Would banning menthol cigarettes, flavored cigars, and flavored e-cigarettes prompt users to seek illicit channels for obtaining them in the United States?

BACKGROUND: Banning flavors in tobacco and nicotine products may reduce youth initiation and prompt quit attempts but such bans may lead to illicit markets. We examined how likely current users would be to seek flavored products from illicit channels under various ban scenarios. METHODS: Cross-sectional surveys of 2552 current users of menthol cigarettes or flavored cigars and 2347 users of flavored e-cigarettes were conducted between 2021 and 2022 in the United States. For each ban scenario, respondents reported if they would have intentions to seek the banned flavored products from any illicit channels and identified the specific illicit channel they would consider. Logistic regressions were used to estimate how the likelihood of having intentions to seek illicit channels was associated with demographics, ban scenarios, and status of tobacco use. RESULTS: Under various ban scenarios, 24-30% of people who smoked said they would seek illicit channels to obtain the banned products compared with 21-41% of dual users and 35-39% of users of flavored e-cigarettes. Online retailers were favored by people who smoked while users of flavored e-cigarettes favored local retailers. Heavy users were more likely to say they would try illicit channels. Under bans restricting more types of flavored tobacco products, users would be less likely to try illegal channels. CONCLUSIONS: A significant proportion of users of flavored tobacco and nicotine products would not reject using illicit banned products. Tailored programs are needed to apply to the groups with a higher risk of seeking illicit channels for banned products.

Prevalence of menthol cigarette use among adults who smoke from the United States by census division and demographic subgroup, 2002-2020: findings from the International Tobacco Control (ITC) project.

BACKGROUND: Targeted marketing of menthol cigarettes in the US influences disparities in the prevalence of menthol smoking. There has been no analysis of sub-national data documenting differences in use across demographic subgroups. This study estimated trends in the prevalence of menthol use among adults who smoke in the nine US census divisions by sex, age, and race/ethnicity from 2002 to 2020. METHODS: Data from 12 waves of the US ITC Survey were used to estimate the prevalence of menthol cigarette use across census divisions and demographic subgroups using multilevel regression and post-stratification (n = 12,020). Multilevel logistic regression was used to predict the prevalence of menthol cigarette use in 72 cross-classified groups of adults who smoke defined by sex, age, race/ethnicity, and socioeconomic status; division-level effects were fit with a random intercept. Predicted prevalence was weighted by the total number of adults who smoke in each cross-classified group and aggregated to divisions within demographic subgroup. Estimates were validated against the Tobacco Use Supplement to the Current Population Survey (TUS-CPS). RESULTS: Overall modeled prevalence of menthol cigarette use was similar to TUS-CPS estimates. Prevalence among adults who smoke increased in each division from 2002 to 2020. By 2020, prevalence was highest in the Middle (46.3%) and South Atlantic (42.7%) and lowest in the Pacific (25.9%) and Mountain (24.2%) divisions. Prevalence was higher among adults aged 18-29 (vs. 50+) and females (vs. males). Prevalence among non-Hispanic Black people exceeded 80% in the Middle Atlantic, East North Central, West North Central, and South Atlantic in all years and varied most among Hispanic people in 2020 (Pacific: 26.5%, New England: 55.1%). CONCLUSIONS: Significant geographic variation in the prevalence of menthol cigarette use among adults who smoke suggests the proposed US Food and Drug Administration (FDA) menthol cigarette ban will exert differential public health benefits and challenges across geographic and demographic subgroups.

Examining the predictive utility of behavioral economic demand indices and subjective effects on the actualized reinforcing value of menthol cigarettes and potential alternatives.

