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Cigarette Smoking Behavior Among Menthol and Nonmenthol Adolescent Smokers
Journal of Adolescent Health xxx (2019) 1e6
www.jahonline.org Original article
Cigarette Smoking Behavior Among Menthol and Nonmenthol Adolescent Smokers Sunday Azagba, Ph.D. a, *, Jessica King, Ph.D. b, Lingpeng Shan, M.S. a, and Lauren Manzione, M.P.H. a a b
Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah Department of Health & Kinesiology, University of Utah, Salt Lake City, Utah
Article history: Received September 6, 2019; Accepted November 18, 2019 Keywords: Menthol; Menthol cigarette; Cigarette smoking; Adolescents
A B S T R A C T
Purpose: As cigarette rates have decreased, the proportion of menthol cigarette use among youth smokers has increased. Thus, it is important to monitor the menthol-associated behaviors among youth. The present study examined the associations between menthol cigarette use and smoking frequency, intention to continue smoking, and quit intention among youth. Methods: We used data from the 2017 and 2018 National Youth Tobacco Surveys. Separate multivariable logistic regression models were used to examine the associations between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit. Results: Across both years, 1,707 youth reported past 30-day cigarette use, 50.7% of whom used menthol cigarettes. Menthol cigarette users had significantly higher odds of smoking at least 10 out of the 30 days before the survey than nonmenthol smokers (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.14e1.94). We found similar results in the stratified analysis by grade level. Menthol cigarette smokers in middle (aOR 2.36, 95% CI 1.01e5.49) and high school (aOR 1.41, 95% CI 1.09e1.82) were more likely to have smoked at least 10 out of the 30 days before the survey than nonmenthol smokers. Menthol cigarette users had higher odds of intention to continue smoking (aOR 1.54, 95% CI 1.08e2.19) than nonmenthol cigarette users. Menthol use was not significantly associated with intention to quit. Conclusions: Compared with nonmenthol cigarette use, menthol cigarette use was associated with smoking more frequently as well as the intention to continue smoking among middle school and high school students. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Tobacco use remains the leading preventable cause of disease and death, with combustible cigarettes accounting for the highest morbidity and mortality [1]. Despite its known risks, youth continue to smoke, but rates have been declining. In 2018, 8.1% of U.S. high school students reported smoking a cigarette in
Conflicts of interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Sunday Azagba, Ph.D., Division of Public Health, Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108. E-mail address: [email protected] (S. Azagba). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.11.307
IMPLICATIONS AND CONTRIBUTION
This study examined the association between menthol cigarette status and smoking frequency, intention to continue smoking, and intention to quit. Youth who used menthol cigarettes smoked cigarettes more frequently and reported higher intentions to continue smoking. The findings provide additional evidence to support efforts to decrease the availability of menthol cigarettes among youth.
the past 30 days, down from 15.8% in 2011 [2]. However, previous U.S. trend analyses have found that although nonmenthol cigarette use has decreased significantly, menthol cigarette use has been relatively stagnant. From 2004 to 2010, nonmenthol smoking rates among adults aged 18e25 years decreased significantly from 25.7% to 17.3%, whereas menthol smoking increased significantly from 14.0% to 16.3% [3]. Among youth aged 12e17 years, nonmenthol smoking rates decreased significantly from 6% in 2004 to 3.4% in 2010 and only decreased from 5.3% to 4.5% for menthol smoking rates [3]. The disparities between menthol and nonmenthol smoking trends have grown
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such that menthol smoking rates are now surpassing nonmenthol smoking rates among U.S. youth [3]. The U.S. Food and Drug Administration (FDA) excluded menthol from the 2009 U.S. ban of flavored additives in cigarettes [4]. As an additive, menthol can desensitize the tongue and reduce the degree of nicotine-induced irritation, making smoking more palatable, in the face of national efforts to reduce smoking's appeal [5]. A qualitative study found promoting the taste and perceived health benefits of menthol to be an effective marketing strategy [6]. Some evidence suggests that the respiratory response to menthol can lead to greater exposure to toxicants from cigarette smoke, whereas other studies have concluded that there is no greater risk of exposure [7e9]. There is also some evidence that menthol cigarette use is associated with initiation, dependence, and quit intention. For example, prior studies suggest that first-time smokers commonly use menthol cigarettes, possibly because they perceive menthol cigarettes as easier to smoke [10e12]. Menthol cigarette use is also associated with progressing from experimental (defined as lifetime use of <100 cigarettes plus last 30-day use) to established (lifetime use of at least 100 cigarettes plus last 30-day use) cigarette use [13,14]. In addition, youth and adults who use menthol cigarettes may be more nicotine dependent than nonmenthol users [10,11,14e16], although some studies have not found this association [17e19]. Many studies suggest that menthol smokers make more quit attempts than nonmenthol smokers but are less likely to quit successfully, particularly among nonwhite smokers [20e23]. However, some studies have failed to find significant differences [24,25]. A few earlier studies have found menthol cigarette use to be associated with reduced quit intention among youth; however, no recent studies have examined this association [26,27]. There is limited literature on menthol cigarette use and frequency of cigarette smoking. The lack of current research about menthol cigarette use and frequency of cigarette smoking among youth leave important questions unanswered. Using a representative sample of both middle school and high school students in the U.S., the present study examined the associations between smoking frequency, intention to continue smoking, and quit intention and menthol cigarette use. Methods Data The present study used data from the 2017 and 2018 National Youth Tobacco Surveys (NYTS). The NYTS was designed to provide comprehensive national data on tobaccorelated indicators for both middle school (grades 6e8) and high school (grades 9e12) students to support the design, implementation, and evaluation of comprehensive tobacco prevention and control programs. The survey was administered in selected schools, and both students and parents were given the opportunity to opt out. Included in the NYTS are questions regarding tobacco-related beliefs, attitudes, behaviors, and exposure to pro- and anti-tobacco influences. The NYTS has been conducted annually since 2011 and is administered collaboratively by the Centers for Disease Control and Prevention and the FDA. The NYTS used a stratified, threestage cluster sample design and a weighting factor for each student, which resulted in nationally representative data for U.S. youth attending middle and high school [28,29].
