- Email: [email protected]
African American Adolescents and Menthol Cigarettes: Smoking Behavior Among Secondary School Students
Journal of Adolescent Health 43 (2008) 570–575
Original article
African American Adolescents and Menthol Cigarettes: Smoking Behavior Among Secondary School Students Jessica L. Muilenburg, Ph.D.a, and Jerome S. Legge, Jr, Ph.D.b,* a
Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia b School of Public and International Affairs, University of Georgia, Athens, Georgia Manuscript received June 5, 2008; manuscript accepted August 27, 2008
Abstract
Purpose: This paper examines the impact of smoking menthol cigarettes among secondary students, primarily African Americans, across five measures of smoking behavior. Methods: Data were gathered from a 2006 survey of six secondary schools in a large urban area in the southeastern United States. Ordered logit analysis is employed to estimate race and menthol effects on cigarette consumption. Results: African American youth smoke at lower rates than white adolescents; menthol smokers consume cigarettes at higher rates irrespective of race. Most importantly, there is a strong interaction effect with black menthol smokers demonstrating the highest levels of cigarette consumption. Conclusions: There is a need to provide adolescent and adult African Americans accurate information on the dangers of menthol cigarettes. Any proposed legislation should consider the special problems of menthol and its relationship to high cigarette consumption, especially for African American adolescents. Ó 2008 Society for Adolescent Medicine. All rights reserved.
Keywords:
Menthol cigarettes; African Americans; Adolescents; Tobacco legislation
Menthol cigarettes and their usage in the black community is of great importance, because over 70% of African American smokers prefer menthols compared to approximately 30% of white Americans [1]. As menthol cigarettes are marketed primarily to African Americans, the chief focus will be on that group. African Americans tend to smoke fewer cigarettes per day than whites, but the mentholated cigarettes that are utilized widely in the black community perhaps may partially account for African Americans suffering disproportionately from tobacco-related diseases such as hypertension, cancers, pregnancy-related problems, and cardiovascularrelated morbidities [2–6].It has been argued that the increased medical problems occurring among menthol cigarette smokers in the African American community can be traced to the significantly higher levels of nicotine, tar, carbon monoxide, and various carcinogenetic compounds found in the menthol brands. In explaining their consumption of menthol cigarettes, African Americans cite the ease of inhalation *Address correspondence to: Jerome S. Legge, Jr., Ph.D., School of Public and International Affairs, University of Georgia, 206 Candler Hall, Athens, GA 30602. E-mail address: [email protected]
and the ability to inhale more deeply in citing a preference for menthol brands. The deeper inhalation combined with higher carcinogenic compounds in menthols may help to explain the greater morbidity and mortality from tobacco-related illness for blacks, even though adolescent blacks smoke less than whites [7,8]. African American youth are an especially important group to consider. Although black youth smoke at lower rates than white teenagers, this disparity evaporates as adulthood is attained [9]. Along with women and African Americans, adolescents are the third target for menthol cigarettes by tobacco companies [6]. The data presented in a Surgeon General’s Report [6] documents increases in menthol smoking among African American and Latino youth during the 1990s compared to whites. Perhaps this trend can be partially explained by the large marketing efforts of tobacco companies that promoted menthols as being ‘‘sophisticated’’ or ‘‘cool,’’ particularly in African American urban communities [6,10–13]. It is possible that the young may be especially vulnerable to such messages. This paper utilizes a sample of secondary school students from a major southeastern city to examine the impact of menthol cigarettes on various measures of smoking behavior.
1054-139X/08/$ – see front matter Ó 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.08.017
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
The major purpose is to analyze data on African American adolescent smoking, particularly the role of menthol in cigarette consumption. We test three hypotheses. First, we hypothesize that African American youth will exhibit lower smoking levels than white adolescents. Second, menthol smokers will have higher levels of cigarette consumption than those who smoke other brands. Third, and most importantly, we hypothesize a strong interaction effect between race and menthols as they relate to the incidence of smoking. We expect, specifically, that African American adolescent smokers will increase consumption levels over and above whites if they smoke menthol cigarettes. Methods The instrument is based on the National Youth Tobacco Survey, which has been employed by the Centers for Disease Control and Prevention to collect smoking data. There were additional tobacco-related questions from the agency’s Question Inventory on Tobacco. The University of Mississippi Medical Center institutional review board granted their approval of the survey. Letters were sent to the parents of the students to inform them of the study. Parents could request that their child not participate, and after the school was notified, they simply did not complete a questionnaire. This is also true of students who elected on their own not to participate. The questionnaire was administered during a designated class period. A pencil-and-paper methodology was employed. The completion time was approximately 30 minutes. After completion, the research team immediately gathered the questionnaires and removed them from school grounds. The 2006 survey is part of a larger study to investigate smoking behavior among African American youth. Five public schools were within the city of interest and contained large numbers of African American students. One additional majority white public school was in a suburban location. Thus, the sample consists of 4336 middle and high school students gathered from six public institutions in a large southeastern metropolitan area. As is the case in similar studies, we are interested primarily in those students who use or have at least experimented with cigarette smoking [14,15]. We eliminated all who never smoked at all. These individuals consist of those who have never taken even a puff on a cigarette. Also, because there are small numbers of Native American, Asian American/Pacific Islander, and Latino students, these youth were eliminated from the analysis. The final model involves a contrast between black and white smokers. After the nonsmokers and other ethnic groups were eliminated, a sample of 2068 remained. Basic demographic and attitudinal data are separated into control, main effects, and dependent variables. These data are presented in Table 1 with relevant coding. Based upon the smoking environment, the sample might be termed as ‘‘high risk’’ for acquiring cigarette smoking. A large percentage (51%) have been suspended or expelled