INTRODUCTION: Considering recent and proposed bans on menthol cigarettes, methods are needed to understand the substitutability of potential menthol cigarette alternatives (MCAs) for menthol cigarettes. This study examined the prospective relationship between behavioral economic demand indices and subjective effects of usual brand menthol cigarettes (UBMC) and preferred MCAs with subsequent performance on a laboratory-based concurrent-choice task comparing UBMC and MCAs. METHODS: Eighty participants who typically smoked menthol cigarettes completed this clinical lab study. After sampling each product, participants completed the cigarette purchase task (CPT) and modified cigarette evaluation questionnaire (mCEQ). Following one-week of substituting their preferred MCA for their UBMC, participants completed a 90-min concurrent-choice self-administration task comparing their UBMC and preferred MCA. Linear regression models explored associations between CPT demand indices and mCEQ subjective effects in the lab with subsequent response effort for UBMCs on the concurrent-choice task. RESULTS: Three demand indices for UBMC were positively associated with UBMC response effort: Essential Value (EV; p=.02), Omax (p=.02), and breakpoint (p=.04). Four CPT demand indices for the preferred MCA significantly corresponded with UBMC response effort: EV (p=.03), Pmax (p=.04), Omax (p=.03), and breakpoint (p=.03). Subjective effects captured by the mCEQ were not associated with response effort. CONCLUSIONS: Demand indices reflecting Persistence (i.e., sensitivity to escalating price) predicted effort to obtain UBMC puffs on the concurrent-choice task. Among this sample, the CPT captured information on the relative reinforcing value (i.e., addiction potential) of combustible tobacco products similar to the longer self-administration task. IMPLICATIONS: In an ever-changing product market, assessing the reinforcing efficacy of menthol cigarettes and putative substitutes quickly and with validity is an important methodological tool for understanding abuse liability. Results suggest that behavioral economic demand indices of cigarette purchase task efficiently capture information on the relative reinforcing value of usual brand menthol cigarettes and plausible alternative tobacco products, similar to a 90-min in-laboratory self-administration task.

Motivation to Quit Smoking Among Black Adults Residing in Los Angeles County Communities With Menthol Cigarette Sales Restrictions.

Background: Research is needed to identify the determinants of motivation to quit smoking among non-Hispanic Black (NHB) adults who smoke menthol cigarettes and reside in communities covered by menthol cigarette bans. Objectives: This study examined the associations between motivation to quit smoking and a range of individual-level predictors, including measures of demographics, harm/risk perception of menthol cigarettes, and awareness of a ban on menthol cigarettes in Los Angeles County unincorporated communities. Self-identified NHB adults who currently smoke menthol cigarettes (N=50; M=47.2 years; SD=13.7; 46% female) were recruited in Los Angeles County unincorporated communities. Participants completed an interviewer-administered cross-sectional survey between January to September 2021. Results: Participants (74%) reported an annual household income of less than $25,000. Participants' mean age at cigarette initiation was 15.7 years old (SD=5.68). Most (88%) were aware of the ordinance banning menthol cigarette sales. Employing multivariable linear regression analysis, harm/risk perception of menthol cigarettes (B=14.69, p<0.01) and awareness of the local menthol ban (B=26.18, p<0.05) were found to be independently associated with motivation to quit smoking. Conclusions: Findings from this community-based sample suggest that among NHB adults who smoke menthol cigarettes, motivation to quit smoking is influenced by their perception of menthol cigarettes as harmful and awareness of local policy banning the sale of menthol cigarettes. Findings underscore the need for community-centered and culturally grounded interventions to facilitate quitting among NHB adults who smoke in order for communities covered by menthol bans to achieve health equity in reducing preventable racial inequities due to menthol cigarettes.

Racial/ethnic differences in the association between menthol cigarette use and mental illness among adults who smoke in the United States.

Data from the National Survey on Drug Use and Health (2012-2018) were used to characterize the association between menthol cigarette use and indicators of Any (AMI) and Serious (SMI) Mental Illness among adults who smoke in the United States. In general, people who smoke menthol cigarettes were more likely to have AMI (aOR = 1.123 [1.063-1.194]) than people who smoke non-menthol cigarettes, but not SMI (aOR = 1.065 [0.966-1.175]). However, among non-Hispanic African American/Black people who smoke, those that used menthol cigarettes had lower adjusted odds of both AMI (aOR = 0.740 [0.572-0.958]) and SMI (aOR = 0.592 [0.390-0.899]) than their counterparts who used non-menthol cigarettes. Results suggest there may be race/ethnicity-specific drivers of the association between menthol cigarette use and mental illness.

