Article

Do Smokers of Menthol Cigarettes Find It Harder to Quit Smoking?

Department of Public Health Sciences & Cancer Institute, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
Nicotine & Tobacco Research (Impact Factor: 3.3). 12/2010; 12 Suppl 2(Supplement 2):S102-9. DOI: 10.1093/ntr/ntq166
Source: PubMed
ABSTRACT
Menthol cigarette smokers may find it harder to quit smoking than smokers of nonmenthol cigarettes.
We conducted a systematic review of published studies examining the association between menthol cigarette smoking and cessation. Electronic databases and reference lists were searched to identify studies published through May 2010, and results were tabulated.
Ten studies were located that reported cessation outcomes for menthol and nonmenthol smokers. Half of the studies found evidence that menthol smoking is associated with lower odds of cessation, while the other half found no such effects. The pattern of results in these studies suggest that the association between smoking menthol cigarettes and difficulty quitting is stronger in (a) racial/ethnic minority populations, (b) younger smokers, and (c) studies carried out after 1999. This pattern is consistent with an effect that relies on menthol to facilitate increased nicotine intake from fewer cigarettes where economic pressure restricts the number of cigarettes smokers can afford to purchase.
There is growing evidence that certain subgroups of smokers find it harder to quit menthol versus nonmenthol cigarettes. There is a need for additional research, and particularly for studies including adequately powered and diverse samples of menthol and nonmenthol smokers, with reliable measurement of cigarette brands, socioeconomic status, and biomarkers of nicotine intake.

Full-text

Available from: Jonathan Foulds
Nicotine & Tobacco Research, Volume 12, Supplement 2 (December 2010) S102–S109
S102
doi: 10.1093/ntr/ntq166
© The Author 2010. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
flavor additive in cigarettes, was not banned. Instead, the FDA
Tobacco Products Scientific Committee has indicated that it
will review the evidence on the public health impact of menthol
as an additive to cigarettes before making a policy recommenda-
tion on this issue.
Menthol is a compound extracted from mint oils or pro-
duced synthetically (Ahijevych & Garrett, 2004; Kluger, 1996)
that activates cold-sensitive neurons in the mammalian nervous
system (Reid, Babes, & Pluteanu, 2002). Due to its cooling and
counterirritant properties, it is used in a variety of products as
an anesthetic (e.g., applied topically to relieve aches and
pains), cooling agent (e.g., medication to treat sunburns), or
to sooth minor throat irritation (e.g., cough medicine). Menthol
is added to some cigarette brands to produce a characteristic
menthol taste (“Menthol” cigarettes), and these menthol
brands are marketed as such to consumers. “NonMenthol” or
“Regular” cigarettes, even if they contain menthol in low
quantities, are not characterized by or branded with emphasis
on their menthol content (Wayne & Connolly, 2004). From
1990 through 2005, menthol cigarettes accounted for 25%
27% of the domestic U.S. cigarette market (Federal Trade
Commission, 2007), and in recent years, menthols have
become the preferred type of cigarette among almost half of
12- to 17-year-old cigarette smokers (48% in 2008, Office of
Applied Studies, 2009).
For most smokers, successfully quitting smoking is a major
challenge, largely because smokers become addicted to the psy-
choactive effects of nicotine delivered by cigarettes. It has been
suggested that the cooling properties of menthol may facilitate
greater smoke (and therefore nicotine) inhalation and poten-
tially create even greater difficulty for smokers attempting to
quit.
One particular challenge in reviewing this issue stems from
evidence that use of menthol cigarettes is not evenly spread
across the population of smokers in the United States. For
example, 83% of African American cigarette smokers smoke
menthol cigarettes, compared to 24% of non-Hispanic white
Abstract
Introduction: Menthol cigarette smokers may find it harder to
quit smoking than smokers of nonmenthol cigarettes.
Methods: We conducted a systematic review of published
studies examining the association between menthol cigarette
smoking and cessation. Electronic databases and reference lists
were searched to identify studies published through May 2010,
and results were tabulated.
Results: Ten studies were located that reported cessation
outcomes for menthol and nonmenthol smokers. Half of the
studies found evidence that menthol smoking is associated with
lower odds of cessation, while the other half found no such
effects. The pattern of results in these studies suggest that the
association between smoking menthol cigarettes and difficulty
quitting is stronger in (a) racial/ethnic minority populations,
(b) younger smokers, and (c) studies carried out after1999. This
pattern is consistent with an effect that relies on menthol to
facilitate increased nicotine intake from fewer cigarettes where
economic pressure restricts the number of cigarettes smokers
can afford to purchase.
Conclusions: There is growing evidence that certain subgroups
of smokers find it harder to quit menthol versus nonmenthol
cigarettes. There is a need for additional research, and particu-
larly for studies including adequately powered and diverse
samples of menthol and nonmenthol smokers, with reliable
measurement of cigarette brands, socioeconomic status, and
biomarkers of nicotine intake.
Introduction
In 2009, the Family Smoking Prevention and Tobacco Control
Act was enacted, giving the U.S. Food and Drug Administration
(FDA) the authority to regulate tobacco products. One of its
early interventions was to ban the addition of candy and fruit
flavors to cigarettes. Menthol, the most common characterizing
Review
Do Smokers of Menthol Cigarettes Find It
Harder to Quit Smoking?
Jonathan Foulds, Ph.D.,
1
Monica Webb Hooper, Ph.D.,
2
Mark J. Pletcher, M.D., M.P.H.,
3
&
Kolawole S. Okuyemi, M.D., M.P.H.
