This Supplement, entitled ‘Mentholated cigarettes: usage patterns, cessation behaviors, policy protection and health profiles’, marks the second Addiction supplement and fifth journal supplement and/or special journal issue published by the Tobacco Research Network on Disparities (TReND) with a focus on tobacco's detrimental influence on populations that experience tobacco-related inequalities. Approximately one-fourth of all cigarettes sold in the United States are mentholated [1]. Menthol cigarettes are used commonly by new, young smokers of all racial/ethnic groups with the overwhelming majority of African American smokers (∼80%) smoking mentholated cigarettes [2,3]. In addition, some studies have suggested that mentholated cigarettes are more addictive and that smoking cessation treatments are less effective for mentholated cigarettes smokers [4–7]. Despite the widespread use of mentholated cigarettes and the disproportionate burden of tobacco-related morbidity experienced by populations who predominantly smoke mentholated cigarettes, there are significant gaps in scientific knowledge about the role of mentholated cigarettes in smoking initiation, nicotine dependence and smoking cessation, including relapse and morbidity. In 2002, the National Cancer Institute (NCI) and Centers for Disease Control and Prevention (CDC) collaborated to host the First Conference on Menthol Cigarettes: Setting the Research Agenda. This 2-day meeting was developed to investigate systematically the potential hazards of menthol cigarettes by examining the current evidence base and laying the groundwork for future research on this topic. The meeting agenda focused on the sociology, marketing, epidemiology, smoking initiation, biochemistry and the physiological impact of menthol. The results from the meeting were published in two key documents: (1) NCI's Executive Summary of the meeting (cancercontrol.cancer.gov/tcrb/MentholExecSumRprt4-10-16.pdf—09-25-2006); and (2) a special journal issue entitled: ‘Menthol cigarettes—setting the research agenda’, published in 2004 by Nicotine & Tobacco Research (vol. 6, Suppl. 1). Since the 2002 Conference on Menthol Cigarettes, there has been little progress to increase our understanding of menthol's role in cancer and other tobacco-related diseases. As a result, TReND commissioned papers to take advantage of two nationally representative surveys sponsored by the NCI and CDC, the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) and the National Health Interview Survey Cancer Control Supplement (NHIS-CCS). These two surveys were chosen because they are nationally representative, have sample sizes large enough to address the research questions of interest and they both contain the same survey items to assess the use of mentholated cigarettes. This journal supplement responded to the need to understand more clearly the smoking of mentholated cigarettes by various socio-demographic groups at the national level. We anticipate that these data will inform intervention studies that prevent the use of menthol cigarette smoking. The 11 original papers in this supplemental issue of Addiction include quantitative secondary data analyses of national survey data in the United States. The manuscripts were commissioned to address four categories of questions responsive to the priority research agenda outlined as a part of the 2002 Conference on Menthol Cigarettes. These questions include: (1) what is the role of mentholated cigarettes in smoking initiation and progression; what is the role of mentholated cigarettes in tobacco addiction and reinforcement; (2) how do mentholated cigarettes affect the smoking cessation processes; (3) to what extent are the higher prevalence rates of mentholated cigarettes preference/use among specific groups influenced by health beliefs and/or neighborhood, social, cultural, economic or other policy-level factors; and (4) do any of these factors operate in combination to exert a synergistic effect on the occurrence of these higher prevalence rates? It is important to note that the papers in this supplement were not intended to address questions related to the morbidity or mortality attributable to use of menthol cigarettes. In ‘National patterns and correlates of mentholated cigarette use in the United States’, based on the TUS-CPS 2003 and 2006–07 data, Lawrence et al. used gender- and race/ethnicity-stratified multivariate logistic regression models to examine the associations between socio-demographic and smoking variables predicting current use of mentholated cigarettes. Due to the large sample size of the data used (66 000+), the authors were able to examine variables within and across multiple racial/ethnic groups. Their research showed that correlates and patterns of use of mentholated cigarettes exist beyond the African American population. With the exception of American Indian/Aleut/Eskimo smokers, non-white smokers were significantly more likely to smoke mentholated cigarettes than were white smokers. Additional significant factors associated with mentholated cigarette smoking included being