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Introduction The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs). Methods After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060. Results As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications. Conclusions and relevance Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.
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LevyDT, etal. Tob Control 2021;0:1–8. doi:10.1136/tobaccocontrol-2021-056604
Public health impact of a US ban on menthol in
cigarettes and cigars: a simulationstudy
David T Levy ,1 Rafael Meza ,2 Zhe Yuan,1 Yameng Li,1 Christopher Cadham,2
Luz Maria Sanchez- Romero ,1 Nargiz Travis ,1 Marie Knoll,1 Alex C Liber ,1
Ritesh Mistry ,2 Jana L Hirschtick,2 Nancy L Fleischer ,2 Sarah Skolnick,2
Andrew F Brouwer ,2 Cliff Douglas ,2 Jihyoun Jeon,2 Steven Cook,2
Kenneth E Warner 2
Original research
To cite: LevyDT, MezaR,
YuanZ, etal. Tob Control
Epub ahead of print: [please
include Day Month Year].
doi:10.1136/
tobaccocontrol-2021-056604
1Department of Oncology,
Lombardi Comprehensive
Cancer Center, Georgetown
University, Washington, DC, USA
2School of Public Health,
University of Michigan, Ann
Arbor, Michigan, USA
Correspondence to
Dr David T Levy, Oncology,
Lombardi Comprehensive
Cancer Center, Georgetown
University, Washington, DC
20009, USA;
dl777@ georgetown. edu
Received 19 February 2021
Accepted 26 July 2021
© Author(s) (or their
employer(s)) 2021. No
commercial re- use. See rights
and permissions. Published
by BMJ.
ABSTRACT
Introduction The US Food and Drug Administration
most recently announced its intention to ban menthol
cigarettes and cigars nationwide in April 2021.
Implementation of the ban will require evidence that it
would improve public health. This paper simulates the
potential public health impact of a ban on menthol in
cigarettes and cigars through its impacts on smoking
initiation, smoking cessation and switching to nicotine
vaping products (NVPs).
Methods After calibrating an established US simulation
model to reflect recent use trends in cigarette and NVP
use, we extended the model to incorporate menthol and
non- menthol cigarette use under a status quo scenario.
Applying estimates from a recent expert elicitation on
the behavioural impacts of a menthol ban, we developed
a menthol ban scenario with the ban starting in 2021.
We estimated the public health impact as the difference
between smoking and vaping- attributable deaths and
life- years lost in the status quo scenario and the menthol
ban scenario from 2021 to 2060.
Results As a result of the ban, overall smoking was
estimated to decline by 15% as early as 2026 due to
menthol smokers quitting both NVP and combustible
use or switching to NVPs. These transitions are projected
to reduce cumulative smoking and vaping- attributable
deaths from 2021 to 2060 by 5% (650 000 in total) and
reduce life- years lost by 8.8% (11.3 million). Sensitivity
analyses showed appreciable public health benefits
across different parameter specifications.
Conclusions and relevance Our findings strongly
support the implementation of a ban on menthol in
cigarettes and cigars.
INTRODUCTION
While US cigarette smoking prevalence has
declined substantially in the past decade, the
prevalence of menthol smoking has remained
constant.1–5 Menthol cigarettes now represent
35% of cigarette sales6 and are disproportionately
used by youth, young adults, women and African-
Americans.3 7 Menthol cigarette use has been associ-
ated with increased smoking initiation and reduced
smoking cessation.8–11 In response, the European
Union, Canada, Brazil, Ethiopia and Turkey have
banned menthol in cigarettes.12 In the USA, more
than 20 localities and the state of Massachusetts have
banned menthol cigarettes.13 Recently, the Food
and Drug Administration announced its intention
to implement a nationwide ban on menthol in
cigarettes and cigars.14 A stronger evidence base is
urgently needed about whether such a ban would
improve public health.15 16
A small body of research has examined the
potential impact of banning menthol in cigarettes.
A simulation model17 projected that a menthol ban
would have major impacts on smoking prevalence
and smoking- attributable deaths. However, that
model simulated a ban starting in 2010 and did not
consider the impact of switching to nicotine vaping
products (NVPs, also known as e- cigarettes). Addi-
tionally, recent evidence finds that a menthol ban
would likely increase smoking cessation, with more
limited evidence of reducing smoking initiation and
switching from smoking to other products.18 To
better gauge the potential impact of a menthol ciga-
rette and cigar ban in the vaping era, we conducted
an expert elicitation to explicitly consider the
impact of the ban on smoking initiation and cessa-
tion and on NVP use.19
This paper applies the results of our expert elici-
tation to evaluate a US menthol ban on all combus-
tibles, including cigarettes and cigars. We use the
previously developed smoking and vaping model
(SAVM)20 to simulate the impact of the ban on ciga-
rette and NVP use. We extend that model to distin-
guish menthol and non- menthol cigarette use and
to estimate the public health impact of a menthol
ban on combustible tobacco products.
METHODS
The SAVM is a compartmental model that simu-
lates the public health impact of cigarette and NVP
use over time for a specific set of birth cohorts in a
given population.20 The model is publicly available
as a Microsoft Excel file with a user manual.21 We
extend SAVM to project menthol and non- menthol
cigarette use in the absence of a ban (status quo
scenario) and in the presence of a ban (menthol ban
scenario). We estimate the public health impact as
the difference in smoking and vaping- attributable
deaths (SVADs) and life- years lost (LYLs) between
scenarios. Further description of the model and
model equations are found in online supplemental
file 1.
Status quo scenario
The SAVM20 first projects never, current and former
smoking prevalence using age and sex- specific
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Original research
initiation and cessation rates for each cohort of males and
females by individual age (0–85) beginning in 2013. The model
parameters were estimated by applying an age- period- cohort
statistical smoking model to National Health Interview Survey
(NHIS) data through 2013,22–25 thereby incorporating trends
before NVP use became more prevalent in 2013.26 Current
smoking is defined as having smoked ≥100 cigarettes during
one’s lifetime and currently smoking at least some days. Current
smokers become former smokers after having quit for 2 years
to reflect cessation net of relapse. Future smoking prevalence is
based on the estimated initiation and cessation rates.
Overlaying the smoking model, SAVM incorporates switching
from smoking to regular NVP use, NVP initiation and cessation,
and smoking initiation and cessation.20 To simplify the analysis
and because dual use is often unstable,27–31 dual users of ciga-
rettes and NVPs are included in SAVM as current smokers.30
Those who vape de novo or who switch from smoking to vaping
before age 35 are treated as exclusive vapers, reflecting the
minimal smoking- related mortality risks of smokers who quit by
age 35.32 33 Those who switch from smoking to vaping after age
35 become former smokers who vape.
An earlier version of the SAVM generally validated well,20 but
underestimated the decline in smoking. Given the importance
of smoking initiation to future smoking rates, we recalibrated
model parameters using 2013–2018 NHIS data, as described in
online supplemental file 1.
To incorporate menthol use, we differentiate menthol and
non- menthol smokers in the model by age and gender. Using
data from the 2013/2014 to 2016/2017 Population Assessment
of Tobacco and Health (PATH) study, menthol smokers are
defined as those whose regular brand is flavoured to taste like
menthol.34 Transitions in the status quo scenario are illustrated
in figure 1.
Smoking initiation rates for menthol and non- menthol smokers
are determined assuming a constant proportion of menthol
smokers among all smokers at age 30 (MP30), an age when most
initiation and smoking patterns have become established.35 36
Based on our analysis of PATH data (see online supplemental file
2), less than 3% of smokers switch between menthol and non-
menthol cigarettes or initiate smoking after age 30. Using PATH
data for ages 25–35, MP30 is estimated as the average proportion
of menthol smokers and is applied to smoker initiation rates at
each age a in year t as:
Menthol initiation ratea,t = MP30 smoking initiation ratea,t
Non menthol initiation ratea,t = (1 MP30) smoking initiation ratea,t
While this method does not explicitly model differences in
the trajectories of menthol and non- menthol use prior to age 30,
it implicitly allows for initiation as well as switching between
menthol and non- menthol use through age 30.
Age and year- specific cessation rates of menthol and non-
menthol smokers are based on transforming overall cessation
using the menthol proportion at each age (MPa) and the ratio
of the menthol to non- menthol cessation rates (RMNCr),
yielding:
Non menthol cessation rate
a,t
= overall cessation rate
a,t
/
(MPaRMNCr + 1MPa)
Menthol cessation ratea,t = non menthol cessation ratea,t RMNCr.