The actual and anticipated effects of a menthol cigarette ban: a scoping review.

BACKGROUND: The United States (US) Food and Drug Administration (FDA), under the 2009 Family Smoking Prevention and Tobacco Control Act, banned characterizing flavors in cigarettes; however, mentholated tobacco products were exempt. Since 2009, over 20 US jurisdictions and numerous countries around the world have extended this restriction to menthol. Currently, the FDA is reconsidering its position on a nation-wide menthol cigarette ban. However, the effects of such a ban remain unclear. We conducted a scoping review to explore the impact of a menthol cigarette ban on individual behaviors (initiation, cessation, and product switching), sales, and compliance. METHODS: We conducted a search of the international literature using PubMed, EBSCO, and Web of Science (to November 25, 2019). We retrieved articles relevant to the impacts of an implemented or hypothetical menthol ban. We also included studies of flavored tobacco product bans due to their potential relevance in gauging compliance and product substitutability. RESULTS: The search identified 493 articles, of which 24 were included. Studies examined the effects of implemented menthol bans (n = 6), hypothetical menthol bans (n = 12) and implemented flavor bans that exclude menthol (n = 6). Menthol bans were found to reduce sales and increase smoking cessation with only partial substitution for non-menthol cigarettes. US smokers' reactions to a hypothetical ban indicate that about 25-64% would attempt to quit smoking and 11-46% would consider switching to other tobacco products, including 15-30% to e-cigarettes. Flavor ban studies indicate reductions in initiation of 6%. Ban compliance was high, but studies indicate that the tobacco industry and retailers have attempted to circumvent their impact via packaging changes and online sales. CONCLUSION: Our review finds that extending the US cigarette flavor ban to menthol products would promote smoking cessation and reduce initiation. This evidence supports further action by the FDA towards mentholated tobacco products. However, few studies have been conducted in the vaping era.

Cigarette butts have adverse effects on initial growth of perennial ryegrass (gramineae: Lolium perenne L.) and white clover (leguminosae: Trifolium repens L.).

Cigarette filters (butts) are currently the most abundant form of anthropogenic litter on the planet, yet we know very little about their environmental impacts on terrestrial ecosystems, including plant germination and primary production. When discarded, filters contain a myriad of chemicals resulting from smoking tobacco and some still contain unsmoked remnants. A greenhouse experiment was used to assess the impacts of discarded filters of regular or menthol cigarette, either from unsmoked, smoked, or smoked cigarettes with remnant tobacco, on the growth and development of Lolium perenne (perennial ryegrass) and Trifolium repens (white clover). After 21 days, shoot length and germination success were significantly reduced by exposure to any type of cigarette filter for the grass and clover. Although total grass biomass was not measurably affected, the root biomass and root:shoot ratio were less in the clover when exposed to filters from smoked regular cigarettes and those with remnant tobacco. Cigarette filters caused an increase in chlorophyll-a in clover shoots and an increase in chlorophyll-b in grass shoots. Accordingly, whilst the chlorophyll a:b ratio was increased in the clover exposed to cigarette filters, it was decreased in grass. This study indicates the potential for littered cigarette filters to reduce growth and alter short-term primary productivity of terrestrial plants.

Flavour capsule cigarette use among US adult cigarette smokers.