571
Table 1 Variable distribution and codes Control variables Variable name Gender Male (0) Female (1)
Values
Percentage
990 1,071 2,061
48.0% 52.0% 100.0%
Age 12 or younger (1) 13 (2) 14 (3) 15 (4) 16 (5) 17 (6) 18 (7) 19 and over (8)
5 0.2% 2 0.1% 276 13.4% 554 26.8% 557 27.0% 472 22.9% 175 8.5% 22 1.1% 2,063 100.0% Have you ever been suspended or expelled from school? No (0) 1,010 49.0% 1,049 51.0% Yes (1) 2,059 100.0% Have you ever seen your parents or guardian smoke cigarettes? No (0) 898 43.6% 1,162 56.4% Yes (1) 2,060 100.0% Do you have any friends who smoke? No (0) 226 11.1% 1,833 88.9% Yes (1) 2,059 100.0% Who is allowed to smoke in your home? Anyone can smoke (0) 1,048 51.0% Adults only (1) 786 38.3% 220 10.7% No one (2) 2,054 100.0% How much do you agree with this statement: smoking is dangerous to my health. Strongly disagree (0) 32 1.5% Disagree (1) 64 3.1% Agree (2) 635 31.0% 1,321 64.4% Strongly agree (3) 2,052 100.0% Main effects Race White (0) 558 27.0% 1,510 73.0% African American (1) 2,068 100.0% Are the cigarettes you usually smoke menthol cigarettes? Other brand (0) 1,685 81.4% 383 18.6% Menthol (1) 2,068 100.0% Dependent variables Variable name
Values
Percentage
About how many cigarettes have you smoked in your entire life? None (0) 257 12.6% Never a whole cigarette (1) 654 32.0% 1 Cigarette (2) 132 6.5% 2–5 Cigarettes (3) 351 17.2% 6–15 Cigarettes (4) 170 8.3% 16–25 Cigarettes (5) 96 4.7% 26–99 Cigarettes (6) 118 5.8% 263 12.9% 100 or more cigarettes (7) 2,041 100.0% (Continued )
572
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
Table 1 Variable distribution and codes (Continued ) Dependent variables Variable name
Values
Percentage
During the past 30 days, on how many days did you smoke cigarettes? 0 days (0) 1,446 71.4% 1 or 2 days (1) 141 7.0% 3 to 5 days (2) 100 4.9% 6 to 9 days (3) 232 11.5% 10 to 19 days (4) 62 3.1% 20 to 29 days (5) 23 1.1% 21 1.0% all 30 days (6) 2,025 100.0% During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day? Did not smoke (0) 1,446 71.4% Less than 1 a day (1) 141 7.0% 1 a day (2) 100 4.9% 2 to 5 a day (3) 232 11.5% 6 to 10 a day (4) 62 3.1% 11 to 20 a day (5) 23 1.1% 21 1.0% More than 20 a day (6) 2,025 100.0% When was the last time you smoked a cigarette, even one or two puffs? Have not smoked (0) 376 18.6% 5 or more years ago (1) 305 15.1% 1 to 4 years ago (2) 401 19.8% Not past 6 months but past year (3) 179 8.9% Not during past 30 days but some time during 205 10.1% past 6 months (4) Not during past 7 days but during past 30 days 112 5.5% (5) Not today but past 7 days (6) 236 11.7% 208 10.3% Earlier today (7) 2,022 100.0% Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days? No (0) 1,679 82.1% 367 17.9% Yes (1) 2,046 100.0%
from school, a majority live in a household where at least one parent smokes, nearly all have close friends who smoke, and a majority of the households permit anyone to smoke within the home. In contrast, 95.4% of all students agree or strongly agree with the statement that ‘‘smoking is dangerous.’’ African Americans comprise 73% of the sample, and 18.6 % of all students have smoked menthol cigarettes. Of the 383 students who have smoked menthols, 73% (287) are African Americans. (This relationship is not shown in Table 1.) The dependent variables consist of five types of smoking behavior: how many cigarettes the youth has consumed in a lifetime, the number of days an individual has smoked in the last month, the number of cigarettes consumed the previous month, the last time smoked, and whether or not the student has ever smoked daily. It should be emphasized that for the multivariate analysis, all individuals with experience of any type of cigarette smoking are included. So it is possible for someone to have smoked, consuming even a portion of a cigarette, to be included in the dependent variables of total
cigarettes in a lifetime, and the amount of days and cigarettes smoked in the last month. For the last time smoked ‘‘have not smoked’’ is a possible category because the individual may not consider experimentation with one or even several cigarettes as ‘‘smoking.’’ We are especially interested in the interaction of menthol cigarettes with race. In line with the scholarly work we have reviewed, we expect African Americans to have a lower level of smoking compared to whites. This hypothesis is generated partially because African American parents have been found to be stricter in prohibiting smoking among their children; also, African American youth have fewer financial resources to purchase tobacco products. We also suspect a relationship between menthol cigarettes and the level of smoking. Because of the possibly greater addictive qualities of menthol cigarettes, and the apparent greater ease and depth of inhalation, we hypothesize that menthol cigarette use will be independently and positively related to the incidence of smoking [1,6,8,9]. Finally, we also expect a strong interaction effect between race and the incidence of smoking. African American adolescents will smoke less than white teens if menthol cigarettes are not their brand of choice, but black consumption will rise if menthol cigarettes are selected. We expect the evidence to suggest that smoking patterns are reversed, with African American youth smoking outpacing whites. To specify the model more fully, we introduce a number of control variables that also might help explain adolescent cigarette consumption. One alternative factor may be gender. In terms of adolescent