-Hispanic Black/African American, are less likely to achieve successful smoking cessation compared with people who smoke non-menthol cigarettes. This study examined the 2003-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) harmonized data to estimate cross-sectional trends in cigarette smoking cessation among U.S. adults, stratified by menthol cigarette use, race/ethnicity, sex, and age. The analytic sample included respondents who smoked for ≥ 2 years (current users and former users who reported quitting during the past year). We tested cessation trends using orthogonal polynomial contrasts for overall, menthol, and non-menthol smoking cessation prevalence and stratified by race/ethnicity, sex, and age in logistic regression models. We also analyzed the 2018-2019 non-harmonized TUS-CPS data among recent quitters to examine differences in characteristics (e.g., demographic characteristics, smoking frequency, use of smoking cessation aids, switching to other tobacco products) by menthol cigarette use. We observed significant linear changes in prevalence trends for overall cigarette smoking cessation, menthol smoking cessation, and non-menthol smoking cessation (p < 0.0001 for all linear trends), and changes in menthol cessation among non-Hispanic White and non-Hispanic Other race/ethnicity categories during 2003-2019. In the 2018-2019 wave, we observed differences in menthol status for sex, race/ethnicity, age, and educational attainment. We did not observe differences for other characteristics. We observed changes in overall cigarette smoking cessation, menthol, and non-menthol smoking cessation prevalence during the study period; however, gains in cigarette smoking cessation were not experienced among non-Hispanic Black/African American adults who smoke.