INTRODUCTION: Flavour capsule cigarettes are a recent product worldwide, and little is known about the epidemiology of their use. We used data from a nationally representative survey to understand the sociodemographic characteristics of flavour capsule cigarette smokers and reasons for flavour capsule use. METHODS: Data were from the nationally representative, U.S. Population Assessment of Tobacco and Health survey (2013-2014). Analyses included 7181 adults, aged 18-44 years, who were current or former established (≥100 lifetime cigarettes) cigarette smokers. Participants reported their usual brand of cigarettes which were classified as non-menthol, menthol or flavour capsule. Analyses assessed differences in participant demographics, smoking patterns and reasons for use by product type among those aged 18-24 years. Analyses were weighted to account for the survey design. RESULTS: Flavour capsule cigarettes were the usual cigarettes among 9.4% of smokers aged 18-24 years and 6.0%, 3.7% and <1% of smokers aged 25-34, 35-44 and ≥45 years, respectively. Among smokers aged 18-24 year, a significantly higher percentage of Hispanic smokers (17.3%) usually used flavour capsule cigarettes versus non-Hispanic white (8.4%, P<0.05) and non-Hispanic black (3.2%, P<0.05) smokers. Flavour capsule use was associated with later onset of smoking and lower levels of nicotine dependency and flavour capsule users placed more emphasis on taste, lower price and pack design than menthol or non-menthol users. CONCLUSIONS: Flavour capsule cigarettes use is highest in young adults, particularly Hispanics. Young adult predominance, lower level of addiction symptoms and emphasis on pack design by flavour capsule users suggest that these products may be positioned as starter products.

Comparison of E-Cigarette Use among Menthol and Non-Menthol Smokers: Findings from a Community Based Sample.

Objective: E-cigarette use is increasing among adult cigarette smokers. With the availability and variety of appealing characteristics, including menthol flavor, e-cigarette use patterns may differ among menthol and non-menthol cigarette smokers. This study compared e-cigarette knowledge and use between current menthol and non-menthol smokers aged ≥18 years. Design: Current adult cigarette smokers (N=223; M=42.1 years; SD=12.2; 68% menthol smokers) recruited in South Florida completed an interviewer-administered survey via telephone during June to November 2014. Main Outcome Measures: E-cigarette use (ever-use, past 30-day use, past 30-day flavored e-cigarette use, and past 30-day mentholated e-cigarette use), consideration of e-cigarette use for quitting/reduction of cigarettes, and knowledge assessments. Bivariate and multivariate analyses tested associations with menthol smoking. Results: Menthol smokers were more likely to be African American or Hispanic (P<.001) and report lower income (P=.02) and education (P<.001) than non-menthol smokers. Adjusted analyses found no association between menthol cigarette use and e-cigarette ever-use. However, menthol smokers demonstrated less e-cigarette knowledge (P<.01) and were more likely to consider using e-cigarettes to quit/reduce smoking (AOR=3.89, CI:1.55-9.78). Among ever-users, there was no association between menthol cigarette use and past 30-day e-cigarette use, yet menthol smokers were more likely to use menthol flavored e-cigarettes (AOR=6.65, CI: 1.94-12.78). Conclusions: Our findings suggest that, compared with current non-menthol smokers, current menthol smokers are more likely to consider using e-cigarettes to help quit/reduce smoking, and are more likely to use menthol flavored e-cigarettes. Further research is needed to better examine low e-cigarette knowledge among menthol smokers, which may represent an important intervention target.

Does removing menthol cigarettes in convenience stores reduce susceptibility to cigarette smoking? An experimental investigation in young people.

BACKGROUND: Evidence for the effectiveness of menthol cigarette bans comes mostly from studies of adults that smoke. This experiment evaluated whether the absence of menthol products from a convenience store influenced young people's susceptibility to cigarette smoking after they shopped in the store. METHODS: This experiment took place in the RAND StoreLab (RSL), a life-sized research convenience store. A three-group, between-subjects design was used. Study conditions differed in the mix of flavored tobacco products the RSL displayed: 1) All tobacco-, sweet-, and menthol-flavors displayed; 2) only tobacco- and menthol-flavors displayed; and 3) only tobacco-flavors displayed. Participants were randomly assigned to shop in the RSL under one of these conditions and after shopping, completed measures of their susceptibility to cigarette smoking, one measure for menthol cigarettes and one for unflavored cigarettes (scores on each susceptibility measure was dichotomized: 0 = not susceptible; 1 = susceptible). RESULTS: Multivariable logistic regression assessed the main effects of condition on susceptibility to smoking menthol and unflavored cigarettes. There was no condition effect on susceptibility to smoking unflavored cigarettes. However, removing menthol-flavored products significantly increased participants' susceptibility to smoking menthol cigarettes compared to when all flavored products were available (OR = 3.66, 95% CI [1.33, 10.03]). This significant effect was only found among young people with some pre-existing risk of cigarette smoking (OR = 5.92, 95% CI [1.81, 19.39]). CONCLUSION: Results suggest the need to consider that menthol bans could unintentionally increase the appeal of menthol cigarettes among youth already at risk of smoking.