4
1
Department of Public Health Sciences & Cancer Institute, Penn State College of Medicine, Hershey, PA
2
Department of Psychology & Biobehavioral Oncology, University of Miami, Coral Gables, FL
3
Department of Epidemiology & Biostatistics, University of California at San Francisco, San Francisco, CA
4
Program in Health Disparities Research, University of Minnesota Medical School, Minneapolis, MN
Corresponding Author: Jonathan Foulds, Ph.D., Cancer Institute, T3428, CH69, Penn State College of Medicine, 500 University
Drive, P.O. Box 850, Hershey, PA 17033-0850, USA. Telephone: 717 531 3504; Fax: 717 531 0480; E-mail: jfoulds@psu.edu
Received July 2, 2010; accepted September 5, 2010
Page 1
S103
Nicotine & Tobacco Research, Volume 12, Supplement 2 (December 2010)
Table 1. Main Characteristics and Findings of Published Studies Comparing Smoking Cessation Outcomes in Menthol and
Nonmenthol Cigarette Smokers
Author (publication
year)/study years Location N M/NM
N—W/AA/
Hisp/Other
Cigarettes/
day (M/NM) Design Intervention?
Definition
(of a quitter)
Evidence of M
effect? Comments
Fu et al. (2008)/
2006
United States—
VA pharmacy
databases
Total = 1,343
M = 342 (25%)/
NM = 1,001 (75%)
M age = 56 (10.3)
All smokers: C
aucasian: 76%
AA: 14%
Other: 10%
Total: 25
M: 20
NM: 30
Cross-sectional
analysis at
end of
interventional
trial
Intervention aimed
to stimulate
repeat quit
attempts
All participants
had previously
failed using NRT
or bupropion
Seven-day point
prevalence,
self-reported
No overall effect of
M on abstinence.
Some evidence of
increased quitting
among menthol
smokers,
restricted to
intervention
group, with lower
menthol quitting
in controls.
Older sample.
One significant
interaction
between menthol
status and
treatment group
only, not
significant after
Bonferroni
correction
Gundersen et al.
(2009)/2005
USA representative
sample of
smokers
(National Health
Interview Survey)
Total = 7,815
M = 2,133 (27%)/
NM = 5682 (73%)
M age = 49 (0.23)
White: 6007
(21% M)
AA: 891
(70% M)
H: 917 (26% M)
1–10 = 45.6%
11–20 = 37.6%
>20 = 16.8%
Cross-sectional
survey. Analysis
on smokers who
had tried to quit
None Ever-smoker
(>100 lifetime
cigs.) who is
no longer a
smoker
Yes, but different
for whites
(M > quitting)
and non-Whites
(M < quitting).
Adj. OR for
non-Whites = 0.55
(0.43–0.710)
The quit attempt
could have been
anytime in the
past.
Cropsey et al.
(2009)/
2004–2006
Women’s prison
in Virginia
N=233 M=159
NM=74
M age = 34
W = 109
(49% M)
AA = 124
(95% M)
(all female)
W = 20
AA = 14
Retrospective
analysis of trial
cohort.
Randomized trial
of NRT plus
group, versus
wait list control
Seven-day point
prevalence by
self-report
(and exhaled
CO < 3 ppm)
at 6 weeks
and 12 months.
No effect of menthol Relatively small
sample of
incarcerated
women (only six
AA nonmenthol
smokers)
Gandhi et al.
(2009)/
2001–2005
Outpatient
Smokers’ Clinic
Central New
Jersey
Total = 1688
M = 778 (46%) /
NM = 910 (54%)
M age = 42 (13.3)
1086/374/149/79
64%/22%/
9%/5%
Total sample:
21 M: 19
NM: 23
Clinic cohort,
followed up
at 4 weeks and
6 months.
Tailored Smoking
cessation
treatment with
meds and
counseling
Self-report of
not smoking in
previous 7 days
at 4 weeks and
6 -month
follow-up.
Biochemical
verification in
those attending
at 4 weeks.
Yes, but restricted
to non-whites.
Also related to
SES. For AAs at
6 months, Adj.
OR = 0.48
(0.25–0.9)
Cigarettes/day lower
in AA and H
menthol smokers.
Follow-up rate=
74% at 4 weeks
and 58% at
6 months.
(continued)
Page 2
S104
Menthol cigarettes and smoking cessation
Author (publication
year)/study years Location N M/NM
N—W/AA/
Hisp/Other
Cigarettes/
day (M/NM) Design Intervention?
Definition
(of a quitter)
Evidence of M
effect? Comments
Okuyemi et al.
(2007)/
2003–2004
Kansas 755 light smokers
(<11 cigarettes/
day) M age = 45.1
(SD = 10.7)
0/755/0/0 M: 7.5 NM: 7.8 Clinical trial
cohort
followed
up at 6m.
Nicotine gum ×
motivational
interviewing
trial (factorial)
Seven-day point
prevalence,
verified by CO/
salivary
cotinine at
6-month
follow-up
Yes, unadjusted:
11.2% vs. 18.8%
M not significant in
fully adjusted
model
(overadjusted by
using number of
appointments
attended?)
(Nollen et al.
2006); M effect
stronger in
age < 50
Okuyemi et al.
(2003)/
1999–2000
Kansas 600 smokers
(471/129)
M age = 44
0/600/0/0 M: 18 NM: 18 Clinical trial
cohort followed
up at 6m.
Bupropion
versus placebo
randomized
controlled trial
Seven-day point
prevalence,
verified by
CO/salivary
cotinine
Yes, in subgroup.