Based on recent studies11 37–41 and PATH data, we set
RMNCr=0.8 for all ages and both genders.
To allow for different switching rates from menthol and non-
menthol smoking to NVP use, we apply a similar method using
the ratio of menthol to non- menthol switching (RMNSw). We
assume that switching rate declines annually by 10% beginning
in 2018 (to reflect that those most amenable to vaping have
already switched).
Non menthol switching rate
a,t
= overall switching rate
a
(10.1)(t2018)/
(MPaRMNSw + (1 MPa))
Menthol switching ratea,t = non menthol switching ratea,t RMNSw
Based on recent PATH data, we set RMNSw at 0.9 for all ages
and both genders.
Given limited evidence of differential mortality,42 43 we assume
no difference in the mortality rates of menthol and non- menthol
smokers.
Online supplemental file 1 shows projected trends. The
proportion of menthol smokers among all smokers shows
an upward trend, consistent with trends reported in recent
studies.1–6
Menthol ban scenario
We model a federal menthol ban beginning in 2021. While the
model focuses on cigarette use, the ban is assumed to apply to
both cigarettes and cigars. We focused on the effect of a ban on
both, since little cigars have been found to be a close substitute
for cigarettes.44–46 Were cigars (especially little cigars) exempted,
many preban menthol cigarette smokers would likely switch to
menthol cigars.
We rely on the aforementioned expert elicitation.19 Finalised
in September 2020, the elicitation was specifically developed to
assess the impact of a menthol ban on smoking initiation and
cessation and on NVP use.19 The panel of experts was selected
using a three- pronged approach: (1) selection of lead and senior
authors of studies identified in a scoping review on the impact
of menthol and flavour bans18; (2) a search in Scopus to iden-
tify individuals who are the most published authors on the topic
of menthol tobacco and with an H- Index of ≥20; and (3) the
advice of an external advisory panel. After selecting 12 of the 82
experts with the highest rated criteria 1 and 2 above and with
Figure 1 Transitions between smoking and nicotine vaping product
(NVP) use states in the status quo scenario.
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Original research
no reported conflicts of interest, our final sample comprised 11
experts after one invitation was declined.
Experts were asked to estimate transitions regarding current
tobacco and NVP use patterns under a menthol cigarette
and cigar ban, including continued (illicit) menthol cigarette
or cigar smoker47; switching to non- menthol cigarettes or
cigars, smokeless tobacco or novel nicotine delivery products
(NNDPs, including NVPs and heated tobacco products); or
ceasing all nicotine product use. Because mortality risks for
cigars are similar to or less than those for cigarettes,48 49 esti-
mated panel transitions into cigar use are modelled as non-
menthol cigarette use. For convenience, the small percentage
of estimated transitions to smokeless tobacco use (2% for
ages 18–24 and <1% for ages 35–54) is also transferred to
non- menthol cigarette use. Although the elicitation included
heated tobacco products in NNDPs, we treat all such tran-
sitions as NVP use based on relatively similar risks.50–52 The
elicitation methodology and results are described further in
online supplemental file 2.
The experts first estimated the impact of a menthol ban on
smoking initiation for those aged 12–24 who, absent a ban,
would have initiated menthol smoking by age 24. Based on
experts’ mean estimates, 38.3% of otherwise menthol smokers
would instead become non- menthol smokers, 2.4% illicit
menthol smokers, 17.3% NVP users and 42.0% would not use
cigarettes or NVPs. These adjustments are applied to the initia-
tion rates of otherwise menthol smokers in 2021 and as ongoing
transitions in future years.
For those already menthol smokers, experts considered tran-
sitions over a 2- year period under the status quo and under
a menthol ban. We model the experts’ estimates of mean net
transitions (the difference in 2- year transitions under the status
quo and a menthol ban). Among current menthol smokers aged
18–24, 10.1% switch to illicit menthol combustibles, 48.0%
switch to non- menthol combustibles, 24.2% switch to NVPs
and 17.7% quit all product use. These transitions are applied
to menthol smokers through age 30. Among current menthol
smokers aged 35–54, 8.8% switch to illicit menthol cigarettes
and cigars, 59.1% switch to non- menthol tobacco use, 17.3%
switch to NVPs and 14.7% quit all product use. These transi-
tions are applied to menthol smokers above age 30. Current
non- menthol smokers were assumed to be unaffected by the ban.
Public health outcomes
Smoking- attributable deaths are estimated as the excess mortality
risk at each age for current and former smokers multiplied by
their respective populations. Vaping- attributable deaths are
measured in the same way, except vaping excess mortality risk
is initially set at 15% of excess smoking risk, higher than previ-
ously published estimates.53 54 Total LYLs are estimated at each
age by the number of SVADs multiplied by the expected years of
life remaining of a never smoker.
We estimate the public health impact of a menthol ban as the
differences in SVADs and LYLs in the status quo and menthol ban
scenarios over a 40- year period, 2021–2060. To address uncer-
tainties about the values of variables applied to both scenarios,
we conduct sensitivity analyses of the public health impacts with
excess mortality risks of NVPs at 5% and 25% that of excess
smoking risks, with smoking and NVP initiation and cessation
transitions and rates of switching from cigarettes to NVPs varied
by −10% and +10% of their baseline levels and with the ratio of
menthol to non- menthol cessation and menthol to non- menthol
switching equal to 1.
RESULTS
Public health impact under the base case status quo and
menthol ban scenarios
Table 1 presents the 2021–2060 menthol and non- menthol
smoking and NVP prevalence, SVADs and LYLs from the model
for US adults (aged >18), males and females combined (weighted
by population). Results from 2026 and 2060 are presented
to display illustrative short- term and long- term status. Online
supplemental file 3 provides breakdowns by gender and with the
time period extended from 2060 to 2080.
Under the status quo scenario, adult (age >18) menthol
smoking prevalence declines from 5.4% in 2021 to 4.5% in
2026 and 2.4% in 2060, while non- menthol smoking prevalence
declines from 7.1% in 2021 to 5.7% in 2026 and 2.7% in 2060.
Cumulative SVADs from 2021 to 2060 of 14.2 million translate
to 143.2 million LYLs.
Under the menthol ban scenario, adult menthol smoking
prevalence declines to 0.3% in 2026 and 0.1% in 2060, while
non- menthol smoking prevalence increases to 8.4% in 2026 but
declines to 4.2% in 2060. Cumulative SVADs of 13.6 million
translate to 131.9 million LYLs.
Figure 2A–C shows menthol, non- menthol and overall
smoking prevalence from 2013 to 2060 under the status quo
scenario and menthol ban scenario. By 2060, combined menthol
and non- menthol smoking prevalence falls from 5.1% under
the status quo to 4.3% with a menthol ban, a 15.1% relative
reduction. Exclusive NVP prevalence increases by 25% under
the menthol ban compared with status quo scenario (7.4% vs
5.8%). Cumulative SVADs by 2060 are reduced by 650 000
(4.6% relative reduction), and LYLs are reduced by 11.3 million
(7.9% relative reduction).
Sensitivity to NVP relative risks and NVP transition
parameters
Table 2 provides sensitivity analyses to variations in model
parameters relative to the baseline levels (case 1). With NVP risk
at 5% of excess smoking mortality risks and baseline levels of
other parameters (case 2), both total averted SVADs and LYLs
increase by 5%. With NVP risks at 25% (case 3), averted SVADs
and LYLs both decline by 5%.
With a 10% change in the smoking initiation rate (case 4, case
5), averted LYLs vary by 2% in the opposite direction and vary
by 6% in the same direction with a 10% change in the overall
smoking cessation rate (case 6, case 7). Equating the menthol to
non- menthol cessation rate (case 8) reduces the averted LYLs by
24%. With a 10% change in the overall switching rate to NVP
use (case 9, case 10), averted LYLs vary by about 3% in the oppo-
site direction. Assuming the same switching rate from menthol
smokers as non- menthol smokers (case 11) reduces averted LYLs
by 24%. Maintaining the switching rate at the 2018 level rather
than assuming a 10% annual decline (case 12) reduces averted
LYLs by 22%.
The results were relatively insensitive to NVP initiation (0.1%
change) and cessation rates (0.6% change) (cases 13–16).