Measures Outcome variables The outcome variables of interest were smoking frequency, intention to continue smoking, and intention to quit. As in previous studies, smoking frequency was measured as currently smoking cigarettes 10 days versus 1e9 days to capture smoking at a higher level [30,31]. This was derived from the question “During the past 30 days, on how many days did you smoke cigarettes?” with the following possible answers: “0 days,” “1 or 2 days,” “3e5 days,” “6e9 days,” “10e19 days,” “20e29 days,” and “All 30 days.” Adolescents with the response “0 days” were excluded from the study. The present study measured intention to continue smoking using the survey question, “Do you think you will smoke a cigarette in the next year?” with possible answers including “Definitely yes,” “Probably yes,” “Probably not,” and “Definitely not.” The dichotomous variable, intention to continue smoking (definitely yes or probably yes), was derived from the provided answers. This question was also used in a previous study to apply to future smoking intention among current smokers, although it is traditionally measured among nonsmokers [27]. This study measured intention to quit using the survey question, “Are you seriously thinking about quitting the use of all tobacco products?” with the following possible answers: “I do not use tobacco products,” “Yes, during the next 30 days,” “Yes, during the next 6 months” “Yes, during the next 12 months,” and “No, I am not thinking about quitting the use of all tobacco products.” The measure of intention to quit (within the next 30 days) was derived from the answers based on the methods of previous studies using NYTS data [32]. Independent variables The main dichotomous variable of interest, menthol cigarette use, was derived from the survey question, “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” with “Yes” and “No” as the possible answers. The analyses adjusted for grade, sex, race/ethnicity, other tobacco use, and survey year. We used the derived race/ethnicity variable from the survey and regrouped the small samples of non-Hispanic Asian, non-Hispanic American Indian/Alaska Native, non-Hispanic Native Hawaiian/Pacific Islander, and multiple races into the “others” group. We measured other tobacco use with the corresponding past 30-day use questions for e-cigarettes, smokeless tobacco, cigars, and all other available tobacco products from the survey. Study sample For the 2017 iteration, the final sample of schools (n ¼ 185 participating schools out of 241) had 17,872 participants with a participation rate of 68.1% [28]. For the 2018 iteration, the final sample of schools (n ¼ 238 participating schools out of 310) had 20,189 participants with an overall participation rate of 68.2% [29]. We restricted our sample to current cigarette users, defined as smoking at least one out of the previous 30 days [2]. Among 38,061 students from the 2017 and 2018 survey, we included the 1,707 students who reported smoking cigarettes on 1 of the past 30 days and responded “Yes” or “No” to the question about
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Table 1 Demographic characteristics and tobacco use by menthol cigarette use status, National Youth Tobacco Survey 2017e2018 Demographics and tobacco use
Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Smoking frequency 1 or 2 days 3e5 days 6e9 days 10e19 days 20e29 days All 30 days Intention to continue smoking Definitely yes Probably yes Probably not Definitely not Intention to quit Yes, during the next 30 days Yes, during the next 6 months Yes, during the next 12 months Yes, but not during the next 12 months No, I am not thinking about quitting cigarettes
Total sample (N ¼ 1,707)
Menthol cigarette use
p value
Yes, n ¼ 728
No, n ¼ 879
34 28 51 95 139 209 262
29 47 64 125 160 208 244
.29 63 75 115 220 299 417 506
(3.2) (3.6) (7.5) (12.7) (18.8) (25.4) (28.8)
(4.1) (3.0) (5.8) (11.8) (19.2) (26.1) (29.9)
(2.4) (4.1) (8.9) (13.4) (18.4) (24.9) (27.9) .74
925 (53.2) 760 (46.8)
451 (53.8) 361 (46.2)
474 (52.7) 399 (47.3)
964 106 406 163
457 43 218 76
507 63 188 87
.15 (64.7) (5.1) (21.3) (9.0)
(62.3) (4.8) (24.3) (8.7)
(66.7) (5.3) (18.7) (9.3) .08
1,371 (81.8) 325 (18.2)
686 (84.0) 135 (16.0)
685 (80.0) 190 (20.0) <.01*
674 269 152 208 135 269
(39.7) (16.6) (8.3) (12.6) (7.9) (14.9)
275 130 68 105 78 172
(33.0) (17.6) (7.7) (13.2) (9.9) (18.6)
399 139 84 103 57 97
(45.5) (15.8) (8.8) (12.1) (6.2) (11.6)
825 617 185 71
(49.0) (36.7) (10.4) (3.9)
449 276 74 24
(54.2) (34.8) (8.2) (2.8)
376 341 111 47
(44.5) (38.4) (12.2) (4.8)
294 138 157 218 491
(21.3) (11.5) (11.6) (17.0) (38.6)
134 70 74 108 260
(20.2) (11.5) (10.5) (17.4) (40.3)
160 68 83 110 231
(22.4) (11.4) (12.5) (16.7) (37.0)
.01*
.75
All variables were reported with unweighted frequency and weighted percentage. *
p < .05.
menthol cigarette use during the 30 days preceding the survey. The University of Utah Institutional Review Board determined that this study using publicly available data from NYTS was exempt from institutional review board oversight or further review. Statistical Analysis The present study described demographic characteristics and tobacco use by menthol cigarette use status (yes and no). All variables were reported with unweighted frequency and weighted percentages. This study used descriptive statistics and Wald chi-square tests to compare characteristics among the two groups. Separate multivariable logistic regression models were used to examine the association between smoking frequency, intention to continue smoking, and intention to quit with menthol cigarette use. Covariates grade, sex, race/ethnicity, other tobacco use, and survey year (time trend) were included in the analyses to adjust for potential confounding effects. We conducted stratified analyses for middle and high school students. In addition, we performed sensitivity analyses by redefining outcome measures in the study. Two additional dichotomous variables were created to measure levels of smoking frequency:
currently smoke cigarettes 20 days versus 1e19 days and currently smoke cigarettes every day (all 30 days) versus 1e29 days. Using survey responses, the intention to continue smoking was redefined as “Definitely yes” and intention to quit were redefined as “Yes, within the next 6 months.” Sampling weights and survey stratum were included in all analyses to account for the complex survey design. All tests were two sided and used the significance level at .05. All the statistical analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, NC). Results Among the 1,707 adolescents who met the inclusion criteria (i.e., smoked at least one cigarette in the last 30 days), 728 (50.7%) used menthol cigarettes during the 30 days before the survey. Among the study sample, 53.2% were male, and 14.3% attended middle school. More than half of the participating adolescents were non-Hispanic white (64.7%), followed by Hispanics (21.3%) and others (9.0%). In terms of tobacco use behaviors, approximately 82% of current smokers used other tobacco products during the 30 days preceding the survey (Table 1). Demographic characteristics did not differ significantly vary by menthol cigarette use status (Table 1). Among
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Table 2 Association between menthol cigarette use and smoking frequency from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
1.48 (1.14e1.94)* Ref
2.36 (1.01e5.49)* Ref
1.41 (1.09e1.82)* Ref
.90 .26 .67 .60 .79 1.00 Ref
(.40e1.99) (.12e.57)* (.37e1.22) (.40e.90)* (.56e1.12) (.70e1.42)
1.55 (.60e4.01) .39 (.14e1.13) Ref -
-
.93 (.74e1.16) Ref
.49 (.22e1.11) Ref
.98 (.77e1.26) ref
Ref .70 (.42e1.16) .89 (.64e1.23) 1.11 (.69e1.77)
Ref .38 (.08e1.88) .85 (.35e2.08) .40 (.09e1.70)
ref .80 (.47e1.36) .87 (.61e1.24) 1.20 (.72e1.98)
4.27 (2.46e7.39)* Ref
3.58 (.99e13.00) Ref
4.35 (2.31e8.18)* Ref
.89 (.69e1.15) Ref
.57 (.26e1.25) Ref
.92 (.70e1.21) Ref
.60 (.40e.90)* .80 (.57e1.12) 1.00 (.71e1.43) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
cigarette users, about 35% used cigarettes at least 10 days during the 30 days before the survey. Approximately 42% of menthol cigarette users and 30% and nonmenthol cigarette users smoked cigarettes at least 10 out of the 30 days before the survey (Table 1).