At 6 weeks in
age < 50: OR
(NM) 2.02
(1.03–3.95)
No significant
effect at 6 months
or in age > 50
Murray et al.
(2007)/
1986–2001
United States Total = 5,883
M = 1,216 (21%)/
NM = 4,671 (79%)
M age = 48.4
(SD = 6.8)
White:95.2%
AA: 3.8%
H: 0.6%
Overall average
26 cigarettes/
day
Pack-years:
M: 38.18
NM: 40.1
Clinical trial
cohort followed
up 5 and
14 years after
enrollment
12-week group
intervention plus
nicotine gum
(repeatable for
5 years) or
usual care
Smoking at
all in past
12 months
Three categories:
sustained quitter,
intermittent
smoker,
continuing
smokers; no
menthol effect
Only 114 AA
menthol smokers
in the study.
Pletcher et al.
(2006)/
1985–2000
Birmingham,
Chicago,
Minneapolis,
and Oakland
1535 smokers
(972/563)
M age= 25.1 (3.6)
657/878/0/0 M: 10 NM: 15 Prospective
cohort study
No
Sustained
cessation: not
current smoker
at last 2 visits
Relapse:
smoker
nonsmoke
smoker at
last exam
Yes
Sustained
cessation: Adj.
OR = 0.71
(0.49-1.02)
Relapse: Adj.
OR = 1.89
(1.17–3.05)
Long-term study,
not in context of a
quit attempt
(continued)
Table 1. Main Characteristics and Findings of Published Studies Comparing Smoking Cessation Outcomes in Menthol and
Nonmenthol Cigarette Smokers (continued)
Page 3
S105
Nicotine & Tobacco Research, Volume 12, Supplement 2 (December 2010)
Author (publication
year)/study years Location N M/NM
N—W/AA/
Hisp/Other
Cigarettes/
day (M/NM) Design Intervention?
Definition
(of a quitter)
Evidence of M
effect? Comments
Muscat et al.
(2002)/
1981–1999
Hospitals in
New York,
Washington
DC, and
Pennsylvania
Total = 19545
NM = 16540 (85%)
M = 3005 (11%)
56%–72%
aged > 54
W = 17,637
(89%)
AA = 1906
(11%)
W: NM = 29
M = 28 AA
NM = 21
M = 18
Cross-sectional
case-control
study based on
convenience
sample of cases
(lung cancer)
and controls
(other medical
patients)
No intervention Ever smoked daily
for a year and
not smoked
daily in
past year.
No effect on
quitting
OR = 1.1
Older and relatively
affluent sample,
with unusually
low menthol rate
in AAs (34%).
Definition of
abstinence
relatively
lenient.
Possible effect of
illness on quitting.
Hyland et al.
(2002)/
1988–1993
22 communities in
North America
N = 13,268
(age 25–64)
M = 3,184 (24%)/
NM = 10,084
(76%)
23% Whites
smoke M, 57%
AAs smoke M. 51%
ages < 45
All smokers:
Caucasian:
10,004 (75%)
AA: 878 (7%)
Hispanic:
693 (5%)
Other: 294 (2%)
Canadian: 1,382
(10%)
Total sample:
23.2/day
Prospective
population
cohort survey,
followed up
after 5 years.
Randomized
community
intervention
trial
Self-report of
no cigarette
use in past
6 months at
5-year
follow-up.
No. (e.g., adjusted
RR for quitting
by AA menthol
smokers = 1.04.)
M smokers more
likely to have 2+
prior quit
attempts. No data
on whether
participants tried
to quit.
Note. M = menthol; NM = nonmenthol; OR= odds ratio; RR= relative risk; adj. = adjusted for other baseline variables; CO = exhaled carbon monoxide concentration; AA= African American; W = white
(non-Hispanic); H = Hispanic/Latino; M age = mean age of sample; SES = Socioeconomic status; NRT = Nicotine Replacement Therapy.
Table 1. Main Characteristics and Findings of Published Studies Comparing Smoking Cessation Outcomes in Menthol and
Nonmenthol Cigarette Smokers (continued)
Page 4
S106
Menthol cigarettes and smoking cessation
smokers (Office of Applied Studies, 2009). Menthol cigarettes
are also used more frequently by female, younger, and low-
income smokers (Office of Applied Studies, 2009). Analysis
of the effects of menthol on smoking cessation, therefore,
should take into account likely differences between menthol
and nonmenthol smokers and might investigate how men-
thol effects differ in different subgroups. This paper aims to
summarize and review the cumulative evidence from studies
that have assessed whether smokers of mentholated ciga-
rettes find it harder to quit smoking than smokers of regular
(nonmenthol) cigarettes.
Methods
We identified relevant studies by conducting a Pubmed search
using the keywords, “menthol” AND “smoking” AND “cessa-
tion”, by reviewing an online bibliography prepared by the U.S.
National Cancer Institute in 2009, that included 343 peer-
reviewed research articles related to menthol cigarette smoking
(U.S. Department of Health and Human Services, 2009), by
reviewing Web sites of relevant scientific organizations and by
reviewing the reference sections of relevant papers. We identi-
fied all studies that directly compared smoking cessation rates
or proportions between smokers of menthol cigarettes and
smokers of regular cigarettes. Each identified study was reviewed
by at least two authors, and where available, key descriptive
and outcome data from each study were extracted and coded
in tabular form. The aim of this narrative review was to reach
conclusions based on analysis of the pattern of methods and
results across differing studies. Quantitative pooling of results
was not feasible given the heterogeneity of study designs and
methods.