smoking, the habit has increased among females. The ‘‘gender gap’’ in smoking has narrowed, with young women catching up with adolescent men [16]. Although behavior is becoming similar, we still anticipate that the males will exhibit greater cigarette consumption than females. Age is a second control variable. The literature has demonstrated that most individuals who take up smoking initiate the habit by age 18. Thus, smoking is learned in the adolescent years. Although the rate of cigarette use has leveled off among teenagers, especially after 2000 [6], we hypothesize that it will rise as age increases, simply because the opportunity to smoke becomes greater with each year. Further, a youth at age 17 is likely to have easier access to cigarettes than an 11 or 12 year old. Suspension/expulsion from school is the third control variable. We believe that smoking incidence will be more prevalent among those with disciplinary problems than others. Suspension may be illustrative of difficulty with adult authorities who may discourage social norm violations such as youth smoking. Other control variables measure the smoking environment and the signals the youth receives regarding smoking. Adolescents are likely to be influenced both by parental and peer smoking behavior [17]. Furthermore, if parents restrict cigarette use in the home, youth will face more pressure to conform and will have fewer smoking opportunities. If parents smoke, the adolescent is more likely to be addicted
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
to cigarettes; if the youth has close friends who are smokers, he/she is more apt to acquire the habit. In contrast, if adolescents believe that smoking is ‘‘dangerous to one’s health,’’ he/she would be less likely to smoke. In summary, the model for the dependent variables may be expressed as follows: Y ¼ (f) (Gender, Age, Suspension, Parents Smoke, Friends Smoke, Home Restrictions, Smoking is Dangerous, Menthol Smoker, Black/White Binary, Black/White Binary 3 Menthol Smoker) Results Main and interaction effects The findings are presented in Table 2. Because the dependent variables are not continuous, we employ an ordered logit technique as described in the STATA software package [18]. Ordered logit relaxes the linearity assumption of ordinary least-squares regression and assures more accurate estimates of the coefficients. The race and menthol variables behave as hypothesized. The main effects of race and menthol are both significant and in the anticipated directions. The proportional odds ratios indicate that the African American adolescents are anywhere from .098 to .151 less likely to fall into the highest smoking categories compared to whites. In contrast, menthol smokers, independent of race, exhibit high risk levels, which range from 3.22 to 5.35. But the most interesting finding appears when menthol and race are interacted. The interaction term essentially separates African American menthol cigarette smokers from whites and recomputes their risk for falling into higher levels of consumption. Black students, who smoke at lower rates than whites, greatly accelerate their cigarette consumption when their brand of choice contains menthol. These African American menthol users are anywhere from 1.66 to 3.46 more likely to fall into a higher category of cigarette consumption than whites. This suggests, very strongly, that smoking menthol cigarettes damages the initial advantage black youth have over whites in terms of their lower rate of smoking in general. Controls The control variables are necessary to assure a complete model specification, but also are interesting in their own right in understanding adolescent smoking. Age, as hypothesized, is associated with heavier smoking except for the last time smoked. There are significant differences between the young men and women in cigarette consumption for three dependent variables; these are: the number of days smoked in a month, the number of cigarettes consumed during the same time period, and daily smoking. In these instances, as hypothesized, males smoke more than females. For other dependent variables, male and female smoking is similar. Disciplinary problems, as measured by school suspension/ expulsion, are associated with all smoking measures. Taken collectively, those who have been suspended/expelled have
573
approximately a 1.5 times greater risk (on average) of falling into the highest categories of smoking than others, with all other variables in the model held constant. The data indicate that parental smoking behavior does not impact the adolescents in this sample as none of the coefficients are significant; however, adolescents with close friends who smoke have considerably greater odds of being in a high smoking category. The ranges are from 2.12 to 4.07. The only exception is the ‘‘ever smoked daily’’ dependent variable, which is in the same direction but insignificant. Rather than by their own smoking behavior, parents do show effectiveness by their imposing home restrictions. The more restrictive the home, the lower the odds of the adolescent falling into a high smoking category, across all dependent variables. This finding agrees with other important literature that has documented less smoking in a restrictive home environment [19,20]. The final control variable indicates that those who believe that smoking is dangerous are considerably less likely to smoke. Discussion Menthol cigarettes have become a central part of many African American communities’ cultures. As is the case of this survey, Newport is the most preferred brand by a wide margin. Among Americans of all ethnicities, menthols account for 25% of the cigarette market [21]. But the races consume menthol disproportionately. Approximately 70% of African American smokers prefer menthols compared to only 30% of whites [1]. There are two possible reasons for this imbalance. The first is the intense marketing of menthol cigarettes in the African American community [1,10,13]. Black Americans are exposed more often to the menthol brands through advertising. In addition, the tobacco companies that sell menthol cigarettes have contributed heavily to African American community organizations, and black institutions of higher education [1,7]. Finally, tobacco companies were among the first corporations to hire African Americans as executives. A second explanation for higher African American use of menthol cigarettes may be genetic [11]. In addition to the intense marketing, African Americans may have a higher propensity to consume menthol products, independent of advertising. Although the genetic explanation is still in its infancy in terms of development, more research is needed on the possibility of genetic effects and a special African American susceptibility to menthol. This study has found that when youth are aware of the dangers of tobacco, they are more likely to shun cigarette smoking. But more specific information has to be disseminated on menthol products because of their special danger to the black community as well as others. For example, many menthol cigarette smokers utilize these products because they are believed to be lower in tar and nicotine, which they are not [22,23]. The higher cotine levels present in the blood of African Americans, compared to whites, is