Table 2 shows the results of multivariable analysis examining the association between menthol cigarette use and smoking frequency. After adjusting for potential confounders, this study found menthol cigarette users had higher odds of smoking cigarettes 10 days (adjusted odds ratio [aOR] 1.48, 95% confidence
Table 3 Association between menthol cigarette use and intention to continue smoking from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
1.54 (1.08e2.19)* Ref
2.03 (.76e5.38) Ref
1.45 (.98e2.14) Ref
.98 1.17 .96 1.24 1.03 1.08 Ref
(.41e2.36) (.63e2.19) (.41e2.26) (.72e2.14) (.61e1.73) (.68e1.70)
1.01 (.26e4.00) 1.16 (.35e3.82) Ref -
1.22 (.71e2.10) 1.02 (.60e1.71) 1.08 (.68e1.71) Ref
1.10 (.79e1.54) Ref
1.63 (.73e3.65) Ref
1.02 (.70e1.46) Ref
Ref .29 (.16e.55)* .61 (.39e.95)* .65 (.37e1.13)
Ref .19 (.04e.93)* .49 (.13e1.87) .21 (.03e1.31)
Ref .31 (.16e.62)* .62 (.38e1.00) .83 (.44e1.54)
4.23 (1.74e10.33)* Ref
2.20 (.35e13.88) Ref
5.73 (1.97e16.69)* Ref
1.41 (.95e2.08) Ref
2.28 (.88e5.92) Ref
1.29 (.84e1.96) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
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Table 4 Association between menthol cigarette use and intention to quit smoking from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
.87 (.64e1.19) Ref
.59 (.23e1.50) Ref
.94 (.69e1.29) Ref
1.16 .99 1.49 .62 1.21 .94 Ref
(.41e3.30) (.49e2.04) (.72e3.10) (.33e1.16) (.71e2.06) (.58e1.54)
1.14 (.35e3.70) .76 (.30e1.92) Ref -
.63 (.34e1.17) 1.22 (.72e2.08) .95 (.58e1.54) Ref
1.19 (.87e1.64) Ref
.76 (.32e1.80) Ref
1.27 (.88e1.84) Ref
Ref 1.12 (.49e2.56) 1.34 (.85e2.12) 1.65 (.90e3.00)
Ref 1.95 (.15e6.05) 1.40 (.49e4.02) 1.81 (.29e11.44)
Ref 1.17 (.47e2.87) 1.33 (.81e2.16) 1.56 (.84e2.90)
.70 (.35e1.38) Ref
.13 (.03e.58)* Ref
.91 (.45e1.83) Ref
.90 (.64e1.26) Ref
.67 (.25e1.77) Ref
.95 (.68e1.31) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
interval [CI] 1.14e1.94) compared with nonmenthol cigarette users. Analyses stratified by school grade level (middle and high school) also showed a significant association between menthol cigarette use and smoking frequency. Specifically, both middle (aOR 2.36, 95% CI 1.01e5.49) and high school (aOR 1.41, 95% CI 1.09e1.82) menthol cigarette users had higher odds of smoking cigarettes 10 days compared with their peers who did not use menthol cigarettes. Table 3 presents the association between menthol cigarette use and intention to continue smoking. Menthol cigarette users were more likely to indicate they would use cigarettes in the following year after the survey, compared with adolescents who were nonmenthol cigarette users. After adjusting for covariates, menthol cigarette users had higher odds of intention to continue smoking (aOR 1.54, 95% CI 1.08e2.19). Similarly, both middle (aOR 2.03, 95% CI .76e5.38) and high school (aOR 1.45, 95% CI .98e2.14) menthol cigarette users had high odds of intention to continue smoking, but the associations were not statistically significant. Table 4 presents the association between menthol cigarette use and intention to quit. Although not statistically significant, menthol cigarette users had lower odds of intention to quit within the next 30 days (aOR .87, 95% CI .64e1.19). Similar results were found in the stratified analysis for middle (aOR .59, 95% CI .23e1.50) and high school (aOR .94, 95% CI .69e1.29) students. Similar results were also found in the sensitivity analyses using different levels of the outcome measures (Appendix 1e4). Menthol cigarette users had higher odds of using at least 20 days and using cigarettes every day during the 30 days preceding the survey in the full sample and the stratified analysis (middle school and high school students). However, the association was not significant between menthol cigarette use and smoking cigarettes every day. Similarly, we found no significant
association between menthol cigarette use and intention to quit (definitely yes) in the full sample or the stratified analysis. Discussion This study provides further evidence about the association between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit among U.S. youth. We found that menthol cigarette use was associated with greater smoking frequency among menthol smokers than nonmenthol smokers. A study of U.S. young adults in 2011 also found that menthol cigarette users were more likely to increase their smoking frequency over 1 year than nonmenthol smokers [33]. Similarly, a 2010e2011 study of Canadian high school students found that menthol cigarette smokers used more cigarettes when compared with those who smoked nonmenthol cigarettes [27]. In contrast, a study using 2000 and 2002 NYTS data reported that 45.1% of menthol cigarette users smoked 20 or more days during the past month, compared with 51.4% of nonmenthol smokers [26]. In addition, we found an association between menthol cigarette use and higher intention to continue smoking. Canadian youth who smoked menthol cigarettes had higher odds of reporting intent to continue smoking than those who smoked nonmenthol cigarettes, in the 2010e2011 study [27]. The present study also found that students who smoked menthol cigarettes had lower intention to quit compared with nonmenthol cigarette smokers, but the association was not significant. A 2011e2012 study of U.S. young adults found that menthol smokers were twice as likely as nonmenthol smokers to report the intention to quit [34]. Similarly, past studies reported lower intention to quit among youth who smoked menthol compared with nonmenthol cigarettes [26,27].