unmarried, divorced/separated, being born in a US territory, living in a non-metropolitan area, being unemployed and lower levels of education. Race/ethnicity stratified analyses showed that women were more likely than men to smoke mentholated cigarettes, and among black smokers young adults (aged 18–24 years) were more likely to smoke mentholated cigarettes compared with individuals 65 years or older. Their paper uniquely highlights the need to not limit research about mentholated cigarettes to African Americans. There is clearly a need for more research to understand more clearly the motivations for using menthol cigarettes in these other socio-demographic groups and develop effective interventions to reduce initiation and enhance cessation of tobacco use. This paper also sets the stage for socio-demographic variables of interest regarding use of mentholated cigarettes for the rest of the supplement. In ‘Menthol and non-menthol smoking: the impact of prices and smoke-free air laws’, Tauras and colleagues examine how menthol and non-menthol prices and smoke-free air laws affect the choice between menthol and non-menthol cigarettes among current smokers. Authors used a regression model to estimate the probability of being a menthol smoker conditional on being a current smoker who had a distinct preference for either non-menthol or menthol cigarettes. The paper reported that smokers did not find menthol and non-menthol cigarettes to be close substitutes for one another. Non-menthol cigarettes were found to be less of a substitute for menthol cigarettes than vice versa. In addition, young adults and African Americans were less responsive to prices with respect to switching between menthol and non-menthol cigarettes than were older adults and non-African Americans, respectively. This is the first study that provides evidence on the degree of substitutability that exists between menthol and non-menthol cigarettes, and could inform policy decisions about whether or not to ban menthol cigarettes. Cubbin et al. presented findings on the differences in smoking behaviors by menthol status stratified by gender and ethnicity. This paper is interesting because it addressed the intricate race–gender interaction in the use of mentholated cigarettes. In addition to a higher prevalence of menthol use among black men and women, they also found that across all races, female smokers used mentholated cigarettes at much higher rates than their male counterparts. These findings are consistent with those reported by Lawrence and colleagues in this supplement. Ahijevych and colleagues examined effects of menthol brand preference, socio-demographic factors and state tobacco control policies on smoking intensity behaviors among young adult daily and some-days smokers. Dependent variables of smoking intensity were operationalized as the average time to the first cigarette (TTF) smoked and the average number of cigarettes smoked per day (cpd). Independent variables examined included preference for mentholated cigarettes and socio-demographic variables. In their final model for daily smokers, there were no significant associations between menthol brand preference and TTF or cpd. However, lower educational attainment, not being in the labor force and the lack of home smoking rules were associated positively with shorter TTF, while lower educational attainment, being white and state excise taxes were associated positively with higher cpd. Among non-daily smokers, menthol brand preference was associated positively with shorter TTF, but associations did not vary with state tobacco control policies. The finding that mentholated cigarettes smokers have a shorter time to first cigarette of the day is consistent with findings by Fagan et al. in this supplement. Although no significant interactions were found between state tobacco control policies and smoking of mentholated cigarettes, the authors in this paper highlight the need to continue to evaluate potential effects of state-level tobacco control policies on cigarette brand preferences. Fagan et al. examined the associations between menthol cigarette smoking status and nicotine dependence and quitting behaviors among daily smokers using data from the 2003 and 2006/07 TUS-CPS. The paper reports that menthol smokers on average smoked fewer cigarettes per day compared to non-menthol smokers. However, despite smoking fewer cigarettes per day, menthol smokers seem to be more nicotine-dependent, as indicated by their being more likely to smoke their first cigarette of the day within 5 minutes of awakening, a finding that is consistent with that of Ahijevych et al. in this supplement. These interesting findings underscore the fact that the number of cigarettes smoked per day may not be a good measure of nicotine dependence, especially for menthol smokers. Stahre and her colleagues examined the relationship between menthol cigarette smoking and the population quit ratio and whether menthol smokers differ in utilization of evidence-based smoking cessation aids among a nationally representative sample of US adult smokers. Their analysis, which was based on the 