DISCUSSION
In the absence of a ban on menthol in cigarettes and cigars, the
proportion of smokers who smoke menthol cigarettes is likely
to continue to increase over time even as overall smoking prev-
alence declines. With a ban implemented in 2021, we estimated
that combined menthol and non- menthol cigarette smoking
would decline by 14.7% by 2026 and by 15.1% by 2060 rela-
tive to combined smoking in the absence of a ban. With these
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Original research
Table 1 Smoking and NVP prevalence, smoking and vaping- attributable deaths, life- years lost and public health impact for both genders
combined, age 18 and above, 2021–2060
Status quo scenario
Category Category/year 2021 2026 2060 Cumulative impact*
Prevalence Menthol smoker 5.4% 4.5% 2.4% −55.7%
Non- menthol smoker 7.1% 5.7% 2.7% −62.6%
Total smokers† 12.6% 10.2% 5.1% −59.6%
Former smoker 19.4% 18.4% 9.2% −52.7%
Exclusive NVP user‡ 3.5% 4.7% 5.8% 64.4%
Former NVP user 0.2% 0.6% 4.6% 1972.5%
Smoking and vaping- attributable
deaths§
Menthol smoker 77 455 74 136 39 418 2 402 279
Non- menthol smoker 122 242 106 124 37 923 2 909 245
Former smoker 175 798 189 490 192 368 8 500 851
Exclusive NVP user‡ 5031 7296 11 032 392 107
Former NVP user 0 0 1717 12 811
Total 380 525 377 046 282 457 14 217 294
Life- years lost Menthol smoker 1 335 250 1 242 012 556 131 37 846 630
Non- menthol smoker 1 949 502 1 655 744 581 810 45 122 020
Former smoker 1 323 247 1 404 460 1 050 414 53 496 563
Exclusive NVP user 86 635 122 874 181 241 6 494 346
Former smoker- NVP user 85 815 117 704 50 734 4 246 249
Former NVP user 0 2 32 110 278 716
Total 4 694 635 4 425 092 2 401 706 143 238 275
Menthol ban scenario
Category Category/year 2021 2026 2060 Cumulative impact*
Prevalence Menthol smoker 5.4% 0.3% 0.1% −98.5%
Non- menthol smoker 7.1% 8.4% 4.2% −40.9%
Total smokers† 12.6% 8.7% 4.3% −65.7%
Former smoker 19.4% 19.1% 9.2% −52.4%
Exclusive NVP user‡ 3.5% 5.7% 7.4% 108.0%
Former NVP user 0.2% 0.6% 5.6% 2418.0%
Smoking and vaping- attributable
deaths§
Menthol smoker 77 455 6792 2557 271 469
Non- menthol smoker 122 242 151 299 55 379 4 157 520
Former smoker 175 798 191 098 195 744 8 620 599
Exclusive NVP user 5031 10 768 12 859 499 475
Former smoker- NVP user 5011 10 640 6815 413 819
Former NVP users 0 0 1895 14 010
Total 380 525 359 958 268 435 13 563 073
Life- years lost Menthol smoker 1 335 250 111 678 30 555 4 174 157
Non- menthol smoker 1 949 502 2 403 756 841 520 64 926 659
Former smoker 1 323 247 1 424 993 1 065 194 54 531 402
Exclusive NVP user‡ 86 635 122 874 181 241 6 494 346
Former smoker- NVP user 85 815 168 033 56 050 5 418 265
Former NVP user 0 2 35 817 306 840
Total 4 694 635 4 113 651 2 182 890 131 927 198
Difference between menthol status quo and menthol ban scenario
Relative reduction in prevalence Menthol smoker −92.5% −96.5%
Non- menthol smoker 47.4% 58.0% –
Total smokers† −14.7% −15.1%
Total NVP users‡ 22.6% 26.5%
Gain Averted deaths 17 088 14 022 654 221
Averted life- years lost 311 441 218 817 11 311 077
*The cumulative impact is measured in terms of the relative change from 2021 to 2060 for prevalence rates (ie, (2060–2021)/2021) and the sum of the smoking and vaping-
attributable deaths or life- years lost over the years 2021 through 2060.
†Total smokers include menthol and non- menthol smokers.
‡Exclusive NVP users include de novo exclusive NVP users and former smokers now using NVPs.
§The number of smoking and vaping- attributable deaths and life- years lost is rounded to the nearest integer.
¶The difference between the Status quo and Menthol ban scenarios includes the comparisons for prevalence in relative terms and for health gains in absolute terms. Relative
reduction in prevalence is measured as the relative difference between the status quo scenario and the menthol ban scenario (ie, (postban–preban)/preban) in years 2026 and
2060; the health gain is measured as the change in averted deaths and life- years lost from the Status quo scenario and the Menthol ban scenario.
NVP, nicotine vaping product.
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Original research
reductions, SVADs were estimated to fall by about 5% and
LYLs by 8.8%, translating to 650 000 deaths averted (16 250
per year) and 11.3 million life- years gained (almost 300 000 per
year) over a 40- year period. These impacts are large relative to
other tobacco control policies,55 and the public health gains are
observed over a wide range of parameter values in the model.
Further, while we focus on health gains over a 40- year period,
much of the impact is on initiation and related health effects that
occur after 40 years. When the analysis is extended to consider
a 60- year period, life- years gained increase from 11.3 to 14.7
million (see online supplemental file 3).
Our analysis expands on previous research by incorporating
NVP use. A relatively large percentage of menthol smokers,
particularly young menthol smokers, switch to NVP use. While
increased NVP use presents its own risks, sensitivity analyses
indicated that assuming NVP excess mortality risks are 25%
those of smokers still yields 620 000 deaths averted and 10.7
million life- years gained under a ban. Increasing the NVP initia-
tion rate and reducing the NVP cessation rate also had minimal
effects, despite our assumption that cessation from NVPs is
no more likely than from cigarettes. Nevertheless, these risks
and the potential for NVPs to be a gateway to smoking, while
uncertain, could influence the public health impact of a menthol
ban in combustibles. If these prove to be a significant problem,
stronger policies may be needed to reduce NVP use among
youth. However, while the public health implications were
relatively insensitive to changes in the rate of NVP initiation
and cessation, they were sensitive to rates of switching from
cigarette to NVP use, suggesting that policies to reduce NVP
use among youth could also reduce their use by adults, thereby
reducing adult smoking cessation.
Our results are conservative in some respects. First, we
considered impacts through 2060. Beyond 2060, deaths averted
would increase both in absolute and relative terms as the effects
on younger generations of reduced smoking are fully realised.
We also limited the direct effects of a menthol ban on current
menthol smokers to 2 years. Further increases might be expected
over time (eg, via additional cessation from illicit menthol or
from non- menthol smoking by previous menthol smokers). Our
analysis does not consider the effects of a menthol ban on non-
menthol smokers. Peer effects of reduced menthol smoking by
family, friends, parents or coworkers may motivate more non-
menthol smokers to quit.18 While the expert elicitation expected
relatively small impacts on non- menthol smokers,19 a 5% reduc-
tion in non- menthol use (as suggested by one expert) spread
equally between NVPs and no tobacco use would further avert
69 000 deaths (a 9% increase compared with our baseline find-
ings) and 1.1 million LYLs (10% increase) by 2060. Finally, we
do not explicitly include current cigar use in this application of
the model. Public health benefits are also likely to accrue for
current cigar smokers, who may quit all use or switch to NVPs
in reaction to a ban.
Figure 2 (A) Current menthol smoking prevalence (age 18 and
above), menthol SAVM, status quo and menthol ban scenarios, 2013–
2060. (B) Current non- menthol smoking prevalence (age 18 and above),
menthol SAVM, status quo and menthol ban scenarios, 2013–2060. (C)
Current overall smoking prevalence (age 18 and above), menthol SAVM,
status quo and menthol ban scenarios, 2013–2060. SAVM, smoking and
vaping model.