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Several limitations of the study are worth mentioning. First, data were self-reported from youth and may be subject to recall or social desirability bias. Also, as the survey was administered in a school setting, the results may not be generalizable to all youth, including those who are homeschooled or have dropped out of school. In addition, the cross-sectional nature of our study did not allow for the determination of temporality. Therefore, no claim about causality was made, given the possibility of uncontrolled or unobservable confounder. Given the availability of study questions, we are unable to determine the intention to quit for specific tobacco products. Because of the small sample size of menthol cigarette users from each racial group, we were unable to examine racial differences in the association between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit. Given the known dissimilarities in racial/ethnic smoking prevalence and menthol cigarette use, the study may mask racial differences [35]. Despite the limitations, the present study found a significant association between menthol cigarette use and smoking more within the past month as well as a stronger intention to continue smoking among middle school and high school students. Given the public health consequence of menthol cigarette use and the increased risk of menthol product use among youth, limiting access to these products may be beneficial, especially for adolescents. The present study found that menthol cigarette use is associated with smoking more frequently and having a stronger intention to continue smoking among middle school and high school students. In light of the FDA and other state and local jurisdictions' discussions on banning or reducing access to menthol cigarettes, this study provides additional support to decrease the availability of such products among youth. Supplementary Data Supplementary data related to this article can be found at http://doi.org/10.1016/j.jadohealth.2019.11.307. References [1] United States, Public Health Services, Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.), and Office on Smoking and Health. The health consequences of smoking-50 years of progress: A report of the surgeon general, 2014. Rockville (MD): U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; 2014. [2] Gentzke AS. “Vital signs: Tobacco product use among middle and high school students d United States, 2011e2018. MMWR Morb Mortal Wkly Rep 2019;68. [3] Giovino GA, Villanti AC, Mowery PD, et al. Differential trends in cigarette smoking in the USA: Is menthol slowing progress? Tob Control 2015;24:28e37. [4] Family Smoking Prevention and Tobacco Control and Federal Retirement Reform, Public Law 111-31, 111th Congress Public Law; 2009. [5] Dessirier J-M, O’Mahony M, Carstens E. Oral irritant properties of menthol: Sensitizing and desensitizing effects of repeated application and crossdesensitization to nicotine. Physiol Behav 2001;73:25e36. [6] Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: A review of tobacco industry documents. Tob Control 2011;20:ii20e8. [7] Garten S, Falkner RV. Role of mentholated cigarettes in increased nicotine dependence and greater risk of tobacco-attributable disease. Prev Med 2004;38:793e8. [8] Benowitz NL, Herrera B, Jacob P. Mentholated cigarette smoking inhibits nicotine metabolism. J Pharmacol Exp Ther 2004;310:1208e15. [9] Wang J, Roethig HJ, Appleton S, et al. The effect of menthol containing cigarettes on adult smokers’ exposure to nicotine and carbon monoxide. Regul Toxicol Pharmacol 2010;57:24e30.
[10] Hersey JC, Nonnemaker JM, Homsi G. Menthol cigarettes contribute to the appeal and addiction potential of smoking for youth. Nicotine Tob Res 2010;12:S136e46. [11] Villanti AC, Collins LK, Niaura RS, et al. Menthol cigarettes and the public health standard: A systematic review. BMC Public Health 2017;17:983. [12] Cohn AM, Rose SW, D’Silva J, Villanti AC. Menthol smoking patterns and smoking perceptions among youth: Findings from the population assessment of tobacco and health study. Am J Prev Med 2019;56:e107e16. [13] Nonnemaker J, Feirman SP, MacMonegle A, et al. Examining the role of menthol cigarettes in progression to established smoking among youth. Addict Behav 2019;98:106045. [14] Nonnemaker J, Hersey J, Homsi G, et al. Initiation with menthol cigarettes and youth smoking uptake. Addiction 2013;108:171e8. [15] Wackowski O, Delnevo CD. Menthol cigarettes and indicators of tobacco dependence among adolescents. Addict Behav 2007;32:1964e9. [16] Gandhi KK, Foulds J, Steinberg MB, et al. Lower quit rates among African American and Latino menthol cigarette smokers at a tobacco treatment clinic. Int J Clin Pract 2009;63:360e7. [17] Frost-Pineda K, Muhammad-Kah R, Rimmer L, Liang Q. Predictors, indicators, and validated measures of dependence in menthol smokers. J Addict Dis 2014;33:94e113. [18] Muscat JE, Chen G, Knipe A, et al. Effects of menthol on tobacco smoke exposure, nicotine dependence, and NNAL glucuronidation. Cancer Epidemiol Biomarkers Prev 2009;18:35e41. [19] Collins CC, Moolchan ET. Shorter time to first cigarette of the day in menthol adolescent cigarette smokers. Addict Behav 2006;31:1460e4. [20] Levy DT, Blackman K, Tauras J, et al. Quit attempts and quit rates among menthol and nonmenthol smokers in the United States. Am J Public Health 2011;101:1241e7. [21] Trinidad DR, Pérez-Stable EJ, Messer K, et al. Menthol cigarettes and smoking cessation among racial/ethnic groups in the United States. Addiction 2010;105 Suppl 1:84e94. [22] Stahre M, Okuyemi KS, Joseph AM, Fu SS. Racial/ethnic differences in menthol cigarette smoking, population quit ratios and utilization of evidence-based tobacco cessation treatments. Addiction 