Results
We identified 10 studies that compared smoking cessation rates
or proportions between mentholated and regular cigarette
smokers. The key descriptive and outcome data from each iden-
tified study is shown in Table 1.
Overall, the results of these studies were mixed, with 5/10
studies finding evidence of lower quit rates among menthol
smokers and 5/10 finding no evidence of differential quit rates.
None of the studies found a significant overall effect of menthol
on smoking cessation at the last study follow-up point, after
controlling for other relevant measured variables.
None of the studies found a significant negative effect of
menthol cigarettes on smoking cessation in non-Hispanic white
smokers and one (Gundersen, Delnevo, & Wackowski, 2009)
found evidence of a higher quit rate among white menthol
smokers. In all four of the studies that found a direct negative
association between menthol cigarettes and quitting (Gandhi,
Foulds, Steinberg, Lu, & Williams, 2009; Gundersen et al., 2009;
Okuyemi et al., 2003 ; Okuyemi, Faseru, Cox Sanderson,
Bronars, & Ahluwalia, 2007), the significant effects were con-
fined to non-White (primarily African American) subsam-
ples of the population. In the other study (Pletcher et al., 2006),
the main significant effect was on relapse rates after achieving
abstinence (higher relapse rate among menthol smokers), rather
than on abstinence per se. The two studies by Okuyemi and col-
leagues focused exclusively on African American smokers, and
in both, the menthol effect was stronger in younger (under age
50) smokers. The studies by Gandhi, Foulds, Steinberg, Lu, &
Williams (2009) and Gundersen et al. (2009), however, both
analyzed effects on Non–Latino-Whites, African Americans and
Latinos. Although these studies were based in entirely different
contexts (Gandhi et al. [2009] was based in a treatment-seeking
clinic population in New Jersey; Gundersen et al. [2009] studied
a representative national sample of smokers who had ever tried
to quit), they found a remarkably similar pattern of results, as
shown in Figure 1 below. Gandhi et al. (2009) found signifi-
cantly lower adjusted quit rates among Latino and African
American menthol smokers relative to nonmenthol smokers at
the 4-week follow-up, and this effect remained significant for
African American smokers at 6 months, whereas there was no
overall quitting disadvantage for white menthol smokers (rela-
tive to white nonmenthol smokers). Gundersen et al. (2009)
found a significantly lower adjusted quit rate for menthol smok-
ers among racial/ethnic minorities (African Americans and
Latinos collapsed into a single group), but a significant quitting
advantage for white menthol smokers relative to white non
menthol smokers.
All four of the studies finding an association between
menthol and lower quit rates were carried out since 1999
(Gandhi et al., 2009; Gundersen et al., 2009; Okuyemi et al.,
2003, 2007), whereas the three large studies finding no menthol
Figure 1. Percentage of smokers attempting to quit who achieve absti-
nence, by cigarette type and race/ethnicity in the Gandhi et al. (2009)
and Gundersen et al. (2009) studies. “*” Indicates a significant differ-
ence in abstinence rate between menthol and nonmenthol smokers
within race/ethnicity grouping after adjusting for other variables.
Page 5
S107
Nicotine & Tobacco Research, Volume 12, Supplement 2 (December 2010)
effects collected data in the 1980s (Hyland, Garten, & Giovino,
2002; Murray, Connett, Skeans, & Tashkin, 2007; Muscat, Richie, &
Stellman, 2002).
Discussion
The pattern of results from studies examining the association
between mentholated cigarette smoking and smoking cessation
is mixed. However, there does appear to be broadly consistent
evidence that menthol smoking is more prevalent in racial/ethnic
minority populations and that menthol smokers tend to
smoke fewer cigarettes per day than regular cigarette smokers
(e.g., Giovino et al., 2004 and most studies in Table 1). There are
also trends suggesting that the association between smoking
menthol cigarettes and greater difficulty quitting is stronger
in (a) racial/ethnic minority populations, (b) younger smokers,
and (c) after the year 1999, as opposed to the 1980s.
One possibility, consistent with this pattern of results, is
that the effect of menthol on quitting smoking is only apparent
in circumstances where the smoker has been forced to reduce
their cigarette consumption, with the most obvious influence
being socioeconomic factors. The price of cigarettes has in-
creased in many parts of the United States since the 1990s.
Young smokers, and racial/ethnic minority smokers tend to be
less affluent and are thus more affected by the increased prices,
forcing them to consume fewer cigarettes per day (as is found in
most studies in these groups). One possible mechanism explain-
ing the menthol effect is that these smokers may increase their
total nicotine intake per cigarette to obtain their preferred dose
of nicotine from fewer cigarettes. The menthol effect on cessa-
tion may stem from the cooling effects of menthol facilitating
such “compensatory” smoking and allowing these smokers to
obtain a larger and perhaps more reinforcing nicotine “hit” per
cigarette. There is some evidence that smokers of menthol ciga-
rettes tend to obtain higher levels of carbon monoxide (CO),
nicotine, and cotinine per cigarette smoked (Clark, Gautam, &
Gerson, 1996; Ahijevych & Parsley, 1999; Benowitz, Herrera, &
Jacob, 2004; Perez-Stable, Herrera, Jacob, & Benowitz, 1998;
Williams et al., 2007). Gandhi et al. (2009) reported that the as-
sociation between menthol smoking and lower quit rates was
stronger among unemployed than full-time employed smokers,
regardless of race/ethnicity, which is consistent with the model
proposed above.