Table 2 Sensitivity analysis of averted smoking and vaping- attributable deaths and life- years lost to NVP relative risks and individual transition
parameters, both genders combined, all ages, 2021–2060
Case Description
Smoking and vaping-
attributable deaths
averted % change*
Smoking and vaping-
attributable life- years
lost averted % change*
1 Base case with NVP at 15% of cigarette excess mortality risk 654 221 11 311 077
2 NVP risk at 5% of cigarette- attributable excess mortality risk 687 209 5.0 11 924 114 5.4
3 NVP risk at 25% of cigarette- attributable excess mortality risk 622 425 −4.9 10 707 764 −5.3
4 Reduce overall smoking initiation rates by 10% 647 128 −1.1 11 083 049 −2.0
5 Increase overall smoking initiation rates by 10% 661 201 1.1 11 535 131 2.0
6 Reduce overall smoking cessation rates by 10% 702 353 7.4 11 979 548 5.9
7 Increase overall smoking cessation rates by 10% 609 459 −6.8 10 679 917 −5.6
8 Menthol cessation rate the same as non- menthol rate 461 006 −29.5 8 577 213 −24.2
9 Reduce overall switching rate by 10% 670 082 2.4 11 612 042 2.7
10 Increase overall switching rate by 10% 638 805 −2.4 11 019 404 −2.6
11 Menthol cessation rate the same as non- menthol rate 461 006 −29.5 8 577 213 −24.2
12 Reduce the annual decline in switching rate from 10% to 0% 520 179 −20.5 8 830 696 −21.9
13 Reduce NVP initiation rates by 10% 654 443 0.03 11 318 431 0.1
14 Increase NVP initiation rates by 10% 654 001 −0.03 11 303 795 −0.1
15 Reduce NVP cessation rates by 10% 650 266 −0.6 11 253 710 −0.5
16 Increase NVP cessation rates by 10% 657 768 0.5 11 363 818 0.5
*% change is in terms of the relative difference from the base case (eg, (687 209–654 221)/654 221 for case 2 relative to case 1).
NVP, nicotine vaping product.
School of Public Health. Protected by copyright. on September 22, 2021 at Public Health Libraryhttp://tobaccocontrol.bmj.com/Tob Control: first published as 10.1136/tobaccocontrol-2021-056604 on 2 September 2021. Downloaded from
6LevyDT, etal. Tob Control 2021;0:1–8. doi:10.1136/tobaccocontrol-2021-056604
Original research
We did not perform analyses of subpopulations within the
USA. Our expert elicitation19 suggested larger impacts on
African- Americans. Under a menthol ban, experts estimated 48%
of African- Americans who would otherwise initiate menthol
smoking would not initiate smoking or vaping compared with
39% for the overall population, and African- American menthol
smokers aged 35–54 would be more likely to quit all tobacco
use (27% vs 22%). With African- Americans having dispropor-
tionately high rates of menthol smoking,3 7 56 a menthol ban
would reduce downstream health disparities in smoking- related
morbidity and mortality.57 58
Limitations
The results depend on parameters and assumptions underlying
the model. While the model was calibrated to incorporate the
increase in NVP use through 2018, youth NVP rates increased
further in 201959 60 and then fell substantially in 2020,59 indi-
cating that NVP use is difficult to predict. Although some
evidence suggests that NVP use may increase smoking initia-
tion,61 62 recent increases in youth vaping coincide with rapid
declines in smoking by youth and young adults.63 64 If these
reductions in youth and young adult smoking are not main-
tained, the increased smoking rates among youth and young
adults would lead to a larger impact from a menthol ban.
Another limitation is that SAVM does not distinguish dual use
of NVPs and cigarettes from exclusive cigarette use. While some
studies indicate stable levels of dual use,65 66 other studies indi-
cate dual use is an unstable use state, with high rates of transition
to exclusive NVP use or cigarette smoking.27–31 Moreover, some
studies suggest similar health risks for dual users as for exclusive
smokers,67–69 although others have suggested higher levels.70–72
Further study is warranted on health impacts and patterns of
dual use. The model also does not distinguish the health impact
experienced by exclusive menthol cigarette smokers who switch
to cigar use as a result of a menthol ban. While a recent study
found similar levels of biomarker- based risk exposure of exclu-
sive cigar and exclusive cigarette users48 73 and smoking patterns
of little cigar users have been found to be similar to those of
cigarette users,74 further exploration is warranted on the health
impacts of cigar use, especially different types of cigars, for
example, little cigars, cigarillos or large cigars. Those switching
to smokeless tobacco were also not distinguished. While our
expert panel indicated minimal switching to smokeless tobacco,
current marketing of oral products, such as ON!,75 may increase
the likelihood of switching to these products.
The results are also subject to uncertainties regarding the
impact of a menthol ban. The menthol ban transitions were
based on results of an expert elicitation.19 While we adopted a
well- defined selection process that screened for menthol- related
research expertise, the results are dependent on the selected
reviewers.19 In addition, because expert elicitations rely on opin-
ions, they are subject to heuristics and biases that are difficult to
correct.76–79 The opinions of individual experts differed consid-
erably, especially regarding the extent of switching to exclusive
NVP and no use. However, the use of median rather than mean
estimates of net transitions (not shown) had little effect on the
results. The elicitation results are also consistent with our recent
review of menthol ban studies,18 while the magnitude of our
findings is broadly consistent with those of a previous menthol
ban model17 and a recent study of menthol bans.80
We modelled a ban on menthol applied to both cigarettes and
cigars to restrict substitution from cigarettes to little cigars.81–84
We did, however, ask the experts about the impact of a menthol
ban on just cigarettes, which the experts indicated would have
substantially less impact. We also asked experts about the impact
of a menthol ban that is extended to all nicotine delivery prod-
ucts, including NVPs, and they indicated that menthol smokers
were less likely to switch out of menthol cigarette use (ie, into
NVPs or no regular use) in that scenario compared with a ban
limited to cigarettes and cigars. This outcome is consistent with
expectations that menthol smokers would be especially likely to
switch to menthol NVPs.85 The effects of a menthol ban will also
depend on other tobacco control policies. In particular, higher
cigarette taxes would reduce smoking initiation and increase
cessation,86–90 and increased enforcement of age 21 purchase
laws would likely reduce smoking initiation.91 92 While these
policies would reinforce the effects of a ban, they may reduce its
relative impact, as suggested by our sensitivity analyses regarding
reduced smoking initiation and increased smoking cessation.
Finally, the results depend on the modelling approach. Further
research might consider expanded categories of nicotine delivery
product types (eg, inclusion of smokeless tobacco, distinguishing
NVP device type) and multiproduct use, feedback loops via
system dynamics models (eg, due to reactions by government or
industry to policy changes) and heterogeneity of the population
via microsimulation (eg, differential effects by race or socioeco-
nomic status).24 25
CONCLUSION
Our findings strongly support the implementation of a ban on
menthol in cigarettes and cigars on public health grounds. These
gains reflect reduced smoking initiation and increased smoking
cessation. Support for a menthol ban is strengthened by sensi-
tivity analyses showing that large public health benefits accrue
under a broad range of model parameters. Additional public
health benefits may be expected through reductions in menthol
cigar use.
What this paper adds
The US Food and Drug Administration (FDA) recently
announced its intention to ban menthol in combustible
products. Previous research has focused on the relationship
between menthol cigarette use and initiation and cessation
and on the impact of menthol use on overall smoking, but
has not considered the potential impact on future cigarette
and nicotine vaping product use if a ban of menthol in
cigarettes and cigars were to be implemented. Additional
evidence is needed by the FDA on its public health impact.
Our model estimates that such a menthol ban on cigarettes
and cigars could prevent 650 000 premature tobacco- related
deaths and reduce life- years lost by 11 million over a 40-
year period. These gains accrue under a broad range of
assumptions.
Our findings strongly support implementation of a ban on
menthol in cigarettes and cigars on public health grounds.
Twitter Alex C Liber @AlexCLiber and Cliff Douglas @cdoug
Acknowledgements We would like to thank Stephanie Land for her helpful
comments.
Contributors DTL and RM supervised the project and were the principal writers
of the original manuscript and the revised manuscript. ZY conducted the original
data analysis and wrote the original methods and results sections. YL conducted the
original data analysis and helped write the original methods and results sections.
CC led the original expert elicitation and helped write the methods section and
revisions. LMS- R and NT helped lead the original expert elicitation and helped write
the methods section and revisions. MK conducted the data analysis on the expert
School of Public Health. Protected by copyright. on September 22, 2021 at Public Health Libraryhttp://tobaccocontrol.bmj.com/Tob Control: first published as 10.1136/tobaccocontrol-2021-056604 on 2 September 2021. Downloaded from
7
LevyDT, etal. Tob Control 2021;0:1–8. doi:10.1136/tobaccocontrol-2021-056604
Original research
elicitation and helped write the methods section and revisions. RMi, JLH, NFL, SS,
AFB, ACL and CD helped write the original paper and revisions. JJ helped conduct
the analysis, and write the original paper and revisions. KEW was a major contributor
to the original paper and revisions.