2010;105 Suppl 1: 75e83. [23] Gundersen DA, Delnevo CD, Wackowski O. Exploring the relationship between race/ethnicity, menthol smoking, and cessation, in a nationally representative sample of adults. Prev Med 2009;49:553e7. [24] Fagan P, Augustson E, Backinger CL, et al. Quit attempts and intention to quit cigarette smoking among young adults in the United States. Am J Public Health 2007;97:1412e20. [25] Keeler C, Max W, Yerger V, et al. The association of menthol cigarette use with quit attempts, successful cessation, and intention to quit across racial/ ethnic groups in the United States. Nicotine Tob Res 2017;19:1450e64. [26] Hersey JC, Ng SW, Nonnemaker JM, et al. Are menthol cigarettes a starter product for youth? Nicotine Tob Res 2006;8:403e13. [27] Azagba S, Minaker LM, Sharaf MF, et al. Smoking intensity and intent to continue smoking among menthol and non-menthol adolescent smokers in Canada. Cancer Causes Control 2014;25:1093e9. [28] Department of Health and Human Services, Office on Smoking and Health. 2017 National Youth Tobacco Survey: Methodology report. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2017. [29] Department of Health and Human Services, Office on Smoking and Health. 2018 National Youth Tobacco Survey: Methodology report. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2018. [30] Reidpath DD, Ling M-L, Wellington E, et al. The relationship between age of smoking initiation and current smoking: An analysis of school surveys in three European countries. Nicotine Tob Res 2013;15:729e33. [31] Reidpath DD, Davey TM, Kadirvelu A, et al. Does one cigarette make an adolescent smoker, and is it influenced by age and age of smoking initiation? Evidence of association from the U.S. Youth Risk Behavior Surveillance System (2011). Prev Med 2014;59:37e41. [32] Azagba S, Shan L, Latham K. Adolescent dual use classification and its association with nicotine dependence and quit intentions. J Adolesc Health 2019;65:195e201. [33] Delnevo CD, Villanti AC, Wackowski OA, et al. The influence of menthol, ecigarettes and other tobacco products on young adults’ self-reported changes in past year smoking. Tob Control 2016;25:571e4. [34] Rath JM, Villanti AC, Williams VF, et al. Patterns of longitudinal transitions in menthol use among U.S. Young adult smokers. Nicotine Tob Res 2015; 17:839e46. [35] Villanti AC, Mowery PD, Delnevo CD, et al. Changes in the prevalence and correlates of menthol cigarette use in the USA, 2004e2014. Tob Control 2016;25:ii14e20.
www.jahonline.org Original article
Cigarette Smoking Behavior Among Menthol and Nonmenthol Adolescent Smokers Sunday Azagba, Ph.D. a, *, Jessica King, Ph.D. b, Lingpeng Shan, M.S. a, and Lauren Manzione, M.P.H. a a b
Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah Department of Health & Kinesiology, University of Utah, Salt Lake City, Utah
Article history: Received September 6, 2019; Accepted November 18, 2019 Keywords: Menthol; Menthol cigarette; Cigarette smoking; Adolescents
A B S T R A C T
Purpose: As cigarette rates have decreased, the proportion of menthol cigarette use among youth smokers has increased. Thus, it is important to monitor the menthol-associated behaviors among youth. The present study examined the associations between menthol cigarette use and smoking frequency, intention to continue smoking, and quit intention among youth. Methods: We used data from the 2017 and 2018 National Youth Tobacco Surveys. Separate multivariable logistic regression models were used to examine the associations between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit. Results: Across both years, 1,707 youth reported past 30-day cigarette use, 50.7% of whom used menthol cigarettes. Menthol cigarette users had significantly higher odds of smoking at least 10 out of the 30 days before the survey than nonmenthol smokers (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.14e1.94). We found similar results in the stratified analysis by grade level. Menthol cigarette smokers in middle (aOR 2.36, 95% CI 1.01e5.49) and high school (aOR 1.41, 95% CI 1.09e1.82) were more likely to have smoked at least 10 out of the 30 days before the survey than nonmenthol smokers. Menthol cigarette users had higher odds of intention to continue smoking (aOR 1.54, 95% CI 1.08e2.19) than nonmenthol cigarette users. Menthol use was not significantly associated with intention to quit. Conclusions: Compared with nonmenthol cigarette use, menthol cigarette use was associated with smoking more frequently as well as the intention to continue smoking among middle school and high school students. Ó 2019 Society for Adolescent Health and Medicine. All rights reserved.
Tobacco use remains the leading preventable cause of disease and death, with combustible cigarettes accounting for the highest morbidity and mortality [1]. Despite its known risks, youth continue to smoke, but rates have been declining. In 2018, 8.1% of U.S. high school students reported smoking a cigarette in
Conflicts of interest: The authors have no conflicts of interest to disclose. * Address correspondence to: Sunday Azagba, Ph.D., Division of Public Health, Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT 84108. E-mail address: [email protected] (S. Azagba). 1054-139X/Ó 2019 Society for Adolescent Health and Medicine. All rights reserved. https://doi.org/10.1016/j.jadohealth.2019.11.307
IMPLICATIONS AND CONTRIBUTION
This study examined the association between menthol cigarette status and smoking frequency, intention to continue smoking, and intention to quit. Youth who used menthol cigarettes smoked cigarettes more frequently and reported higher intentions to continue smoking. The findings provide additional evidence to support efforts to decrease the availability of menthol cigarettes among youth.