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J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
Table 2 Ordered logit: estimates of smoking behavior (odds ratios)
Main effects Black/white Binary Menthol smoker Interaction effect Race 3 menthol Controls Age Gender Suspended from school Parents smoke Friends smoke Home restrictions Smoking is dangerous N Pseudo R2 Chi-square
Total cigs. Smoked ever
Days smoked In month
Cigs. smoked in month
Last time Smoked
Ever Smoked Daily
0.098*** (19.39) 4.35*** (6.38)
0.129*** (13.93) 5.35*** (7.59)
0.114*** (14.37) 4.58*** (6.90)
0.151*** (16.91) 3.22*** (5.56)
0.114*** (11.63) 3.41*** (4.75)
1.66* (1.95)
1.95*** (2.57)
2.39*** (3.34)
3.46*** (5.12)
2.10*** (2.33)
1.12*** (3.39) 0.971 (0.35) 1.52*** (4.77) 0.991 (0.10) 2.12*** (5.49) 0.777*** (3.59) 0.564*** (8.01) 1988 0.127 948.45***
1.25*** (4.82) 0.818* (1.78) 1.50*** (3.33) 0.961 (0.032) 4.07*** (4.26) 0.693*** (4.11) 0.461*** (8.98) 1983 0.183 788.44***
1.24*** (4.61) 0.772** (2.26) 1.51*** (3.27) 0.881 (1.00) 3.37*** (3.77) 0.688*** (4.16) 0.465*** (9.03) 1975 0.194 775.16 ***
0.966(1.01) 1.07 (0.79) 1.30*** (3.07) 1.03 (0.32) 2.19*** (5.92) 0.830*** (2.71) 0.616*** (6.69) 1972 0.106 835.48***
1.33*** (4.90) 0.783* (1.74) 1.72*** (3.54) 1.02 (0.10) 1.53 (1.24) 0.597*** (4.80) 0.523*** (6.16) 1992 0.257 472.82***
Z scores in parentheses. *** p .01. ** p .05. * p .10.
largely unexplained but could be because of the higher menthol consumption, especially because black youth smoke less than whites of a similar age. There is also a strong possibility that the tobacco companies manipulate menthol content levels in cigarettes both to entice adolescents to begin the habit and to maintain nicotine dependence in older smokers [24]. In this article, we have presented evidence similar to other studies that suggest strongly that menthol cigarettes are a special and dangerous problem within the African American community. Because African Americans consume so much of the menthol products, exempting menthols from any current or future legislation or regulation is tantamount to separating African American smoking and its consequences from other citizens. The chief limitation of the survey is its voluntary nature. Because of the need to protect confidentiality and other logistical problems, we were not able to conduct surveys based on a random sampling technique in any school. But our methodology did produce a large sample size, which may not have been attained through a random survey. Several parents did call to determine the nature of the survey, but none objected to their child participating. However, we did have to rely on the good will of the students to complete the instruments. We do not have an exact determination of how many students refused to complete the questionnaires and why. Nor is it possible to determine whether smokers or nonsmokers were more inclined not to complete the survey. However, we have collected a large sample of students and attained approximate proportions of African Americans and whites as they are represented in the general population of these schools. Further, the proportion of menthol cigarettes utilized in this population, compared to other surveys is in the general expected usage rate, especially among African Americans.
References [1] Gardiner PS. The African Americanization of menthol cigarettes in the United States. Nicotine Tob Res 2004;6(Suppl 1):S55–65. [2] Benowitz N. Smoking cessation trials targeted to racial and economic minority groups. JAMA 1988;288:497–9. [3] Harris RE, Zang EA, Anderson JI, et al. Race and sex differences in lung cancer risk associated with cigarette smoking. Int J Epidemiol 1993;22:592–9. [4] Herbert JR, Kabat GC. Menthol cigarette smoking and esophageal cancer. Int J Epidemiol 1989;18:37–44. [5] Savitz DA, Dole N, Terry JW Jr, et al. Smoking and pregnancy outcome among African-American and white women in central North Carolina. Epidemiology 2001;12:636–42. [6] Tobacco Use among U.S. Racial/Ethnic Minority Groups. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention and Health Promotion, Office on Smoking and Health, 1998. [7] Henningfield JE, Djordjevic MV. Menthol cigarettes: research needs and challenges. Nicotine Tob Res 2004;6(Suppl 1):S11–6. [8] Hymowitz N, Mouton C, Edkholdt H. Menthol cigarette smoking in African Americans and whites. Tob Control 1995;4:194–5. [9] Ellickson PL, Orlando M, Tucker JS, et al. From adolescence to young adulthood: racial/ethnic disparities in smoking. Am J Public Health 2004;94:293–9. [10] Balbach ED, Gasior RJ, Barbeau EM. R.J. Reynold’s targeting of African-Americans: 1988–2000. Am J Public Health 2003;93:822–7. [11] Shields AE, Fortun M, Hammonds EM, et al. The use of race variables in genetic studies of complex traits and the goal of reducing health disparities: a transdisciplinary perspective. Am Psychol 2005;60:77–103. [12] Stillman FA, Bone L, Avila-Tang E, et al. Barriers to smoking cessation in inner-city African American young adults. Am J Public Health 2007;97:1405–8. [13] Sutton CD, Robinson RG. The marketing of menthol cigarettes in the United States: populations, messages, and channels. Nicotine Tob Res 2004;6(Suppl 1):S83–91. [14] Collins CC, Moolchan ET. Shorter time to first cigarette of the day in menthol adolescent cigarette smokers. Addict Behav 2005;31:1460–4. [15] Pletcher MJ, Hulley BJ, Houston T, et al. Menthol cigarettes, smoking cessation, artherosclerosis, and pulmonary function. Arch Intern Med 2006;166:1915–22.