Adolescent smokers are a group that could be particularly
sensitive to the menthol effect mechanism being proposed here as
their cigarette consumption is often restricted by parental/school/
legal rules as well as by financial constraints. There are no studies
comparing quit rates between adolescent menthol and nonmen-
thol smokers. However national surveys of adolescent smokers
that included indirect measures of dependence have consistently
found that menthol smokers, compared to nonmenthol smokers,
are significantly more likely to smoke within an hour of waking
and that menthol smokers are more likely than nonmenthol
smokers to experience cravings after not smoking for a few hours
(Hersey et al., 2006; Wackowski & Delnevo, 2007).
Ahijevych, Weed, and Clarke (2004) conducted an experi-
mental test of the theory that menthol enables smokers to inhale
more nicotine per cigarette when forced to reduce daily cigarette
consumption. This study examined smoking behavior in 25
women (13 African American) while they resided at a research
center for 6 days and were given access to either: (a) their usual
number of cigarettes, (b) cigarettes restricted to 50% of normal,
or (c) 167% of their normal consumption. In this study, all 13 of
the African American women smoked menthols, as did a third of
the white women. There were significantly higher percentage in-
creases in exhaled CO levels among menthol smokers compared
to nonmenthol smokers in the increased and restricted condi-
tions. Also, African American menthol smokers had significant-
ly higher percentage increases in exhaled CO compared with
white menthol smokers in the restricted condition. This study
also identified “efficient smokers” by their high baseline coti-
nine/cigarette ratio and found that their nicotine intake per ciga-
rette increased even more in the “restricted” condition.
Specifically, the pre-post cigarette “boost” in blood nicotine
went up from 32 to 47 ng/ml. The typical blood nicotine boost
from smoking a cigarette is about 10–15 ng/ml (Foulds et al.,
1992; Patterson et al., 2003). All but one of these “efficient”
smokers were menthol smokers. The data from this study are
consistent with the theory that menthol smokers increase their
smoke (CO and nicotine) intake per cigarette more than non
menthol smokers when access to cigarettes is restricted. It may
be that the large rapid increases in blood nicotine concentration
resulting from this more “efficient” style of smoking (blood
nicotine boost of 47 ng/ml per cigarette in the the study by
Ahijevych et al., 2004) produces more reinforcement per ciga-
rette and consequently greater difficulty quitting.
This hypothetical model explaining how menthol may in-
fluence smoking cessation needs to be evaluated in further stud-
ies. If true, one might expect the putative menthol effect on
cessation to become stronger over time as cigarette prices and
smoking restrictions have increased dramatically since the be-
ginning of the 21st century and when the United States is in a
period of economic recession.
Other factors may also be involved. For example, there is
evidence that menthol may itself inhibit nicotine metabolism,
causing greater nicotine exposure per unit inhaled (Benowitz et
al., 2004 ). In addition, the studies to date have mainly assumed
that the only factor that differs between the brands being
smoked is the mentholation. In reality, each cigarette sub-brand
can vary on a number of additional dimensions, including filter
ventilation, standardized machine-measured nicotine yield, and
cigarette length. It has been noted that a very high proportion of
African American smokers smoke specific brands (e.g., New-
port) with little filter ventilation, and relatively high machine-
measured nicotine yield, whereas whites tend to smoke ventilated
low or medium machine-measured nicotine yield cigarettes such
as Marlboro/Marlboro Lights (Melikian, Djordjevic, Chen, &
Richie 2007; Okuyemi, Ebersole-Robinson, Nazir, & Ahluwalia,
2004). Rose and Behm (2010) recently presented the reanalyses
of two clinical trials examining the association between absti-
nence, menthol preference, and various other variables. They
found that among menthol smokers, preference for higher nic-
otine-yield cigarettes was strongly related to lower socioeco-
nomic status and that this mediated the link between menthol
smoking and low quit rates (6-month point abstinence among
menthol smokers of high yield cigarettes = 11% as compared
with 26% for high yield nonmenthol smokers, p = .005 when
adjusting for other covariates). They also found significantly
higher baseline cotinine per cigarette in menthol versus non
menthol smokers.
Page 6
S108
Menthol cigarettes and smoking cessation
Consistent with Rose and Behm’s (2010) findings, Farrelly,
Loomis, and Mann (2007) found that over the years 1994–2004,
U.S. inflation-adjusted cigarette prices increased by over 50%,
and this was associated with increased consumption of higher
machine-measured nicotine yield cigarettes, with this effect being
larger for menthol versus nonmenthol cigarettes. This data,
derived from analyses of over 800,000 cigarette purchases at U.S.
supermarkets, is consistent with the idea that as cigarette prices
increase, menthol cigarettes are particularly consumed in a man-
ner that facilitates greater nicotine absorption per cigarette.
It should be noted that most of the studies to date have not
been designed specifically to evaluate the effects of menthol on
cessation, and even the relatively large studies (e.g., Hyland
et al., 2002 and Murray et al., 2007) suffered from a lack of sta-
tistical power to detect within-race effects, partly because such a
low proportion of African Americans smoke nonmenthol
brands. Future analyses of existing and ongoing national survey
datasets (e.g. National Health Interview Survey, National Health
And Nutrition Examination Survey) may help clarify this issue.
Where possible, such analyses should include an assessment of
the effects of socioeconomic status (via measures of income,
financial assets, employment status, and education), nicotine/
smoke intake (e.g., via biomarkers such as CO and cotinine),
and also indicators of cigarette price (which can be estimated
from the person’s home state and preferred brand). Future
studies should collect adequate measurement of cigarette brand
and sub-brand smoked (including whether it is a menthol
brand), brand switching, the socioeconomic status of partici-
pants, and their biomarker concentrations. This is also true for
clinical trials not necessarily designed to assess the effects of
menthol on cessation.