Funding This project was funded through the National Cancer Institute (NCI) and
the Food and Drug Administration (FDA) grant U54CA229974.
Disclaimer The opinions expressed in this article are the authors’ own and do not
reflect the views of the National Institutes of Health, the Department of Health and
Human Services, or the US government.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request. The
model and data will be provided upon request.
Supplemental material This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
ORCID iDs
David TLevy http:// orcid. org/ 0000- 0001- 5280- 3612
RafaelMeza http:// orcid. org/ 0000- 0002- 1076- 5037
Luz MariaSanchez- Romero http:// orcid. org/ 0000- 0001- 7951- 3965
NargizTravis http:// orcid. org/ 0000- 0001- 6305- 8259
Alex CLiber http:// orcid. org/ 0000- 0001- 7863- 3906
RiteshMistry http:// orcid. org/ 0000- 0003- 1514- 1466
Nancy LFleischer http:// orcid. org/ 0000- 0002- 4371- 9133
Andrew FBrouwer http:// orcid. org/ 0000- 0002- 3779- 5287
CliffDouglas http:// orcid. org/ 0000- 0001- 6910- 2599
Kenneth EWarner http:// orcid. org/ 0000- 0002- 8214- 1776
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... 7 8 The Menthol Smoking and Vaping Model (SAVM) estimated the public health impact of a menthol ban on the total US population. 9 10 The recent FDA menthol ban proposal 6 cited public health impact projections from the original menthol SAVM model 10 in support of banning menthol in cigarettes. On page 93, however, the report noted that failure to separately consider 'vulnerable populations', particularly the non-Hispanic black (NHB) population, was a limitation of the analysis. ...
... 7 8 The Menthol Smoking and Vaping Model (SAVM) estimated the public health impact of a menthol ban on the total US population. 9 10 The recent FDA menthol ban proposal 6 cited public health impact projections from the original menthol SAVM model 10 in support of banning menthol in cigarettes. On page 93, however, the report noted that failure to separately consider 'vulnerable populations', particularly the non-Hispanic black (NHB) population, was a limitation of the analysis. ...
... The SAVM is a publicly available model 16 that simulates the public health impact of cigarette and NVP use. 17 On distinguishing menthol and non-menthol cigarette use, menthol SAVM 10 ...
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Introduction With the US Food and Drug Administration recently proposing to implement a ban on menthol cigarettes, it is critical to estimate the potential public health effects of such a ban. With high rates of menthol cigarette use and important smoking-related health disparity implications, the impact of the ban on the non-Hispanic black (NHB) population merits strong consideration. Methods We apply the previously developed Menthol Smoking and Vaping Model to the NHB population. A status quo scenario is developed using NHB-specific population, smoking and vaping initiation, cessation and death rates. Estimates from a recent expert elicitation on behavioural impacts of a menthol cigarette ban on the NHB population are used to develop a menthol ban scenario implemented in 2021. The public health impacts of the menthol ban are estimated as the difference between smoking and vaping attributable deaths (SVADs) and life years lost (LYLs) in the status quo and the menthol ban scenarios from 2021 to 2060. Results Under the menthol ban scenario, overall smoking is projected to decline by 35.7% in 2026 and by 25.3% in 2060 relative to the status quo scenario. With these reductions, SVADs are estimated to fall by about 18.5% and LYLs by 22.1%, translating to 255 895 premature deaths averted, and 4.0 million life years gained over a 40-year period. Conclusions A menthol cigarette ban will substantially reduce the smoking-associated health impact on the NHB population, thereby reducing health disparities.
... To inform the debate over national policy and future studies of the effects of these policies, [22] we synthesize the current literature on implemented or hypothetical restrictions on product sales that include flavoured ENDS. Given the novelty of flavoured ENDS restrictions and the limited availability of data, we opted to conduct a scoping review to identify the current evidence on the impacts of restrictions and ongoing knowledge gaps with the goal of providing an overview of the evidence [23]. ...
... These studies illustrate how the impacts of an ENDS flavour restriction may depend on other flavour restrictions, such as menthol in cigarettes. However, it remains hard to disentangle the effects from the identified studies and extrapolate to the population level [22,67]. ...
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Objective To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions. Data sources PubMed, Scopus, Embase and Web of Science before May 3, 2022. Study selection Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions. Data extraction Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance. Data synthesis We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6–39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products. Conclusion Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.
... 8 Research suggests that banning menthol may reduce overall tobacco use, promote smoking cessation, prevent initiation, and substantially reduce tobacco-attributable deaths and life-years lost. [9][10][11][12][13][14] Most of the research to date, however, has been disadvantaged by the lack of real-world menthol policies in place, 8 consisting of simulation models, [13][14][15][16] analyses of sales data, 17 18 studies relying on expert elicitation to produce estimates of the impact of a hypothetical menthol ban, 19 experimental studies, 20 and survey studies assessing behavioural intentions of menthol smokers in response to a hypothetical or future ban. [21][22][23][24] To date, population-level longitudinal studies of the actual behavioural impact of menthol bans have been conducted in Canada, where menthol cigarettes were banned between May 2015 and July 2017 among some provinces, progressing to a national ban in October 2017. ...
... Bivariate and multivariable analyses were conducted in Stata/ SE V. 16 oversampling of those aged 18-24 years old. Longitudinal inflation weights for the current cohort sample (those who participated in waves 1-3) were calibrated to represent the Dutch population of smokers at wave 1 by sex and age, education and region. ...
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Introduction To reduce the appeal of tobacco, the European Union (EU) banned menthol as a characterising flavour in cigarettes in May 2020. This pre/post-study evaluated the impact of the menthol ban on smoking cessation outcomes among a representative cohort of Dutch smokers. Methods Adult (18+ years) smokers were recruited at wave 1 (pre-ban) of the International Tobacco Control Netherlands Surveys (February–March 2020) and followed post-ban at wave 2 (September–November 2020) and wave 3 (June–July 2021) (N=1326 participated in all three waves). Weighted bivariate, logistic regression and generalised estimating equation model analyses were conducted. Results Usual menthol use decreased from pre-ban (7.8%) to post-ban (4.0% at wave 2 and 4.4% at wave 3) (p<0.001). Pre-ban menthol smokers had greater odds of making a post-ban quit attempt than non-menthol smokers (66.9% vs 49.6%, adjusted OR (aOR)=1.89, 95% CI: 1.13 to 3.16). Compared with pre-ban non-menthol smokers, a higher proportion of menthol smokers quit by wave 2 (17.8% vs 10.2%, p=0.025) and by wave 3 (26.1% vs 14.1%, p=0.002), although this was not significant after adjusting for other factors. Female pre-ban menthol smokers had greater odds of quitting by wave 3 than female non-menthol smokers (aOR=2.23, 95% CI: 1.10 to 4.51). Most pre-ban menthol smokers (n=99) switched to non-menthol cigarettes (40.0%) or reported that they continued to smoke menthol cigarettes (33.0%) at wave 3. Conclusions The EU menthol ban was effective in reducing menthol use and in increasing quit attempts and quitting among pre-ban menthol smokers. Impact could be maximised by closing gaps that allow post-ban menthol cigarette use.
... Evidence indicates that NVP use [74][75][76][77] and HTP use [57][58][59][60][61][62][63][64][65][66] are likely much less harmful than cigarette use. NVP use is often estimated at 5% to 15% of the excess mortality risks of cigarettes [6,[40][41][42][43][44]78], although there is considerable controversy on the precise level of the difference [44,79,80]. HTPs are likely more harmful than NVPs, with some estimates ranging from 1.5 to 2 times more harmful than NVPs [43,61,65,[81][82][83], implying HTP risks at about 7.5% to 30% of the excess mortality risks of cigarettes. ...
Article
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Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.
... 29 In the US, banning menthol cigarettes and cigars is estimated to reduce overall smoking prevalence and smoking-related deaths. 30 Evidence on the outcomes of menthol bans among youth outside of Canada is lacking. among these groups. ...