2005 NHIS-CCS, revealed significant differences in the population quit ratio for menthol versus non-menthol among African American smokers but not among whites. Their multiple logistic regression analysis showed a significant interaction between race and menthol smoking status, in that African American menthol smokers were significantly less likely than white non-menthol smokers to have quit smoking after controlling for age group, sex, marital status, region and average number of cigarettes smoked per day. Menthol smoking status was not associated with differences in utilization of quit aids. Future research is warranted to examine why there was no association between menthol cigarettes smoking and cessation among whites. Trinidad et al. present some interesting and unique findings in the paper: ‘Menthol cigarettes and smoking cessation among racial/ethnic groups in the United States’, based on the 2003 and 2006/07 TUS-CPS data. The paper examined the relationship between the use of mentholated cigarettes and measures of smoking cessation among African American, Asian American/Pacific Islander, Hispanic/Latino, Native American and non-Hispanic white adults in the United States. The large sample size of the data set utilized presented the authors with a unique opportunity to examine the menthol–cessation relation across multiple racial/ethnic groups, which is often not possible due to limited sample sizes of other data sets. The researchers used adjusted logistic regression models to predict successful smoking cessation (cessation greater than 6 months) among former smokers, stratified by racial/ethnic group. Results showed that those who smoked mentholated cigarettes were significantly less likely to have quit successfully for at least 6 months, for all racial/ethnic groups except Native Americans/Alaska Natives. This was despite the fact that greater proportions of African American and Latino menthol smokers thought that they would probably succeed in quitting. Therefore, the higher confidence for quitting reported by menthol smokers may be negated by the poorer success in quitting. This area warrants further research. The finding of a negative association between use of menthol cigarettes and cessation is consistent with the study by Stahre et al. in this supplement, despite the fact that the latter study used quit ratio to operationalize cessation. Alexander et al. sought to understand an important question about whether or not there is a relationship between the existence of smoking cessation programs in the work-place and menthol preference, as well as quitting behaviors and occupational status, using data from the 2006–07 TUS-CPS. Although researchers did not find any differences in quitting behaviors by menthol status, their findings are consistent with existing research in showing that menthol smokers were younger [1,3], from the northeast region of the United States [1] and more likely to be service workers compared to non-menthol smokers [4]. The paper also found that white-collar workers were more likely to have a work-place clean indoor air policy and an employer-sponsored cessation program compared to blue-collar and service workers. Blue-collar workers were also less likely to quit compared to white-collar workers. In the first of two papers, Fernander and her colleagues examined the relationship between age of smoking initiation, purchasing patterns and menthol smoking status using data from the 2003 and 2006/07 TUS-CPS. Some of the findings from this paper confirm existing research while others do not. Results showing associations between menthol smoking and female gender, racial/ethnic minority status, younger age, higher income and completing a high school education are also reported by other researchers [3], as well as Lawrence et al. and Cubbin et al. in this supplement. Their multivariate logistic model revealed that age of smoking initiation predicted menthol smoking; that is, the longer the delay of initiation the more likely it was that an individual smoked menthol cigarettes. The finding that the longer the delay of smoking initiation, the more likely an individual smoked menthol cigarettes, does not support the notion that menthol promotes early smoking initiation. However, this finding may be confounded by the fact that menthol cigarettes are smoked predominantly by African Americans who in general have a later onset of smoking initiation compared to whites. In their second paper, Fernander and colleagues examined interesting questions about whether menthol cigarette smoking is related to exposure to smoke-free home and work-place policies, availability of cessation services at work and knowledge of cessation resources among current smokers. The authors found that menthol smokers were less likely to have a smoke-free policy at both work and home. Menthol smoking was not related to availability of cessation services offered at work or knowledge of cessation services. Their study finding that menthol cigarette smoking was a risk factor for lack of home or work-place smoke-free policies has not been reported previously and