In conclusion, research to date finds little evidence of an
association between menthol cigarette smoking and increased
difficulty quitting among middle-aged (and older) white
smokers. However, recent studies have consistently found that
racial/ethnic minority smokers of menthol cigarettes have a
lower quit rate than comparable smokers of regular cigarettes,
particularly among younger smokers. This pattern of results is
consistent with an effect that relies on menthol to facilitate in-
creased nicotine intake from fewer cigarettes where economic
pressures restrict the number of cigarettes smokers can afford
to purchase.
Funding
No specific funding was provided for this paper, but the authors
were recently supported as follows: JF was supported by grants
from New Jersey Department of Health & Senior Services and
Rutgers Community Health Foundation; MJP was supported
by a grant to the Kaiser Foundation Research Institute, N01-
HC-48050, from the National Heart, Lung, and Blood Institute;
and MWH was supported by grants from the American Can-
cer Society and the Florida Department of Health.
Declaration of Interests
J.F. has worked as a consultant for pharmaceutical companies
involved in the manufacture of smoking cessation products (Pfizer,
GSK, Novartis).
References
Ahijevych, K., & Garrett, B.E. (2004). Menthol pharmacology
and its potential impact on smoking behavior. Nicotine &
Tobacco Research, 6(Suppl. 1):S17–S28. doi:10.1080/146222003
10001649469
Ahijevych, K., & Parsley, L. A. (1999). Smoke constituent expo-
sure and stage of change in Black and White women cigarette
smokers. Addictive Behaviors, 24, 115–120. doi:10.1016/S0306-
4603(98)00031-8
Ahijevych, K., Weed, H., & Clarke, J. (2004). Levels of cigarette
availability and exposure in Black and White women and effi-
cient smokers. Pharmacology, Biochemistry and Behavior, 77,
685–693. doi:10.1016/j.pbb.2004.01.016
Benowitz, N. L., Herrera, B., & Jacob, P., III (2004). Mentholated
cigarette smoking inhibits nicotine metabolism. The Journal of
Pharmacology and Experimental Therapeutics, 310, 1208–1215.
doi:10.1124/jpet.104.066902
Clark, P. I., Gautam, S., & Gerson, L. W. (1996). Effect of men-
thol cigarettes on biochemical markers of smoke exposure
among black and white smokers. Chest, 110, 1194–1198.
doi:10.1378/chest.110.5.1194
Cropsey, K. L., Weaver, M. F., Eldridge, G. D., Villaobos, G. C.,
Best, A. M., & Stitzer, M. L. (2009). Differential success rates in
racial groups: Results of a clinical trial of smoking cessation
among female prisoners. Nicotine & Tobacco Research, 11,
690–697. doi:10.1093/ntr/ntp051
Farrelly, M. C., Loomis, B. R., & Mann, N. H. (2007). Do in-
creases in cigarette prices lead to increases in sales of cigarettes
with high tar and nicotine yields? Nicotine & Tobacco Research,
9, 1015–1020.
Federal Trade Commission. (2007). Federal Trade Commission
Cigarette Report for 2004 and 2005, Retrieved May 14, 2010,
from http://www.ftc.gov/reports/tobacco/2007cigarette2004-
2005.pdf
Foulds, J., Stapleton, J., Feyerabend, C., Vesey, C., Jarvis, M., &
Russell, M. A. H. (1992). Effect of transdermal nicotine patches
on cigarette smoking: A double blind crossover study. Psycho-
pharmacology, 106, 421–427. doi:10.1007/BF02245429
Fu, S. S., Okuyemi, K. S., Partin, M. R., Ahluwalia, J. S.,
Nelson, D. B., Clothier, B. A., et al. (2008). Menthol ciga-
rettes and smoking cessation during an aided quit attempt.
Nicotine and Tobacco Research, 10, 457–462. doi:10.1080
/14622200801901914
Gandhi, K. K., Foulds, J., Steinberg, M. B., Lu, S. E., & Williams,
J. M. (2009). Lower quit rates among African American and
Latino menthol smokers at a tobacco treatment clinic. Interna-
tional Journal of Clinical Practice, 63, 360–367. doi:10.1111/
j.1742-1241.2008.01969.x
Giovino, G. A., Sidney, S., Gfroerer, J. C., O’Malley, P. M.,
Allen, J. A., Richter, P. A., & Cummings, K. M. (2004). Epidemi-
ology of menthol cigarette use. Nicotine & Tobacco Research,
6(Suppl. 1): S67–S81. doi:10.1080/14622203710001649696
Page 7
S109
Nicotine & Tobacco Research, Volume 12, Supplement 2 (December 2010)
Gundersen, D. A., Delnevo, C. D., & Wackowski, O. (2009).
Exploring the relationship between race/ethnicity, menthol
smoking, and cessation in a nationally representative sample of
adults. Preventive Medicine, 49, 553–557. doi:10.1016/j.ypmed.
2009.10.003
Hersey, J. C., Ng, S. W., Nonnemaker, J. M., Mowery, P. M.,
Thomas, K. Y., Vilsaint, M. C., Allen, J. A., & Haviland, M. L.
(2006). Are menthol cigarettes a starter product for youth?
Nicotine & Tobacco Research, 8, 403–413. doi:10.1080/
14622200600670389
Hyland, A., Garten, S., & Giovino, G. A. (2002). Mentholated
cigarettes and smoking cessation: Findings from COMMIT.