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Importance: Menthol cigarettes were prohibited in England in May 2020 and nationally in Canada in October 2017 but remain permitted in the US. Evidence on the outcomes of menthol cigarette bans among youth outside of Canada, and the characteristics of youth smokers, is lacking. Objectives: To evaluate the outcomes of menthol cigarette bans on youth menthol cigarette smoking and to characterize youth menthol cigarette smokers in terms of demographics and cigarette consumption and dependence. Design, setting, and participants: This survey study uses data from online repeat cross-sectional International Tobacco Control Youth Tobacco and Vaping Surveys conducted in 2018, 2019, February 2020, and August 2020. Participants included past 30-day smokers aged 16 to 19 years. Data analysis was performed from March 2021 to January 2022. Main outcomes and measures: Usually smoke a brand of cigarettes that was menthol, including capsule. Exposures: Menthol cigarette ban, comparing 3 countries over time: Canada, where a ban already existed, England, where a ban was implemented during the study, and the US, where no national ban was present. Age, sex, race, and consumption and dependence were also examined by menthol smoking in each country, and in England before vs after the ban. Results: The analytical sample comprised 7067 participants aged 16 to 19 years, of whom 4129 were female and 5019 were White. In England, the weighted percentage of youth smokers who reported smoking a menthol or capsule cigarette brand was stable in the 3 survey waves before the menthol ban (2018 to February 2020, 9.4% vs 12.1%; adjusted odds ratio [AOR], 1.03; 95% CI, 0.99-1.06; P = .15) but decreased to 3.0% after the ban (February 2020 vs August 2020, AOR, 1.07; 95% CI, 1.04-1.10; P < .001). The decrease between February and August 2020 in England was similar across all demographic groups but was greater among youth who perceived themselves as addicted to cigarettes (AOR, 0.37; 95% CI, 0.41-0.97; P = .04). In the 2 comparison countries, menthol or capsule smoking was stable across all waves (2018 to August 2020: US, 33.6%-36.9%; Canada, 3.1%-2.3%) and was more prevalent in the US than in England (AOR, 5.58; 95% CI, 4.63-6.72; P < .001). Menthol or capsule smoking was also more prevalent among smokers in England who were female vs male (10.9% vs 7.2%; AOR, 1.04; 95% CI, 1.01-1.06; P = .002); among smokers in the US who identified as Black vs White (60.6% vs 31.9%; AOR, 1.33; 95% CI, 1.23-1.44; P < .001) or who were frequent smokers (AOR, 1.07; 95% CI, 1.01-1.13; P = .03), smoked more cigarettes per day (2-5 vs 1, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1, AOR, 1.10; 95% CI, 1.03-1.18; P = .007), or had urges to smoke every or most days (AOR, 1.08; 95% CI, 1.02-1.14; P = .006); and among smokers in Canada who perceived themselves as addicted to cigarettes (AOR, 1.02; 95% CI, 1.00-1.03; P = .01). Conclusions and relevance: In this survey study, the proportion of youth smokers who smoke menthol (including capsule) cigarettes decreased substantially after the menthol ban in England. This association was consistent across all demographic groups. Perceived addiction among menthol smokers was also lower where menthol cigarettes were banned.
... We believe that applying our Canadian effect size from our pooled Canadian population cohort data to African American smokers might underestimate the possible impact of a menthol cigarette ban in the US, given the findings of surveys asking menthol smokers what they would do if menthol cigarettes were banned, which show that African American menthol smokers were more likely than White menthol smokers to say that they would quit 7,14 , a pattern that is also suggested in the expert elicitation studies. 9,10 The most specific data regarding what quit rates might be for Black menthol smokers relative to Non-Blacks in the US following a menthol ban come from our pooled Canadian analysis. Despite our low sample size of only 30 Black smokers, of which 4 were mainly menthol smokers, we did find that Black menthol smokers had a significantly higher quit rate than non-Black menthol smokers (p=0.029; ...
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Introduction: Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA. Methods: Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health. Results: After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans). Conclusions: This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.
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Introduction The Food and Drug Administration (FDA) has issued proposed product standards banning menthol as a characterising flavour in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared with usual brand menthol cigarettes (UBMC). Methods Ninety-eight adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and three menthol cigarette alternatives in random order at the subsequent visits: (1) a preassembled menthol roll-your-own (mRYO) cigarette using menthol pipe tobacco and mentholated cigarette tube, (2) a menthol filtered little cigar (mFLC) and (3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects and behavioural economic demand indices were assessed. Results Compared with UBMC, menthol cigarette alternatives resulted in different puffing topography and CO exposure (except mRYO), and lower levels of positive subjective experience and behavioural economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase and use the mRYO product regularly compared with mFLC and NMC. Conclusions and relevance mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA’s proposed ban.
Article
Background The purpose of this study was to determine the effects of smoking and other outcomes of assigning cigarettes with reduced nicotine and/or no menthol to female menthol smokers. Aims and Methods Nontreatment-seeking female menthol smokers (N = 263) participated in a randomized controlled trial in which levels of menthol and nicotine in cigarettes were manipulated using experimental cigarettes. After a baseline period, participants were assigned to the following conditions for 6 weeks: (1) their own brand of cigarette (conventional nicotine with menthol), (2) a conventional nicotine cigarette with no menthol, (3) a cigarette with reduced nicotine (RNC) with menthol, or (4) a RNC cigarette and no menthol. Participants then returned to using their own brand and were followed for another 6 weeks. Outcomes included cigarettes smoked, biomarkers of exposure, and dependence measures. Results Results indicated that, after an initial increase, rates of smoking of all three experimental cigarettes were at or below baseline rates of smoking of one’s own brand. Levels of biomarkers also decreased during the experimental phase but rebounded somewhat after participants resumed smoking their own brand. There was evidence that the overall amount of smoking decreased similarly among women who switched to non-menthol and/or RNC cigarettes. Conclusions These results suggest that no detrimental effect will occur in nicotine or toxicant exposure levels with a ban on characterizing menthol and/or a product standard on nicotine content in cigarettes. Implications The implication of this work is that there would be no risk to women menthol smokers associated with regulations restricting nicotine and eliminating menthol in cigarettes.
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Mechanistic and biologically based mathematical models of chronic and behavioral disease processes aim to capture the main mechanistic or biological features of the disease development, and to connect these with epidemiological outcomes. These approaches have a long history in epidemiological research and are complementary to traditional epidemiological or statistical approaches to investigate the role of risk factor exposures on disease risk. In the article by Simonetto et al. (Am J Epidemiol. XXXX;XXX(XX):XXXX–XXXX)), the authors present a mechanistic, process-oriented, model to investigate the role of smoking, hypertension and dyslipidemia on the development of atherosclerotic lesions and their progression to myocardial infarction (MI). Their approach builds on and brings to cardiovascular disease the ideas and perspectives of earlier mechanistic and biologically based models for the epidemiology of cancer and other chronic diseases, providing important insights into the mechanisms and epidemiology of smoking related MI. We argue that although mechanistic modeling approaches have demonstrated their value and place in epidemiology, they are highly underutilized. We call for efforts to grow mechanistic and biologically based modeling research, expertise and awareness in epidemiology, including the development of training and collaboration opportunities to attract more students and researchers from STEM areas into the epidemiology field.
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Purpose To describe patterns of menthol/non-menthol cigarettes with flavored e-cigarettes (tobacco, menthol, sweet/spicy, and other flavorings) use. Design We used cross-sectional data from the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Setting United States. Subjects Adults over 18 years old. Sample A nationally representative sample (n = 135 329). Measures We generated a 15-category variable of all combinations of cigarette and e-cigarette flavoring use. Analysis We estimated population prevalence (PP) for the 15-category flavored cigarette and e-cigarette use variable and proportion of flavored cigarette and e-cigarette use among adults who used cigarettes or e-cigarettes (PAU) by age, sex, race/ethnicity, and income. Results Exclusive menthol cigarette use was higher among NH Black (PP = 8.79%, PAU = 68.96%) and low-income (PP = 4.86%, PAU = 29.09%) compared to NH White (PP = 2.63%, PAU = 18.83%) and high-income participants (PP = 1.25%, PAU = 19.02%). Exclusive sweet/spicy e-cigarette use (PP = 1.32%, PAU = 10.22%) and exclusive menthol e-cigarette use (PP = .95%, PAU = 7.40%) was higher in younger (18-34) vs older (35+) adults (PP = .34% and PAU = 2.76%, and PP = .14%, PAU = 1.11%, respectively). Older dual users tended to combine the same flavor in both products (eg, menthol cigarettes + menthol e-cigarettes), while younger adults were more likely to combine menthol and non-menthol cigarettes with sweet/spicy e-cigarettes. Conclusion Findings suggest that a menthol cigarette ban might be most effective in conjunction with sweet/spicy e-cigarette flavor restrictions, given these flavors are attractive for younger adults.