warrants further study. ‘Health profile differences for menthol and non-menthol smokers: findings from the National Health Interview Survey’, by Mendiondo and colleagues, presents new and intriguing findings from their analyses that looked at differences between self-reported health characteristics for menthol and non-menthol smokers. The value of this study is its attempt to look beyond what has been reported previously about menthol smoking by advancing the discussion about potential health effects of mentholated cigarettes beyond cancer and cardiovascular diseases. After controlling for sex, age and race, the mean number of cigarettes smoked per day by current smokers is significantly lower for menthol smokers when compared to non-menthol smokers (odds ratio = 0.99; 95% confidence interval = 0.98, 1.00). Also, former menthol smokers had higher body mass indices (BMIs) and were more likely to have visited the emergency room due to asthma. Because the topic of health effects of menthol cigarettes is not well understood, this paper makes an important contribution and also highlights the need for more research in this area, especially those examining possible biological mechanisms. Taken together, the papers in this supplement present exciting findings, drawing on large national data sets to examine further the role of menthol smoking patterns, nicotine dependence, smoke-free policies, smoking cessation and short-term health effects. There was a fair degree of consistency across the studies showing that mentholated cigarette smokers tend to be female and racial/ethnic minorities, have poorer cessation success, have less protection from work-place tobacco-free policies and are more likely to have a higher BMI. As a result, menthol smokers could be at higher risk from tobacco and other life-style-related diseases. Also, menthol and non-menthol cigarettes may not be close substitutes for one another. The papers in this supplement have created a synergistic body of population-based empirical evidence that researchers can build upon for designing future research addressing the mechanisms underlying the role of menthol and the development of effective cessation interventions for menthol smokers. Future research is warranted to examine if the negative health behavior risk profile (e.g. shorter time to first cigarette of the day, poorer cessation outcomes, less protection from work-place tobacco-free policies and higher BMI) associated with smoking of mentholated cigarettes leads to worse tobacco-related morbidity for mentholated cigarette smokers. Research in this direction has potential for significant contributions for reducing tobacco-related health disparities related especially to the use of mentholated cigarettes. Dr Lawrence is currently an employee of Pinney Associates, Inc., a scientific consulting company that provides services to pharmaceutical companies.
This exploratory study sought to examine the relationships among occupational status, menthol smoking preference and employer-sponsored smoking cessation programs and policies on quitting behaviors.Data for this cross-sectional study were obtained from the 2006 Tobacco Use Supplement to the Current Population Survey (TUS CPS), a large national survey representative of the civilian population, containing approximately 240,000 respondents. The total sample for the current study was 30,176.The TUS CPS regularly collects data on cigarette prevalence, quitting behaviors, smoking history and consumption patterns. We performed a logistic regression with 'life-time quitting smoking for 1 day or longer because they were trying to quit' as outcome variable. Independent variables included type of occupation, employer-sponsored cessation programs and policies and menthol status.When controlling for occupational status and work-place policies, there were no differences for menthol versus non-menthol smokers on quitting behaviors [odds ratio (OR) = 0.98; 95% confidence interval (CI) = 0.83, 1.15]. Service workers were less likely to quit compared with white-collar workers (OR = 0.80; 95% CI = 0.69, 0.94), and those with no employer-sponsored cessation program were less likely to quit (OR = 0.70; 95% CI = 0.60, 0.83). White-collar workers, compared with blue-collar and service workers, were more likely to have a smoking policy in the work area (93% versus 86% versus 88%, respectively).When occupational status and work-place smoking policies are controlled for, smokers of menthol cigarettes in the United States appear to have similar self-reported life-time rates of attempts to stop smoking to non-menthol smokers.
Abstract Purpose The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents. Methods High school students (N = 566) from north‐central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health‐related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants’ geographic rurality and class membership were evaluated using a series of multinomial logistic regressions. Findings LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users. Conclusions The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas.