the past 30 days, down from 15.8% in 2011 [2]. However, previous U.S. trend analyses have found that although nonmenthol cigarette use has decreased significantly, menthol cigarette use has been relatively stagnant. From 2004 to 2010, nonmenthol smoking rates among adults aged 18e25 years decreased significantly from 25.7% to 17.3%, whereas menthol smoking increased significantly from 14.0% to 16.3% [3]. Among youth aged 12e17 years, nonmenthol smoking rates decreased significantly from 6% in 2004 to 3.4% in 2010 and only decreased from 5.3% to 4.5% for menthol smoking rates [3]. The disparities between menthol and nonmenthol smoking trends have grown
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such that menthol smoking rates are now surpassing nonmenthol smoking rates among U.S. youth [3]. The U.S. Food and Drug Administration (FDA) excluded menthol from the 2009 U.S. ban of flavored additives in cigarettes [4]. As an additive, menthol can desensitize the tongue and reduce the degree of nicotine-induced irritation, making smoking more palatable, in the face of national efforts to reduce smoking's appeal [5]. A qualitative study found promoting the taste and perceived health benefits of menthol to be an effective marketing strategy [6]. Some evidence suggests that the respiratory response to menthol can lead to greater exposure to toxicants from cigarette smoke, whereas other studies have concluded that there is no greater risk of exposure [7e9]. There is also some evidence that menthol cigarette use is associated with initiation, dependence, and quit intention. For example, prior studies suggest that first-time smokers commonly use menthol cigarettes, possibly because they perceive menthol cigarettes as easier to smoke [10e12]. Menthol cigarette use is also associated with progressing from experimental (defined as lifetime use of <100 cigarettes plus last 30-day use) to established (lifetime use of at least 100 cigarettes plus last 30-day use) cigarette use [13,14]. In addition, youth and adults who use menthol cigarettes may be more nicotine dependent than nonmenthol users [10,11,14e16], although some studies have not found this association [17e19]. Many studies suggest that menthol smokers make more quit attempts than nonmenthol smokers but are less likely to quit successfully, particularly among nonwhite smokers [20e23]. However, some studies have failed to find significant differences [24,25]. A few earlier studies have found menthol cigarette use to be associated with reduced quit intention among youth; however, no recent studies have examined this association [26,27]. There is limited literature on menthol cigarette use and frequency of cigarette smoking. The lack of current research about menthol cigarette use and frequency of cigarette smoking among youth leave important questions unanswered. Using a representative sample of both middle school and high school students in the U.S., the present study examined the associations between smoking frequency, intention to continue smoking, and quit intention and menthol cigarette use. Methods Data The present study used data from the 2017 and 2018 National Youth Tobacco Surveys (NYTS). The NYTS was designed to provide comprehensive national data on tobaccorelated indicators for both middle school (grades 6e8) and high school (grades 9e12) students to support the design, implementation, and evaluation of comprehensive tobacco prevention and control programs. The survey was administered in selected schools, and both students and parents were given the opportunity to opt out. Included in the NYTS are questions regarding tobacco-related beliefs, attitudes, behaviors, and exposure to pro- and anti-tobacco influences. The NYTS has been conducted annually since 2011 and is administered collaboratively by the Centers for Disease Control and Prevention and the FDA. The NYTS used a stratified, threestage cluster sample design and a weighting factor for each student, which resulted in nationally representative data for U.S. youth attending middle and high school [28,29].
Measures Outcome variables The outcome variables of interest were smoking frequency, intention to continue smoking, and intention to quit. As in previous studies, smoking frequency was measured as currently smoking cigarettes 10 days versus 1e9 days to capture smoking at a higher level [30,31]. This was derived from the question “During the past 30 days, on how many days did you smoke cigarettes?” with the following possible answers: “0 days,” “1 or 2 days,” “3e5 days,” “6e9 days,” “10e19 days,” “20e29 days,” and “All 30 days.” Adolescents with the response “0 days” were excluded from the study. The present study measured intention to continue smoking using the survey question, “Do you think you will smoke a cigarette in the next year?” with possible answers including “Definitely yes,” “Probably yes,” “Probably not,” and “Definitely not.” The dichotomous variable, intention to continue smoking (definitely yes or probably yes), was derived from the provided answers. This question was also used in a previous study to apply to future smoking intention among current smokers, although it is traditionally measured among nonsmokers [27]. This study measured intention to quit using the survey question, “Are you seriously thinking about quitting the use of all tobacco products?” with the following possible answers: “I do not use tobacco products,” “Yes, during the next 30 days,” “Yes, during the next 6 months” “Yes, during the next 12 months,” and “No, I am not thinking about quitting the use of all tobacco products.” The measure of intention to quit (within the next 30 days) was derived from the answers based on the methods of previous studies using NYTS data [32]. Independent variables The main dichotomous variable of interest, menthol cigarette use, was derived from the survey question, “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” with “Yes” and “No” as the possible answers. The analyses adjusted for grade, sex, race/ethnicity, other tobacco use, and survey year. We used the derived race/ethnicity variable from the survey and regrouped the small samples of non-Hispanic Asian, non-Hispanic American Indian/Alaska Native, non-Hispanic Native Hawaiian/Pacific Islander, and multiple races into the “others” group. We measured other tobacco use with the corresponding past 30-day use questions for e-cigarettes, smokeless tobacco, cigars, and all other available tobacco products from the survey. Study sample For the 2017 iteration, the final sample of schools (n ¼ 185 participating schools out of 241) had 17,872 participants with a participation rate of 68.1% [28]. For the 2018 iteration, the final sample of schools (n ¼ 238 participating schools out of 310) had 20,189 participants with an overall participation rate of 68.2% [29]. We restricted our sample to current cigarette users, defined as smoking at least one out of the previous 30 days [2]. Among 38,061 students from the 2017 and 2018 survey, we included the 1,707 students who reported smoking cigarettes on 1 of the past 30 days and responded “Yes” or “No” to the question about
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3
Table 1 Demographic characteristics and tobacco use by menthol cigarette use status, National Youth Tobacco Survey 2017e2018 Demographics and tobacco use
Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Smoking frequency 1 or 2 days 3e5 days 6e9 days 10e19 days 20e29 days All 30 days Intention to continue smoking Definitely yes Probably yes Probably not Definitely not Intention to quit Yes, during the next 30 days Yes, during the next 6 months Yes, during the next 12 months Yes, but not during the next 12 months No, I am not thinking about quitting cigarettes
Total sample (N ¼ 1,707)
Menthol cigarette use
p value
Yes, n ¼ 728
No, n ¼ 879
34 28 51 95 139 209 262
29 47 64 125 160 208 244
.29 63 75 115 220 299 417 506
(3.2) (3.6) (7.5) (12.7) (18.8) (25.4) (28.8)
(4.1) (3.0) (5.8) (11.8) (19.2) (26.1) (29.9)
(2.4) (4.1) (8.9) (13.4) (18.4) (24.9) (27.9) .74
925 (53.2) 760 (46.8)
451 (53.8) 361 (46.2)
474 (52.7) 399 (47.3)
964 106 406 163
457 43 218 76
507 63 188 87
.15 (64.7) (5.1) (21.3) (9.0)
(62.3) (4.8) (24.3) (8.7)
(66.7) (5.3) (18.7) (9.3) .08
1,371 (81.8) 325 (18.2)
686 (84.0) 135 (16.0)
685 (80.0) 190 (20.0) <.01*
674 269 152 208 135 269
(39.7) (16.6) (8.3) (12.6) (7.9) (14.9)
275 130 68 105 78 172
(33.0) (17.6) (7.7) (13.2) (9.9) (18.6)
399 139 84 103 57 97
(45.5) (15.8) (8.8) (12.1) (6.2) (11.6)
825 617 185 71
(49.0) (36.7) (10.4) (3.9)
449 276 74 24
(54.2) (34.8) (8.2) (2.8)
376 341 111 47
(44.5) (38.4) (12.2) (4.8)
294 138 157 218 491
(21.3) (11.5) (11.6) (17.0) (38.6)
134 70 74 108 260
(20.2) (11.5) (10.5) (17.4) (40.3)
160 68 83 110 231
(22.4) (11.4) (12.5) (16.7) (37.0)
.01*
.75
All variables were reported with unweighted frequency and weighted percentage. *
p < .05.