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575 [16] Perkins KA. Smoking cessation in women. Special considerations. CNS Drugs 2001;15:391–411. [17] Scragg R, Laugesen M. Influence of smoking by family and best friend on adolescent tobacco smoking: results from the 2002 New Zealand National Survey of year 10 students. Aust N Z J Public Health 2007;3:217–23. [18] STATA 10 Reference Manual. Volume 2. College Station, TX: Stata Press, 2007. [19] Farkas AJ, Gilpin EA, Distefan JM, et al. The effects of household and workplace smoking restrictions on quitting behaviors. Tob Control 1999;8:261–5. [20] Farkas AJ, Gilpin EA, White MM, et al. Association between household and workplace smoking restrictions and adolescent smoking. JAMA 2000;284:717–22.
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[21] Clark PI, Gardiner PS, Djordjevic MV, et al. Menthol cigarettes: setting the research agenda. Nicotine Tob Res 2004;6(Suppl 1):S5–9. [22] Muscat JE, Richie JP Jr, Stellman SD. Mentholated cigarettes and smoking habits in whites and blacks. Tob Control 2002; 11:368–71. [23] Richter P, Beistle D, Pederson L, et al. Small-group discussions on menthol cigarettes: listening to adult African American smokers in Atlanta, Georgia. Ethn Health 2008;13:171–82. [24] Kreslake JM, Wayne GF, Alpert HR, et al. Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults. Am J Public Health 2008;98:1685–92.
Original article
African American Adolescents and Menthol Cigarettes: Smoking Behavior Among Secondary School Students Jessica L. Muilenburg, Ph.D.a, and Jerome S. Legge, Jr, Ph.D.b,* a
Department of Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia b School of Public and International Affairs, University of Georgia, Athens, Georgia Manuscript received June 5, 2008; manuscript accepted August 27, 2008
Abstract
Purpose: This paper examines the impact of smoking menthol cigarettes among secondary students, primarily African Americans, across five measures of smoking behavior. Methods: Data were gathered from a 2006 survey of six secondary schools in a large urban area in the southeastern United States. Ordered logit analysis is employed to estimate race and menthol effects on cigarette consumption. Results: African American youth smoke at lower rates than white adolescents; menthol smokers consume cigarettes at higher rates irrespective of race. Most importantly, there is a strong interaction effect with black menthol smokers demonstrating the highest levels of cigarette consumption. Conclusions: There is a need to provide adolescent and adult African Americans accurate information on the dangers of menthol cigarettes. Any proposed legislation should consider the special problems of menthol and its relationship to high cigarette consumption, especially for African American adolescents. Ó 2008 Society for Adolescent Medicine. All rights reserved.
Keywords:
Menthol cigarettes; African Americans; Adolescents; Tobacco legislation
Menthol cigarettes and their usage in the black community is of great importance, because over 70% of African American smokers prefer menthols compared to approximately 30% of white Americans [1]. As menthol cigarettes are marketed primarily to African Americans, the chief focus will be on that group. African Americans tend to smoke fewer cigarettes per day than whites, but the mentholated cigarettes that are utilized widely in the black community perhaps may partially account for African Americans suffering disproportionately from tobacco-related diseases such as hypertension, cancers, pregnancy-related problems, and cardiovascularrelated morbidities [2–6].It has been argued that the increased medical problems occurring among menthol cigarette smokers in the African American community can be traced to the significantly higher levels of nicotine, tar, carbon monoxide, and various carcinogenetic compounds found in the menthol brands. In explaining their consumption of menthol cigarettes, African Americans cite the ease of inhalation *Address correspondence to: Jerome S. Legge, Jr., Ph.D., School of Public and International Affairs, University of Georgia, 206 Candler Hall, Athens, GA 30602. E-mail address: [email protected]
and the ability to inhale more deeply in citing a preference for menthol brands. The deeper inhalation combined with higher carcinogenic compounds in menthols may help to explain the greater morbidity and mortality from tobacco-related illness for blacks, even though adolescent blacks smoke less than whites [7,8]. African American youth are an especially important group to consider. Although black youth smoke at lower rates than white teenagers, this disparity evaporates as adulthood is attained [9]. Along with women and African Americans, adolescents are the third target for menthol cigarettes by tobacco companies [6]. The data presented in a Surgeon General’s Report [6] documents increases in menthol smoking among African American and Latino youth during the 1990s compared to whites. Perhaps this trend can be partially explained by the large marketing efforts of tobacco companies that promoted menthols as being ‘‘sophisticated’’ or ‘‘cool,’’ particularly in African American urban communities [6,10–13]. It is possible that the young may be especially vulnerable to such messages. This paper utilizes a sample of secondary school students from a major southeastern city to examine the impact of menthol cigarettes on various measures of smoking behavior.