Tobacco Control, 11, 135–139. doi:10.1136/tc.11.2.135
Kluger, R. (1996). Ashes to ashes: America’s hundred-year ciga-
rette war, the public health, and the unabashed triumph of Philip
Morris. New York: Knopf.
Melikian, A. A., Djordjevic, M. V., Chen, S., & Richie, J. (2007).
Effect of delivered dosage of cigarette smoke toxins on levels of uri-
nary biomarkers of exposure. Cancer Epidemiology Biomarkers and
Prevention, 16, 1408–1415. doi:10.1158/1055-9965.EPI-06-1097
Murray, R. P., Connett, J. E., Skeans, M. A., & Tashkin, D. P.
(2007). Menthol cigarettes and health risks in Lung Health
Study data. Nicotine & Tobacco Research, 9, 101–107.
doi:10.1080/14622200601078418
Muscat, J. E., Richie, J. P., & Stellman, S. D. (2002). Mentho-
lated cigarettes and smoking habits in whites and blacks. Tobacco
Control, 11, 368–371. doi:10.1136/tc.11.4.368
Nollen, N.L., Mayo, M.S., Sanderson Cox, L., Okuyemi, K.S.,
Choi, W.S., Kaur, H., & Ahluwalia, J.S. (2006). Predictors
of quitting among African American light smokers enrolled
in a randomized, placebo-controlled trial. Journal of General
Internal Medicine, 21, 590–595. doi:10.1111/j.1525-1497.2006.
00404.x
Office of Applied Studies. (2009). Results from the 2008 National
Survey on Drug Use and Health: National findings (DHHS
Publication No. SMA 09-4434, NSDUH Series H-36). Rockville,
MD: Substance Abuse and Mental Health Services Administra-
tion. Retrieved May 19, 2010, from http://oas.samhsa.gov
Okuyemi, K. S., Ahluwalia, J. S., Ebersole-Robinson, M., Catley,
D., Mayo, M. S., & Resnicow, K. (2003). Does menthol attenu-
ate the effect of bupropion among African American smokers?
Addiction, 98, 1387–1393. doi:10.1046/j.1360-0443.2003.00443.x
Okuyemi, K. S., Ebersole-Robinson, M., Nazir, N., &
Ahluwalia, J. S. (2004). African-American menthol and nonm-
enthol smokers: Differences in smoking and cessation experi-
ences. Journal of the National Medical Association, 95, 1208–1211.
Okuyemi, K. S., Faseru, B., Cox Sanderson, L., Bronars, C. A., &
Ahluwalia, J. S. (2007). Relationship between menthol cigarettes
and smoking cessation among African American light smokers. Ad-
diction, 102, 1979–1986. doi:10.1111/j.1360-0443.2007.02010.x
Patterson, F., Benowitz, N., Shields, P., Kaufmann, V., Jepson,
C., Wileyto, P., et al. (2003). Individual differences in nicotine
intake per cigarette. Cancer Epidemiology, Biomarkers & Preven-
tion, 12, 468–471.
Perez-Stable, E. J., Herrera, B., Jacob, P., III, & Benowitz, N. L.
(1998). Nicotine metabolism and intake in Black and White smok-
ers. The Journal of the American Medical Association, 280, 152–156.
Pletcher, M. J., Hulley, B. J., Houston, T., Kiefe, C. I., Benowitz,
N., & Sidney, S. (2006). Menthol cigarettes, smoking cessation,
atherosclerosis, and pulmonary function. Archives of Internal
Medicine, 166, 1915–1922. doi:10.1001/archinte.166.17.1915
Reid, G., Babes, A., & Pluteanu, F. (2002). A cold- and menthol-
activated current in rat dorsal root ganglion neurones: Proper-
ties and role in cold transduction. Journal of Physiology, 545,
595–614. doi:10.1113/jphysiol.2002.024331
Rose, J. E., & Behm, F. M. Menthol smokers, SES and quit
smoking outcome. Paper presented at the 2010 Annual Meeting
of the Society for Research on Nicotine and Tobacco, Baltimore,
MD, POS5–58, p.148. Retrieved from http://www.srnt.org
/conferences/2010/pdf/2010_Program.pdf
U.S. Department of Health and Human Services. (2009). Bibli-
ography of literature on menthol and tobacco. Bethesda, MD:
National Cancer Institute. Accessed online on May 19, 2010, re-
trieved from http://www.fda.gov/downloads/AdvisoryCommitt
ees/CommitteesMeetingMaterials/TobaccoProductsScientificA
dvisoryCommittee/UCM204340.pdf
Wayne, F. G., & Connolly, G. N. (2004). Application, function,
and effects of menthol in cigarettes: A survey of tobacco indus-
try documents. Nicotine & Tobacco Research, 6, S43–S54. doi:10.