menthol cigarette use during the 30 days preceding the survey. The University of Utah Institutional Review Board determined that this study using publicly available data from NYTS was exempt from institutional review board oversight or further review. Statistical Analysis The present study described demographic characteristics and tobacco use by menthol cigarette use status (yes and no). All variables were reported with unweighted frequency and weighted percentages. This study used descriptive statistics and Wald chi-square tests to compare characteristics among the two groups. Separate multivariable logistic regression models were used to examine the association between smoking frequency, intention to continue smoking, and intention to quit with menthol cigarette use. Covariates grade, sex, race/ethnicity, other tobacco use, and survey year (time trend) were included in the analyses to adjust for potential confounding effects. We conducted stratified analyses for middle and high school students. In addition, we performed sensitivity analyses by redefining outcome measures in the study. Two additional dichotomous variables were created to measure levels of smoking frequency:
currently smoke cigarettes 20 days versus 1e19 days and currently smoke cigarettes every day (all 30 days) versus 1e29 days. Using survey responses, the intention to continue smoking was redefined as “Definitely yes” and intention to quit were redefined as “Yes, within the next 6 months.” Sampling weights and survey stratum were included in all analyses to account for the complex survey design. All tests were two sided and used the significance level at .05. All the statistical analyses were performed using SAS 9.4 (SAS Institute, Inc., Cary, NC). Results Among the 1,707 adolescents who met the inclusion criteria (i.e., smoked at least one cigarette in the last 30 days), 728 (50.7%) used menthol cigarettes during the 30 days before the survey. Among the study sample, 53.2% were male, and 14.3% attended middle school. More than half of the participating adolescents were non-Hispanic white (64.7%), followed by Hispanics (21.3%) and others (9.0%). In terms of tobacco use behaviors, approximately 82% of current smokers used other tobacco products during the 30 days preceding the survey (Table 1). Demographic characteristics did not differ significantly vary by menthol cigarette use status (Table 1). Among
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Table 2 Association between menthol cigarette use and smoking frequency from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
1.48 (1.14e1.94)* Ref
2.36 (1.01e5.49)* Ref
1.41 (1.09e1.82)* Ref
.90 .26 .67 .60 .79 1.00 Ref
(.40e1.99) (.12e.57)* (.37e1.22) (.40e.90)* (.56e1.12) (.70e1.42)
1.55 (.60e4.01) .39 (.14e1.13) Ref -
-
.93 (.74e1.16) Ref
.49 (.22e1.11) Ref
.98 (.77e1.26) ref
Ref .70 (.42e1.16) .89 (.64e1.23) 1.11 (.69e1.77)
Ref .38 (.08e1.88) .85 (.35e2.08) .40 (.09e1.70)
ref .80 (.47e1.36) .87 (.61e1.24) 1.20 (.72e1.98)
4.27 (2.46e7.39)* Ref
3.58 (.99e13.00) Ref
4.35 (2.31e8.18)* Ref
.89 (.69e1.15) Ref
.57 (.26e1.25) Ref
.92 (.70e1.21) Ref
.60 (.40e.90)* .80 (.57e1.12) 1.00 (.71e1.43) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
cigarette users, about 35% used cigarettes at least 10 days during the 30 days before the survey. Approximately 42% of menthol cigarette users and 30% and nonmenthol cigarette users smoked cigarettes at least 10 out of the 30 days before the survey (Table 1).
Table 2 shows the results of multivariable analysis examining the association between menthol cigarette use and smoking frequency. After adjusting for potential confounders, this study found menthol cigarette users had higher odds of smoking cigarettes 10 days (adjusted odds ratio [aOR] 1.48, 95% confidence
Table 3 Association between menthol cigarette use and intention to continue smoking from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
1.54 (1.08e2.19)* Ref
2.03 (.76e5.38) Ref
1.45 (.98e2.14) Ref
.98 1.17 .96 1.24 1.03 1.08 Ref
(.41e2.36) (.63e2.19) (.41e2.26) (.72e2.14) (.61e1.73) (.68e1.70)
1.01 (.26e4.00) 1.16 (.35e3.82) Ref -
1.22 (.71e2.10) 1.02 (.60e1.71) 1.08 (.68e1.71) Ref
1.10 (.79e1.54) Ref
1.63 (.73e3.65) Ref
1.02 (.70e1.46) Ref
Ref .29 (.16e.55)* .61 (.39e.95)* .65 (.37e1.13)
Ref .19 (.04e.93)* .49 (.13e1.87) .21 (.03e1.31)
Ref .31 (.16e.62)* .62 (.38e1.00) .83 (.44e1.54)
4.23 (1.74e10.33)* Ref
2.20 (.35e13.88) Ref
5.73 (1.97e16.69)* Ref
1.41 (.95e2.08) Ref
2.28 (.88e5.92) Ref
1.29 (.84e1.96) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
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5
Table 4 Association between menthol cigarette use and intention to quit smoking from the National Youth Tobacco Survey 2017e2018
Menthol cigarette use Yes No Grade 6th 7th 8th 9th 10th 11th 12th Sex Male Female Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Others Other tobacco use Yes No Survey year 2017 2018
Total sample
Middle school
High school
.87 (.64e1.19) Ref
.59 (.23e1.50) Ref
.94 (.69e1.29) Ref
1.16 .99 1.49 .62 1.21 .94 Ref
(.41e3.30) (.49e2.04) (.72e3.10) (.33e1.16) (.71e2.06) (.58e1.54)
1.14 (.35e3.70) .76 (.30e1.92) Ref -
.63 (.34e1.17) 1.22 (.72e2.08) .95 (.58e1.54) Ref
1.19 (.87e1.64) Ref
.76 (.32e1.80) Ref
1.27 (.88e1.84) Ref
Ref 1.12 (.49e2.56) 1.34 (.85e2.12) 1.65 (.90e3.00)
Ref 1.95 (.15e6.05) 1.40 (.49e4.02) 1.81 (.29e11.44)
Ref 1.17 (.47e2.87) 1.33 (.81e2.16) 1.56 (.84e2.90)
.70 (.35e1.38) Ref
.13 (.03e.58)* Ref
.91 (.45e1.83) Ref
.90 (.64e1.26) Ref
.67 (.25e1.77) Ref
.95 (.68e1.31) Ref
The aORs were estimated by logistic regression adjusting for grade, sex, race, other tobacco use, and survey year (time trend). aOR ¼ adjusted odds ratio; CI ¼ confidence interval; Ref ¼ reference category. * p < .05.