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Background Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA. Methods SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses. Results The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters. Discussion Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data. Conclusion The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.
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Objective To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018. Methods Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey. 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans. Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting. Results At follow-up, 59.1% of pre-ban menthol smokers switched to non-menthol cigarettes; 21.5% quit smoking and 19.5% still smoked menthols, primarily purchased from First Nations reserves. Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=1.61, 95% CI 1.03 to 2.51), and to remain quit (aOR=2.30, 95% CI 1.06 to 5.01). Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=1.72, 95% CI 0.98 to 3.01); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=2.21, 95% CI 1.15 to 4.24), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=2.81, 95% CI 1.15 to 6.85). Conclusions Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban. Results confirm and extend evaluation of Ontario’s menthol ban across provinces covering 83% of the Canadian population.
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Despite overall reductions in U.S. smoking prevalence, prior evidence suggests similar reductions may not have occurred for menthol cigarette users. This study examines nationally representative current menthol and non-menthol cigarette use prevalence and trends for adults (18+) overall and by sociodemographic and geographic characteristics using the 2005 (n = 31,132), 2010 (n = 26,967), and 2015 (n = 33,541) National Health Interview Survey. Between 2005 and 2015, non-menthol cigarette use decreased overall (14.7% to 9.6%, p < 0.001) and within all sociodemographic and geographic subgroups analyzed (i.e., by sex, age, race/ethnicity, sexual orientation, education, family income, and geographic region), except non-Hispanic American Indians/Alaskan Natives (NH AI/AN) and non-Hispanic Others. Menthol cigarette use significantly decreased overall (5.3% to 4.4%, p < 0.001), and among females (5.6% to 4.6%); participants aged 18–24 (7.1% to 4.3%) and 35–54 (6.2% to 4.9%); non-Hispanic Whites (4.1% to 3.6%) and non-Hispanic Blacks (14.8% to 11.9%); participants with high school degrees/GEDs (7.0% to 5.9%); participants with a family income of $75,000 or higher (3.4% to 2.3%); and participants residing in the Northeast (6.0% to 4.3%). Menthol cigarette use remained stable or did not significantly decrease among males; adults aged 25–34 and 55 years and older; NH AI/ANs, NH Others, and Hispanics; participants with less than high school education, some college, or a college degree; participants with a family income below $75,000; and participants residing in the North Central/Midwest, South, and West. Given that menthol cigarette use did not significantly change or decrease for multiple subgroups, further restriction on menthol manufacturing may help reduce tobacco use disparities.
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Importance Use of e-cigarettes increased among adolescents between 2011 and 2019. However, whether these changes are affecting patterns of use of other tobacco products, especially cigarettes, remains unclear. Objective To examine the long-term and recent trends in cigarette smoking and smokeless tobacco product use among US adolescents by grade (8th, 10th, and 12th), sex (male and female), and race (White and Black). Design, Setting, and Participants In this cross-sectional study, joinpoint regression analyses were performed to characterize trends in tobacco product use for key sociodemographic groups, identifying change of trend years (joinpoints). Students in the 8th, 10th, and 12th grades at US secondary schools and high schools who participated in the nationally representative Monitoring the Future survey from January 7, 1991, to June 3, 2019, were evaluated. Exposures Cigarette smoking and smokeless tobacco product use during the past 30 days. Main Outcomes and Measures Past 30-day and daily prevalence of cigarette smoking and smokeless tobacco product use by year, grade, sex, and race. The prevalence trend segments, change of trend years (joinpoints), and annual percentage change (APC) in prevalence within each trend segment were estimated using joinpoint regression. Results Since 1991, 487 335 8th-grade, 447 310 10th-grade, and 424 236 12th-grade students have completed the Monitoring the Future survey (including 663 663 girls and 632 698 boys [those who did not respond to the sex question in the survey were excluded from the sex analyses]). Past 30-day and daily smoking prevalence increased in all groups analyzed from 1991 until 1996 and 1997 and has been decreasing ever since, with more rapid reductions in recent years. For example, daily smoking among 12th-grade boys increased at an APC of 4.9% (95% CI, 3.5%-6.3%) from 1991 to 1998, decreased at an APC of −8.0% (95% CI, –9.3% to –6.7%) from 1998 to 2006, decreased at an APC of −1.6% (95% CI, –4.6% to 1.5%) from 2006 to 2012, and decreased at an APC of −17.4% (95% CI, –19.4% to –15.4%) from 2012 to 2019. Similar results were observed for boys in the 8th grade (5.0% [95% CI, 0.1%-10.2%] for 1991-1996, –8.8% [95% CI, –10.0% to –7.6%] for 1996-2011, and –17.3% [95% CI, –22.2% to –12.0%] for 2011-2019) and 10th grade (7.1% [95% CI, 3.7%-10.7%] for 1991-1997, –11.1% [95% CI, –13.9% to –8.2%] for 1997-2005,–0.7% [95% CI, –5.9% to 4.9%] for 2005-2011, and −17.9 [95%, –21.7% to –13.9%] for 2011-2019), for girls in 8th grade (10.9% [95% CI, 5.0%-17.2%] for 1991-1996 and –10.8% [95% CI, –11.7% to –10.0% for 1996-2019), 10th grade (7.2% [95% CI, 3.9%-10.7%] for 1991-1997, –9.5% [95% CI, –10.5% to –8.6%] for 1997-2012, and –16.3% [95% CI, –21.8% to –10.4%] for 2012-2019), and 12th grade (6.5% [95% CI, 3.6%-9.5%] for 1991-1997, –7.2% [95% CI, –8.1% to –6.3%] for 1997-2012, and –17.5% [95% CI, –21.2% to –13.6%] for 2012-2019). Results were similar, too, for Black adolescents (2015-2019 average annual percentage change: –8.6% [95% CI, –10.3% to –6.8%] for 8th graders; –17.7% [95% CI, –26.3% to –8.2%] for 10th graders; and –18.3% [95% CI, –23.9% to –12.2%] for 12th graders) and White adolescents (2015-2019 average annual percentage change: –17.3% [95% CI, –20.6% to –13.7%] for 8th graders; –16.9% [95% CI, –20.5% to –13.2%] for 10th graders; and –17.0% [95% CI, –20.5% to –13.2%] for 12th graders). Smokeless tobacco was used more variably through 2012, followed by consistent decreases in the past 5 years. For instance, smokeless tobacco use in the past 30 days in 10th-grade boys decreased at an APC of –6.5% (95% CI, –7.5% to –5.4%) from 1991 to 2004, increased at an APC of 3.1% (95% CI, –0.8% to 7.1%) from 2004 to 2012, and decreased at an APC of –11.6% (95% CI, –15.7% to –7.4%) from 2012 to 2019. Similarly, daily smokeless tobacco use in 12th-grade boys decreased at an APC of –3.8% (95% CI, –5.4% to –2.1%) from 1992 to 2005, increased at an APC of 3.1% (95% CI, –0.2% to 6.5%) from 2005 to 2015, and decreased at an APC of –23.0% (95% CI, –33.3% to –11.0%) from 2015 to 2019. Conclusions and Relevance This cross-sectional study suggests that, despite the increase in the prevalence of e-cigarette use among adolescents between 2011 and 2019, the prevalence of cigarette and smokeless tobacco use has decreased more rapidly during the same period compared with earlier years.
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Introduction The US FDA announced its intention to ban menthol in cigarettes. However, information is needed on how a federal ban would affect population health. We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the US. Methods We developed and pilot tested a questionnaire that focused on tobacco use transitions of current smokers (age 18-24 menthol, age 35-54 menthol, and age 35-54 non-menthol) and potential menthol smokers (age 12-24). Using a structured expert elicitation, we estimated mean net transitions under a ban from cigarette use to combustible tobacco product, smokeless tobacco, novel nicotine delivery product (NNDPs, such as e-cigarettes) use, or no tobacco use. Results Eleven experts provided responses. Of those ages 12-24 who would have initiated menthol cigarette use in the absence of a ban, the experts estimated that 41% would still initiate combustible products under a ban, while 18% would initiate with NNDPs and 39% would not initiate regular tobacco use. Combustible use by menthol smokers ages 35-54 was expected to decline by 20% post-ban relative to pre-ban rates, half switching to NNDPs and half quitting all tobacco use. Menthol smokers ages 18-24 were expected to reduce combustible use by 30%, with 16% switching to NNDPs. Greater reductions in combustible use were estimated for African-Americans across the three age groups. Negligible impacts were expected for current adult non-menthol smokers. Conclusions According to expert opinion, a menthol ban is expected to substantially reduce smoking initiation and combustible tobacco product use among current menthol smokers.