1054-139X/08/$ – see front matter Ó 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.08.017
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
The major purpose is to analyze data on African American adolescent smoking, particularly the role of menthol in cigarette consumption. We test three hypotheses. First, we hypothesize that African American youth will exhibit lower smoking levels than white adolescents. Second, menthol smokers will have higher levels of cigarette consumption than those who smoke other brands. Third, and most importantly, we hypothesize a strong interaction effect between race and menthols as they relate to the incidence of smoking. We expect, specifically, that African American adolescent smokers will increase consumption levels over and above whites if they smoke menthol cigarettes. Methods The instrument is based on the National Youth Tobacco Survey, which has been employed by the Centers for Disease Control and Prevention to collect smoking data. There were additional tobacco-related questions from the agency’s Question Inventory on Tobacco. The University of Mississippi Medical Center institutional review board granted their approval of the survey. Letters were sent to the parents of the students to inform them of the study. Parents could request that their child not participate, and after the school was notified, they simply did not complete a questionnaire. This is also true of students who elected on their own not to participate. The questionnaire was administered during a designated class period. A pencil-and-paper methodology was employed. The completion time was approximately 30 minutes. After completion, the research team immediately gathered the questionnaires and removed them from school grounds. The 2006 survey is part of a larger study to investigate smoking behavior among African American youth. Five public schools were within the city of interest and contained large numbers of African American students. One additional majority white public school was in a suburban location. Thus, the sample consists of 4336 middle and high school students gathered from six public institutions in a large southeastern metropolitan area. As is the case in similar studies, we are interested primarily in those students who use or have at least experimented with cigarette smoking [14,15]. We eliminated all who never smoked at all. These individuals consist of those who have never taken even a puff on a cigarette. Also, because there are small numbers of Native American, Asian American/Pacific Islander, and Latino students, these youth were eliminated from the analysis. The final model involves a contrast between black and white smokers. After the nonsmokers and other ethnic groups were eliminated, a sample of 2068 remained. Basic demographic and attitudinal data are separated into control, main effects, and dependent variables. These data are presented in Table 1 with relevant coding. Based upon the smoking environment, the sample might be termed as ‘‘high risk’’ for acquiring cigarette smoking. A large percentage (51%) have been suspended or expelled
571
Table 1 Variable distribution and codes Control variables Variable name Gender Male (0) Female (1)
Values
Percentage
990 1,071 2,061
48.0% 52.0% 100.0%
Age 12 or younger (1) 13 (2) 14 (3) 15 (4) 16 (5) 17 (6) 18 (7) 19 and over (8)
5 0.2% 2 0.1% 276 13.4% 554 26.8% 557 27.0% 472 22.9% 175 8.5% 22 1.1% 2,063 100.0% Have you ever been suspended or expelled from school? No (0) 1,010 49.0% 1,049 51.0% Yes (1) 2,059 100.0% Have you ever seen your parents or guardian smoke cigarettes? No (0) 898 43.6% 1,162 56.4% Yes (1) 2,060 100.0% Do you have any friends who smoke? No (0) 226 11.1% 1,833 88.9% Yes (1) 2,059 100.0% Who is allowed to smoke in your home? Anyone can smoke (0) 1,048 51.0% Adults only (1) 786 38.3% 220 10.7% No one (2) 2,054 100.0% How much do you agree with this statement: smoking is dangerous to my health. Strongly disagree (0) 32 1.5% Disagree (1) 64 3.1% Agree (2) 635 31.0% 1,321 64.4% Strongly agree (3) 2,052 100.0% Main effects Race White (0) 558 27.0% 1,510 73.0% African American (1) 2,068 100.0% Are the cigarettes you usually smoke menthol cigarettes? Other brand (0) 1,685 81.4% 383 18.6% Menthol (1) 2,068 100.0% Dependent variables Variable name
Values
Percentage
About how many cigarettes have you smoked in your entire life? None (0) 257 12.6% Never a whole cigarette (1) 654 32.0% 1 Cigarette (2) 132 6.5% 2–5 Cigarettes (3) 351 17.2% 6–15 Cigarettes (4) 170 8.3% 16–25 Cigarettes (5) 96 4.7% 26–99 Cigarettes (6) 118 5.8% 263 12.9% 100 or more cigarettes (7) 2,041 100.0% (Continued )
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Table 1 Variable distribution and codes (Continued ) Dependent variables Variable name
Values
Percentage
During the past 30 days, on how many days did you smoke cigarettes? 0 days (0) 1,446 71.4% 1 or 2 days (1) 141 7.0% 3 to 5 days (2) 100 4.9% 6 to 9 days (3) 232 11.5% 10 to 19 days (4) 62 3.1% 20 to 29 days (5) 23 1.1% 21 1.0% all 30 days (6) 2,025 100.0% During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day? Did not smoke (0) 1,446 71.4% Less than 1 a day (1) 141 7.0% 1 a day (2) 100 4.9% 2 to 5 a day (3) 232 11.5% 6 to 10 a day (4) 62 3.1% 11 to 20 a day (5) 23 1.1% 21 1.0% More than 20 a day (6) 2,025 100.0% When was the last time you smoked a cigarette, even one or two puffs? Have not smoked (0) 376 18.6% 5 or more years ago (1) 305 15.1% 1 to 4 years ago (2) 401 19.8% Not past 6 months but past year (3) 179 8.9% Not during past 30 days but some time during 205 10.1% past 6 months (4) Not during past 7 days but during past 30 days 112 5.5% (5) Not today but past 7 days (6) 236 11.7% 208 10.3% Earlier today (7) 2,022 100.0% Have you ever smoked cigarettes daily, that is, at least one cigarette every day for 30 days? No (0) 1,679 82.1% 367 17.9% Yes (1) 2,046 100.0%
from school, a majority live in a household where at least one parent smokes, nearly all have close friends who smoke, and a majority of the households permit anyone to smoke within the home. In contrast, 95.4% of all students agree or strongly agree with the statement that ‘‘smoking is dangerous.’’ African Americans comprise 73% of the sample, and 18.6 % of all students have smoked menthol cigarettes. Of the 383 students who have smoked menthols, 73% (287) are African Americans. (This relationship is not shown in Table 1.) The dependent variables consist of five types of smoking behavior: how many cigarettes the youth has consumed in a lifetime, the number of days an individual has smoked in the last month, the number of cigarettes consumed the previous month, the last time smoked, and whether or not the student has ever smoked daily. It should be emphasized that for the multivariate analysis, all individuals with experience of any type of cigarette smoking are included. So it is possible for someone to have smoked, consuming even a portion of a cigarette, to be included in the dependent variables of total