interval [CI] 1.14e1.94) compared with nonmenthol cigarette users. Analyses stratified by school grade level (middle and high school) also showed a significant association between menthol cigarette use and smoking frequency. Specifically, both middle (aOR 2.36, 95% CI 1.01e5.49) and high school (aOR 1.41, 95% CI 1.09e1.82) menthol cigarette users had higher odds of smoking cigarettes 10 days compared with their peers who did not use menthol cigarettes. Table 3 presents the association between menthol cigarette use and intention to continue smoking. Menthol cigarette users were more likely to indicate they would use cigarettes in the following year after the survey, compared with adolescents who were nonmenthol cigarette users. After adjusting for covariates, menthol cigarette users had higher odds of intention to continue smoking (aOR 1.54, 95% CI 1.08e2.19). Similarly, both middle (aOR 2.03, 95% CI .76e5.38) and high school (aOR 1.45, 95% CI .98e2.14) menthol cigarette users had high odds of intention to continue smoking, but the associations were not statistically significant. Table 4 presents the association between menthol cigarette use and intention to quit. Although not statistically significant, menthol cigarette users had lower odds of intention to quit within the next 30 days (aOR .87, 95% CI .64e1.19). Similar results were found in the stratified analysis for middle (aOR .59, 95% CI .23e1.50) and high school (aOR .94, 95% CI .69e1.29) students. Similar results were also found in the sensitivity analyses using different levels of the outcome measures (Appendix 1e4). Menthol cigarette users had higher odds of using at least 20 days and using cigarettes every day during the 30 days preceding the survey in the full sample and the stratified analysis (middle school and high school students). However, the association was not significant between menthol cigarette use and smoking cigarettes every day. Similarly, we found no significant
association between menthol cigarette use and intention to quit (definitely yes) in the full sample or the stratified analysis. Discussion This study provides further evidence about the association between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit among U.S. youth. We found that menthol cigarette use was associated with greater smoking frequency among menthol smokers than nonmenthol smokers. A study of U.S. young adults in 2011 also found that menthol cigarette users were more likely to increase their smoking frequency over 1 year than nonmenthol smokers [33]. Similarly, a 2010e2011 study of Canadian high school students found that menthol cigarette smokers used more cigarettes when compared with those who smoked nonmenthol cigarettes [27]. In contrast, a study using 2000 and 2002 NYTS data reported that 45.1% of menthol cigarette users smoked 20 or more days during the past month, compared with 51.4% of nonmenthol smokers [26]. In addition, we found an association between menthol cigarette use and higher intention to continue smoking. Canadian youth who smoked menthol cigarettes had higher odds of reporting intent to continue smoking than those who smoked nonmenthol cigarettes, in the 2010e2011 study [27]. The present study also found that students who smoked menthol cigarettes had lower intention to quit compared with nonmenthol cigarette smokers, but the association was not significant. A 2011e2012 study of U.S. young adults found that menthol smokers were twice as likely as nonmenthol smokers to report the intention to quit [34]. Similarly, past studies reported lower intention to quit among youth who smoked menthol compared with nonmenthol cigarettes [26,27].
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Several limitations of the study are worth mentioning. First, data were self-reported from youth and may be subject to recall or social desirability bias. Also, as the survey was administered in a school setting, the results may not be generalizable to all youth, including those who are homeschooled or have dropped out of school. In addition, the cross-sectional nature of our study did not allow for the determination of temporality. Therefore, no claim about causality was made, given the possibility of uncontrolled or unobservable confounder. Given the availability of study questions, we are unable to determine the intention to quit for specific tobacco products. Because of the small sample size of menthol cigarette users from each racial group, we were unable to examine racial differences in the association between menthol cigarette use and smoking frequency, intention to continue smoking, and intention to quit. Given the known dissimilarities in racial/ethnic smoking prevalence and menthol cigarette use, the study may mask racial differences [35]. Despite the limitations, the present study found a significant association between menthol cigarette use and smoking more within the past month as well as a stronger intention to continue smoking among middle school and high school students. Given the public health consequence of menthol cigarette use and the increased risk of menthol product use among youth, limiting access to these products may be beneficial, especially for adolescents. The present study found that menthol cigarette use is associated with smoking more frequently and having a stronger intention to continue smoking among middle school and high school students. In light of the FDA and other state and local jurisdictions' discussions on banning or reducing access to menthol cigarettes, this study provides additional support to decrease the availability of such products among youth. Supplementary Data Supplementary data related to this article can be found at http://doi.org/10.1016/j.jadohealth.2019.11.307. References [1] United States, Public Health Services, Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.), and Office on Smoking and Health. The health consequences of smoking-50 years of progress: A report of the surgeon general, 2014. Rockville (MD): U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; 2014. [2] Gentzke AS. “Vital signs: Tobacco product use among middle and high school students d United States, 2011e2018. MMWR Morb Mortal Wkly Rep 2019;68. [3] Giovino GA, Villanti AC, Mowery PD, et al. Differential trends in cigarette smoking in the USA: Is menthol slowing progress? Tob Control 2015;24:28e37. [4] Family Smoking Prevention and Tobacco Control and Federal Retirement Reform, Public Law 111-31, 111th Congress Public Law; 2009. [5] Dessirier J-M, O’Mahony M, Carstens E. Oral irritant properties of menthol: Sensitizing and desensitizing effects of repeated application and crossdesensitization to nicotine. Physiol Behav 2001;73:25e36. [6] Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: A review of tobacco industry documents. Tob Control 2011;20:ii20e8. [7] Garten S, Falkner RV. Role of mentholated cigarettes in increased nicotine dependence and greater risk of tobacco-attributable disease. Prev Med 2004;38:793e8. [8] Benowitz NL, Herrera B, Jacob P. Mentholated cigarette smoking inhibits nicotine metabolism. J Pharmacol Exp Ther 2004;310:1208e15. [9] Wang J, Roethig HJ, Appleton S, et al. The effect of menthol containing cigarettes on adult smokers’ exposure to nicotine and carbon monoxide. Regul Toxicol Pharmacol 2010;57:24e30.
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