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Tobacco use is the leading cause of preventable disease and death in the United States; nearly all tobacco product use begins during youth and young adulthood (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2019 and 2020 National Youth Tobacco Surveys (NYTS) to determine changes in the current (past 30-day) use of seven tobacco products among U.S. middle (grades 6-8) and high (grades 9-12) school students. In 2020, current use of any tobacco product was reported by 16.2% (4.47 million) of all students, including 23.6% (3.65 million) of high school and 6.7% (800,000) of middle school students. Electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high school (19.6%; 3.02 million) and middle school (4.7%; 550,000) students. From 2019 to 2020, decreases in current use of any tobacco product, any combustible tobacco product, multiple tobacco products, e-cigarettes, cigars, and smokeless tobacco occurred among high school and middle school students; these declines resulted in an estimated 1.73 million fewer current youth tobacco product users in 2020 than in 2019 (6.20 million) (3). From 2019 to 2020, no significant change occurred in the use of cigarettes, hookahs, pipe tobacco, or heated tobacco products. The comprehensive and sustained implementation of evidence-based tobacco control strategies at the national, state, and local levels, combined with tobacco product regulation by FDA, is warranted to help sustain this progress and to prevent and reduce all forms of tobacco product use among U.S. youths (1,2).
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Cigarette smoking remains the leading cause of preventable disease and death in the United States (1). The prevalence of current cigarette smoking among U.S. adults has declined over the past several decades, with a prevalence of 13.7% in 2018 (2). However, a variety of combustible, noncombustible, and electronic tobacco products are available in the United States (1,3). To assess recent national estimates of tobacco product use among U.S. adults aged ≥18 years, CDC analyzed data from the 2019 National Health Interview Survey (NHIS). In 2019, an estimated 50.6 million U.S. adults (20.8%) reported currently using any tobacco product, including cigarettes (14.0%), e-cigarettes (4.5%), cigars (3.6%), smokeless tobacco (2.4%), and pipes* (1.0%).† Most current tobacco product users (80.5%) reported using combustible products (cigarettes, cigars, or pipes), and 18.6% reported using two or more tobacco products.§ The prevalence of any current tobacco product use was higher among males; adults aged ≤65 years; non-Hispanic American Indian/Alaska Native (AI/AN) adults; those whose highest level of educational attainment was a General Educational Development (GED) certificate; those with an annual household income <$35,000; lesbian, gay, or bisexual (LGB) adults; uninsured adults and those with Medicaid; those with a disability; or those with mild, moderate, or severe generalized anxiety disorder. E-cigarette use was highest among adults aged 18-24 years (9.3%), with over half (56.0%) of these young adults reporting that they had never smoked cigarettes. Implementing comprehensive, evidence-based, population level interventions (e.g., tobacco price increases, comprehensive smoke-free policies, high-impact antitobacco media campaigns, and barrier-free cessation coverage), in coordination with regulation of the manufacturing, marketing, and sale of all tobacco products, can reduce tobacco-related disease and death in the United States (1,4). As part of a comprehensive approach, targeted interventions are also warranted to reach subpopulations with the highest prevalence of use, which might vary by tobacco product type.
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Introduction Even prior to 2018, electronic nicotine delivery systems (ENDS) began to dramatically change the landscape of tobacco products and product use patterns in the USA. Methods Using a Markov multistate transition model accounting for complex survey design, transition rates between never, non-current, cigarette, ENDS and dual use states were estimated for 23 253 adult participants in waves 1–4 (approximately 2013–2017) of the Population Assessment of Tobacco and Health study. We made short-term transition projections and estimated HRs for age, sex, race/ethnicity, education and income. Results Cigarette use was persistent among adults, with 89.7% (95% CI 89.1% to 90.3%) of exclusive cigarette users and 86.1% (95% CI 84.4% to 87.9%) of dual users remaining cigarette users (either exclusive or dual) after one wave. In contrast, ENDS use was less persistent, with 72.1% (95% CI 69.6% to 74.6%) of exclusive ENDS users and 50.5% (95% CI 47.8% to 53.3%) of dual users remaining ENDS users (with or without cigarettes) after one wave. Exclusive ENDS users were more likely to start cigarette use after one wave than either never users (HR 25.2; 95% CI 20.9 to 30.5) or non-current users (HR 5.0; 95% CI 4.3 to 5.8). Dual users of ENDS and cigarettes were more likely to stop using cigarettes than exclusive cigarette users (HR 1.9; 95% CI 1.6 to 2.3). Transition rates varied among sociodemographic groups. Conclusions Multistate transition models are an effective tool for uncovering and characterising longitudinal patterns and determinants of tobacco use from complex survey data. ENDS use among US adults was less persistent than cigarette use prior to 2018.
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Introduction Some, but not all, studies suggest that menthol cigarette smokers have more difficulty quitting than non-menthol cigarette smokers. Inconsistent findings may be a result of differences in smoker characteristics (e.g. daily vs. non-daily smokers) across studies. This study examines the relationship between menthol cigarette use, cessation and relapse in a longitudinal, nationally representative study of tobacco use in the United States. Methods Data come from four waves of the Population Assessment of Tobacco and Health Study. Waves 1-4 were conducted approximately annually from September 2013 to January 2018. Generalized estimating equation models were used to prospectively examine the relationship between menthol cigarette use, cessation, and relapse in non-daily and daily adult (18+) smokers. Cessation was defined as smokers who had not used cigarettes within the past 30 days at their subsequent assessment. Relapse was defined as cessation followed by past 30-day smoking in the next assessment. Results Among daily smokers (n=13,710), 4.0% and 5.3% of menthol and non-menthol smokers quit after one year, respectively. In an adjusted model, menthol smokers were less likely to quit compared to non-menthol smokers (OR=0.76 [0.63, 0.91]). When the sample was stratified by race/ethnicity, African-American (OR=0.58 [0.34, 0.99]) and White (OR=0.58 [0.34, 0.99]) daily menthol users were less likely to have quit. Among non-daily smokers (n=3,608), there were no significant differences in quit rates. Among daily and non-daily former smokers, there were also no differences in relapse rates between menthol and non-menthol smokers. Conclusions Menthol cigarette use is associated with lower odds of cessation. Implications Findings from this study suggest that menthol cigarette use is associated with lower odds of cessation, but not relapse. Removing menthol cigarettes from the market may improve cessation rates.
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Introduction: The trends in e-cigarette prevalence and population count of users according to cigarette smoking histories are unknown. These data are needed to inform public health actions against a rapidly changing U.S. e-cigarette market. Methods: Data collected between 2014 and 2018 (analyzed in 2020) from cross-sectional, nationally representative National Health Interview Surveys were used to estimate current e-cigarette prevalence, adjusted prevalence differences (percentage points), and population counts of users. Analyses were stratified by age group (younger, 18-29 years, n=25,445; middle age, 30-49 years, n=47,745; older, ≥50 years, n=79,517) and cigarette smoking histories (current smokers, recent quitters [quit <1 year ago], near-term quitters [quit 1-8 years ago], long-term quitters [quit >8 years ago], never smokers). Results: Among younger adults, e-cigarette use increased in all groups of smokers, with notable increases between 2014 and 2018 among never smokers (1.3%-3.3%, adjusted prevalence difference=2%, p<0.001) and near-term quitters (9.1%-19.2%, adjusted prevalence difference=8.8%, p=0.024). Conversely, the only substantial increase in e-cigarette use between 2014 and 2018 among middle-aged (5.8%-14.4%, adjusted prevalence difference=8.2%, p<0.001) and older (6.3%-9.5%, adjusted prevalence difference=3.3%, p=0.045) adults was among near-term quitters. The largest absolute population increase in e-cigarette users between 2014 and 2018 was among younger-adult never smokers (0.49-1.35 million), followed by near-term quitters among middle-aged (0.36-0.95 million), younger (0.23-0.57 million), and older (0.35-0.50 million) adults. Conclusions: The continuous increase among younger-adult never smokers suggests a rise in primary nicotine initiation with e-cigarettes. The concomitant increase among near-term quitters of all age groups suggests continuing e-cigarette use among smokers who may have switched from cigarettes previously.