cigarettes in a lifetime, and the amount of days and cigarettes smoked in the last month. For the last time smoked ‘‘have not smoked’’ is a possible category because the individual may not consider experimentation with one or even several cigarettes as ‘‘smoking.’’ We are especially interested in the interaction of menthol cigarettes with race. In line with the scholarly work we have reviewed, we expect African Americans to have a lower level of smoking compared to whites. This hypothesis is generated partially because African American parents have been found to be stricter in prohibiting smoking among their children; also, African American youth have fewer financial resources to purchase tobacco products. We also suspect a relationship between menthol cigarettes and the level of smoking. Because of the possibly greater addictive qualities of menthol cigarettes, and the apparent greater ease and depth of inhalation, we hypothesize that menthol cigarette use will be independently and positively related to the incidence of smoking [1,6,8,9]. Finally, we also expect a strong interaction effect between race and the incidence of smoking. African American adolescents will smoke less than white teens if menthol cigarettes are not their brand of choice, but black consumption will rise if menthol cigarettes are selected. We expect the evidence to suggest that smoking patterns are reversed, with African American youth smoking outpacing whites. To specify the model more fully, we introduce a number of control variables that also might help explain adolescent cigarette consumption. One alternative factor may be gender. In terms of adolescent smoking, the habit has increased among females. The ‘‘gender gap’’ in smoking has narrowed, with young women catching up with adolescent men [16]. Although behavior is becoming similar, we still anticipate that the males will exhibit greater cigarette consumption than females. Age is a second control variable. The literature has demonstrated that most individuals who take up smoking initiate the habit by age 18. Thus, smoking is learned in the adolescent years. Although the rate of cigarette use has leveled off among teenagers, especially after 2000 [6], we hypothesize that it will rise as age increases, simply because the opportunity to smoke becomes greater with each year. Further, a youth at age 17 is likely to have easier access to cigarettes than an 11 or 12 year old. Suspension/expulsion from school is the third control variable. We believe that smoking incidence will be more prevalent among those with disciplinary problems than others. Suspension may be illustrative of difficulty with adult authorities who may discourage social norm violations such as youth smoking. Other control variables measure the smoking environment and the signals the youth receives regarding smoking. Adolescents are likely to be influenced both by parental and peer smoking behavior [17]. Furthermore, if parents restrict cigarette use in the home, youth will face more pressure to conform and will have fewer smoking opportunities. If parents smoke, the adolescent is more likely to be addicted
J.L. Muilenburg and J.S. Legge Jr., / Journal of Adolescent Health 43 (2008) 570–575
to cigarettes; if the youth has close friends who are smokers, he/she is more apt to acquire the habit. In contrast, if adolescents believe that smoking is ‘‘dangerous to one’s health,’’ he/she would be less likely to smoke. In summary, the model for the dependent variables may be expressed as follows: Y ¼ (f) (Gender, Age, Suspension, Parents Smoke, Friends Smoke, Home Restrictions, Smoking is Dangerous, Menthol Smoker, Black/White Binary, Black/White Binary 3 Menthol Smoker) Results Main and interaction effects The findings are presented in Table 2. Because the dependent variables are not continuous, we employ an ordered logit technique as described in the STATA software package [18]. Ordered logit relaxes the linearity assumption of ordinary least-squares regression and assures more accurate estimates of the coefficients. The race and menthol variables behave as hypothesized. The main effects of race and menthol are both significant and in the anticipated directions. The proportional odds ratios indicate that the African American adolescents are anywhere from .098 to .151 less likely to fall into the highest smoking categories compared to whites. In contrast, menthol smokers, independent of race, exhibit high risk levels, which range from 3.22 to 5.35. But the most interesting finding appears when menthol and race are interacted. The interaction term essentially separates African American menthol cigarette smokers from whites and recomputes their risk for falling into higher levels of consumption. Black students, who smoke at lower rates than whites, greatly accelerate their cigarette consumption when their brand of choice contains menthol. These African American menthol users are anywhere from 1.66 to 3.46 more likely to fall into a higher category of cigarette consumption than whites. This suggests, very strongly, that smoking menthol cigarettes damages the initial advantage black youth have over whites in terms of their lower rate of smoking in general. Controls The control variables are necessary to assure a complete model specification, but also are interesting in their own right in understanding adolescent smoking. Age, as hypothesized, is associated with heavier smoking except for the last time smoked. There are significant differences between the young men and women in cigarette consumption for three dependent variables; these are: the number of days smoked in a month, the number of cigarettes consumed during the same time period, and daily smoking. In these instances, as hypothesized, males smoke more than females. For other dependent variables, male and female smoking is similar. Disciplinary problems, as measured by school suspension/ expulsion, are associated with all smoking measures. Taken collectively, those who have been suspended/expelled have