Genital herpes simplex virus infections are widespread throughout the world and are characterized by stigma, myth, and anxiety by patients and the public but are perceived as trivial by most physicians. Surveys in the United States, Europe, Australia, and South Africa have measured the unfavorable effect of genital herpes on infected patients, health care resources, and workplace productivity. These surveys identified limited satisfaction of patients with current care and support (41% satisfied), although satisfaction scores were greater for patients receiving suppressive antiviral therapy (56% satisfied). Bridging the gap between patients and physicians is vital for improving the management of genital herpes. Key to facilitating patient-physician partnerships is education and recognition by physicians that patients with genital herpes may have expert knowledge. In effective partnerships, physicians and patients can have informed constructive discussions such that patients share in the responsibility for managing their disease and in therapeutic decision making
Abstract Existing data show that lung cancer disparities are not explained by cigarette smoking dose and duration alone. Data from the Multiethnic Cohort Study show that Native Hawaiians and African Americans who smoked 10 cigarettes per day have an elevated risk of lung cancer compared to Japanese American, White, and Latino smokers. Prior studies also suggest that African Americans have slower nicotine metabolism compared to Whites. It remains unclear why we consistently observe slower rates of nicotine metabolism among African Americans, but higher rates of lung cancer since studies suggest that smokers with low levels of CPY2A6 activity may be less efficient in bioactivating tobacco smoke pre-carcinogens to carcinogens. Little is known about nicotine metabolism among Native Hawaiians and Filipinos who have disproportionate and unexplained lung cancer rates like African Americans. This study compares biomarkers of tobacco smoke exposure in Native Hawaiian, Filipino, and White young adult daily smokers. We hypothesized that Native Hawaiians and Filipinos, like African Americans, would have slower nicotine metabolism compared to Whites. We collected data on sociodemographics, smoking history, and psychosocial risk factors among young adult daily smokers aged 18-35. We measured height, weight, and carbon monoxide levels among all smokers. A saliva sample was collected from each smoker using standard passive drool procedures. The geometric means were calculated for nicotine, cotinine, trans 3' hydroxycotinine, the nicotine metabolite ratio, and expired carbon monoxide and the data were compared among racial/ethnic groups. Two analysis of covariance models tested biomarker differences among racial/ethnic groups. Model 1, the unadjusted model, contained no covariates. Model 2 included gender, body mass index (BMI), menthol smoking status, Hispanic ethnicity, and the number of cigarettes smoked per day as covariates. The sample included 44% Native Hawaiians, 16% Filipinos, and 40% Whites (n=186). Twenty-four percent of young adults were of Hispanic origin, 48% were females, and smokers had a mean BMI of 28. Forty-one percent of Filipino smokers reported Hispanic ethnicity compared to 27% of Native Hawaiian and 15% of White smokers (p< 0.02). Native Hawaiians had a higher BMI than Filipinos and Whites (31.9, 24.5, 24.8, p<0.001). Eighty-seven percent of Native Hawaiians, 72% of Filipinos, and 48% of White young adults reported menthol cigarette use. There were no differences in smoking duration or smoking consumption among racial/ethnic groups. Smokers had smoked daily for 1.5 years and smoked a mean of 14.4 cigarettes per day. In the unadjusted and adjusted models, cotinine levels were higher among Native Hawaiians compared to Whites, but these differences were not significant among racial/ethnic groups. In the unadjusted model, the nicotine metabolic ratio was significantly lower in Native Hawaiian and Filipino smokers compared to White smokers (NMR: 0.17, 0.15, 0.27, p<0.001). In the adjusted model, the nicotine metabolite ratio remained significantly lower in Native Hawaiian and Filipino smokers compared to White smokers (NMR: 0.20, 0.19, 0.33, p<0.001). In summary, our data show that Native Hawaiian and Filipino daily smokers have slower nicotine metabolism than White daily smokers as indicated by the nicotine metabolite ratio. Studies show that the nicotine metabolite ratio is a reliable phenotypic marker for CYP2A6 activity. However, is it not clear whether the algorithm suggesting that slow nicotine metabolizers have reduced lung cancer risk applies to all racial/ethnic groups. Resolving the complex problem of lung cancer disparities requires further investigation of multiple biological pathways to determine which lung cancer risk algorithms apply to specific racial/ethnic groups. Such investigations will allow to us to improve community, clinical, and policy-based interventions to reduce disparities. Citation Format: Pebbles Fagan, Eric T. Moolchan, Pallav Pokhrel, Thaddeus Herzog, Kevin Cassel, Ian Pagano, Adrian Franke, Joseph Keawe'aimoku Kaholokula, Angela Sy, Linda A. Alexander, Dennis R. Trinidad, Kari-Lyn Sakuma, Carl Anderson Johnson, Alyssa M. Antonio, Dorothy Jorgensen, Tania Lynch, Crissy Kawamoto, Mark S. Clanton. Resolving the complex problem of tobacco-caused lung cancer disparities in the U.S. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA47.
Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66).Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fisher's exact test, and Pearson's correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations.Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose.Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity.The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDA's interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.