1080/14622203310001649513
Wackowski, O., & Delnevo, C. D. (2007). Menthol cigarettes and
indicators of tobacco dependence among adolescents. Addictive
Behaviors, 32, 1964–1969. doi:10.1016/j.addbeh.2006.12.023
Williams, J. M., Gandhi, K. K., Steinberg, M. L., Foulds, J.,
Ziedonis, Z. M., & Benowitz, N. L. (2007). Higher nicotine and
carbon monoxide levels in menthol smokers with and without
schizophrenia. Nicotine & Tobacco Research, 9, 873–881.
doi:10.1080/14622200701484995
Page 8
  • Source
    • "Evidence also suggests that smoking of mentholated cigarettes is more prevalent in racial/ethnic minority populations (for reviews, Giovino et al., 2004; Ahijevych and Garrett, 2010; Foulds et al., 2010). An association between smoking menthol cigarettes and a greater difficulty in quitting smoking is also greater in racial/ethnic minority populations as well as young smokers (Foulds et al., 2010). Therefore it is important to elucidate the molecular and cellular mechanism of interaction between menthol and nAChRs. "
    [Show abstract] [Hide abstract] ABSTRACT: Monoterpenes are a structurally diverse group of phytochemicals and a major constituent of plant-derived 'essential oils'. Monoterpenes such as menthol, carvacrol, and eugenol have been utilized for therapeutical purposes and food additives for centuries and have been reported to have anti-inflammatory, antioxidant and analgesic actions. In recent years there has been increasing interest in understanding the pharmacological actions of these molecules. There is evidence indicating that monoterpenes can modulate the functional properties of several types of voltage and ligand-gated ion channels, suggesting that some of their pharmacological actions may be mediated by modulations of ion channel function. In this report, we review the literature concerning the interaction of monoterpenes with various ion channels. Copyright © 2015. Published by Elsevier Inc.
    Full-text · Article · May 2015 · Pharmacology [?] Therapeutics
  • Source
    • "Exotic flavours like menthol, vanilla, candy, alcohol, chocolate make the cigarettes desirable for teenagers, women and especially young ones [3,6]. It has been found that tobacco products having a characterized flavour other than tobacco may influence smoking initiation, higher exposure to smoke constituents, greater dependence on nicotine or worse smoking cessation outcomes [7-12]. Flavoured cigarettes not only have a more pleasant taste that makes smoking initiation easier, but the menthol’s cooling and anesthetic effects mask the short-term negative physiological effects of smoking such as throat pain, burning and cough. "
    [Show abstract] [Hide abstract] ABSTRACT: Nowadays the European Union faces a debate on the ban of sale of flavoured cigarettes. There is growing evidence that certain subgroups of smokers are more vulnerable to the use of flavoured cigarettes. However in some European countries, figures on the use of these cigarettes are still scarce. The aim of the study was to assess the prevalence of flavoured cigarettes use in Poland, and examine whether its use among adults varies by socio-demographic characteristics. Data on tobacco use including flavoured cigarettes and other characteristics were derived from the Global Adult Tobacco Survey (GATS). GATS is a cross-sectional, household survey implemented in Poland between 2009 and 2010. GATS provided data on a representative sample of 7,840 individuals covering 2,254 current smokers. Logistic regression model was used to obtain odds ratios (ORs) and 95% confidence interval (CI) of the selected socio-economic variables on the use of flavoured cigarettes. Among females the aromatized cigarettes use was 26.1% compared to 10.5% in males (OR = 2.3; 95% CI:1.62-3.2; p <= 0.001). Respondents aged 20-29 years had an increased likelihood of using flavoured cigarettes compared to subjects aged 60 years or older (OR = 2.7; 95% CI: 1.1-6.5; p <= 0.001). Respondents aware of negative health consequences of smoking had OR = 1.4 95% CI: 1.1-2.1 (p <= 0.05) of smoking aromatized cigarettes compared to those who were unaware. Participants who perceived some kinds of cigarettes less harmful than others were also more likely to use flavoured cigarettes compared to subjects who were convinced that all cigarettes are equally harmful (OR = 1.4; 95% CI: 1.1-1.8; p <= 0.01). High educational attainment, living in large cities, being non-economically active was also associated with use of flavoured cigarettes. Our results are consistent with majority of epidemiology studies on this topic to date and should be considered in the enactment of tobacco control legislation at the national as well as European levels. For combating tobacco epidemic, further efforts need to be made to prevent smoking uptake. Ban of flavoured cigarettes could considerably support achieving this goal.
    Full-text · Article · Feb 2014 · BMC Public Health
  • Source
    • "Both chronic and acute menthol administrations diminish the effect of nicotine on body temper- ature [10]. It is interesting to consider that menthol, a common cigarette additive, has been associated with a greater tobacco dependence potential and lower success in cessation attempts [3,7,4]. A reduction in a7 nACh receptor function has been proposed to constitute a biological mechanism for increased motivation for cigarette smoking [53,54]. "
    [Show abstract] [Hide abstract] ABSTRACT: Menthol is a common compound in pharmaceutical and commercial products and a popular additive to cigarettes. The molecular targets of menthol remain poorly defined. In this study we show an effect of menthol on the α7 subunit of the nicotinic acetylcholine (nACh) receptor function. Using a two-electrode voltage-clamp technique, menthol was found to reversibly inhibit α7-nACh receptors heterologously expressed in Xenopus oocytes. Inhibition by menthol was not dependent on the membrane potential and did not involve endogenous Ca(2+)-dependent Cl(-) channels, since menthol inhibition remained unchanged by intracellular injection of the Ca(2+) chelator BAPTA and perfusion with Ca(2+)-free bathing solution containing Ba(2+). Furthermore, increasing ACh concentrations did not reverse menthol inhibition and the specific binding of [(125)I] α-bungarotoxin was not attenuated by menthol. Studies of α7- nACh receptors endogenously expressed in neural cells demonstrate that menthol attenuates α7 mediated Ca(2+) transients in the cell body and neurite. In conclusion, our results suggest that menthol inhibits α7-nACh receptors in a noncompetitive manner.
    Full-text · Article · Jul 2013 · PLoS ONE
Show more