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approximately a 1.5 times greater risk (on average) of falling into the highest categories of smoking than others, with all other variables in the model held constant. The data indicate that parental smoking behavior does not impact the adolescents in this sample as none of the coefficients are significant; however, adolescents with close friends who smoke have considerably greater odds of being in a high smoking category. The ranges are from 2.12 to 4.07. The only exception is the ‘‘ever smoked daily’’ dependent variable, which is in the same direction but insignificant. Rather than by their own smoking behavior, parents do show effectiveness by their imposing home restrictions. The more restrictive the home, the lower the odds of the adolescent falling into a high smoking category, across all dependent variables. This finding agrees with other important literature that has documented less smoking in a restrictive home environment [19,20]. The final control variable indicates that those who believe that smoking is dangerous are considerably less likely to smoke. Discussion Menthol cigarettes have become a central part of many African American communities’ cultures. As is the case of this survey, Newport is the most preferred brand by a wide margin. Among Americans of all ethnicities, menthols account for 25% of the cigarette market [21]. But the races consume menthol disproportionately. Approximately 70% of African American smokers prefer menthols compared to only 30% of whites [1]. There are two possible reasons for this imbalance. The first is the intense marketing of menthol cigarettes in the African American community [1,10,13]. Black Americans are exposed more often to the menthol brands through advertising. In addition, the tobacco companies that sell menthol cigarettes have contributed heavily to African American community organizations, and black institutions of higher education [1,7]. Finally, tobacco companies were among the first corporations to hire African Americans as executives. A second explanation for higher African American use of menthol cigarettes may be genetic [11]. In addition to the intense marketing, African Americans may have a higher propensity to consume menthol products, independent of advertising. Although the genetic explanation is still in its infancy in terms of development, more research is needed on the possibility of genetic effects and a special African American susceptibility to menthol. This study has found that when youth are aware of the dangers of tobacco, they are more likely to shun cigarette smoking. But more specific information has to be disseminated on menthol products because of their special danger to the black community as well as others. For example, many menthol cigarette smokers utilize these products because they are believed to be lower in tar and nicotine, which they are not [22,23]. The higher cotine levels present in the blood of African Americans, compared to whites, is
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Table 2 Ordered logit: estimates of smoking behavior (odds ratios)
Main effects Black/white Binary Menthol smoker Interaction effect Race 3 menthol Controls Age Gender Suspended from school Parents smoke Friends smoke Home restrictions Smoking is dangerous N Pseudo R2 Chi-square
Total cigs. Smoked ever
Days smoked In month
Cigs. smoked in month
Last time Smoked
Ever Smoked Daily
0.098*** (19.39) 4.35*** (6.38)
0.129*** (13.93) 5.35*** (7.59)
0.114*** (14.37) 4.58*** (6.90)
0.151*** (16.91) 3.22*** (5.56)
0.114*** (11.63) 3.41*** (4.75)
1.66* (1.95)
1.95*** (2.57)
2.39*** (3.34)
3.46*** (5.12)
2.10*** (2.33)
1.12*** (3.39) 0.971 (0.35) 1.52*** (4.77) 0.991 (0.10) 2.12*** (5.49) 0.777*** (3.59) 0.564*** (8.01) 1988 0.127 948.45***
1.25*** (4.82) 0.818* (1.78) 1.50*** (3.33) 0.961 (0.032) 4.07*** (4.26) 0.693*** (4.11) 0.461*** (8.98) 1983 0.183 788.44***
1.24*** (4.61) 0.772** (2.26) 1.51*** (3.27) 0.881 (1.00) 3.37*** (3.77) 0.688*** (4.16) 0.465*** (9.03) 1975 0.194 775.16 ***
0.966(1.01) 1.07 (0.79) 1.30*** (3.07) 1.03 (0.32) 2.19*** (5.92) 0.830*** (2.71) 0.616*** (6.69) 1972 0.106 835.48***
1.33*** (4.90) 0.783* (1.74) 1.72*** (3.54) 1.02 (0.10) 1.53 (1.24) 0.597*** (4.80) 0.523*** (6.16) 1992 0.257 472.82***
Z scores in parentheses. *** p .01. ** p .05. * p .10.
largely unexplained but could be because of the higher menthol consumption, especially because black youth smoke less than whites of a similar age. There is also a strong possibility that the tobacco companies manipulate menthol content levels in cigarettes both to entice adolescents to begin the habit and to maintain nicotine dependence in older smokers [24]. In this article, we have presented evidence similar to other studies that suggest strongly that menthol cigarettes are a special and dangerous problem within the African American community. Because African Americans consume so much of the menthol products, exempting menthols from any current or future legislation or regulation is tantamount to separating African American smoking and its consequences from other citizens. The chief limitation of the survey is its voluntary nature. Because of the need to protect confidentiality and other logistical problems, we were not able to conduct surveys based on a random sampling technique in any school. But our methodology did produce a large sample size, which may not have been attained through a random survey. Several parents did call to determine the nature of the survey, but none objected to their child participating. However, we did have to rely on the good will of the students to complete the instruments. We do not have an exact determination of how many students refused to complete the questionnaires and why. Nor is it possible to determine whether smokers or nonsmokers were more inclined not to complete the survey. However, we have collected a large sample of students and attained approximate proportions of African Americans and whites as they are represented in the general population of these schools. Further, the proportion of menthol cigarettes utilized in this population, compared to other surveys is in the general expected usage rate, especially among African Americans.
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