Tax incidence for menthol cigarettes by race: Evidence from Nielsen Homescan data.

We use Nielsen Homescan data to examine whether the incidence of cigarette taxes on menthol products varies with race. We find that taxes are shifted at significantly lower rates to Black smokers of menthol cigarettes than any other smokers. One possible explanation is that the industry targets price promotions to Black menthol smokers because they tend to be more responsive to cigarette prices relative to other smokers. We find evidence that Black smokers receive significantly more price discounts for menthol products than white menthol smokers. Our findings indicate that increasing cigarette taxes would effectively reduce menthol smoking among Black Americans because tax pass-through rate for Black menthol smokers is still substantially above zero.

Public Perceptions of the Food and Drug Administration's Proposed Rules Prohibiting Menthol Cigarettes on Twitter: Observational Study.

BACKGROUND: On April 28, 2022, the Food and Drug Administration (FDA) proposed rules that prohibited all menthol-flavored cigarettes and other flavored cigars to prevent the initiation of tobacco use in youth and reduce tobacco-related diseases and death. OBJECTIVE: The objective of this study was to investigate public perceptions of the FDA's proposed menthol cigarette rules on Twitter. METHODS: Through the Twitter streaming application programming interface, tobacco-related tweets were collected between April 28, 2022, and May 27, 2022, using a set of keywords, such as smoking, cigarette, and nicotine. Furthermore, 1941 tweets related to the FDA's proposed menthol cigarette rules were extracted. Based on 300 randomly selected example tweets, the codebook for the attitudes toward the FDA's proposed rules and related topics was developed by 2 researchers and was used to label the rest of the tweets. RESULTS: Among tweets related to the FDA's proposed menthol cigarette rules, 536 (27.61%) showed a positive attitude, 443 (22.82%) had a negative attitude, and 962 (49.56%) had a neutral attitude toward the proposed rules. Social justice (210/536, 39%) and health issues (117/536, 22%) were two major topics in tweets with a positive attitude. For tweets with a negative attitude, alternative tobacco or nicotine products (127/443, 29%) and racial discrimination (84/536, 16%) were two of the most popular topics. CONCLUSIONS: In general, the public had a positive attitude toward the FDA's proposed menthol cigarette rules. Our study provides important information to the FDA on the public perceptions of the proposed menthol cigarette rules, which will be helpful for future FDA regulations on menthol cigarettes.

Price differences between capsule, menthol non-capsule and unflavoured cigarettes in 65 countries in 2018.

The global consumption of flavoured cigarettes, particularly capsule and menthol non-capsule cigarettes, has been rising rapidly. Their attractiveness has been fuelled by perceptions of improved palatability, along with industry marketing tactics such as lower price points in some regions. This study aimed to compare prices of unflavoured, capsule, and menthol non-capsule cigarettes across 65 countries by analysing 2018 cigarette price data from Euromonitor Passport. Median prices of capsule and menthol non-capsule cigarettes were each compared to unflavoured cigarettes at the country-level. Countries were included in the analysis if they contained price data for capsule or menthol non-capsule and unflavoured cigarettes (n = 65). The median price of capsule cigarettes was the same as unflavoured cigarettes in 12 out of 50 countries and not statistically different in another 31 countries (p > 0.05). Capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in two (p < 0.05). The median price of menthol non-capsule cigarettes was the same as unflavoured cigarettes in 6 out of 51 countries and not statistically different in another 39 countries (p > 0.05). Menthol non-capsule cigarettes were more expensive than unflavoured cigarettes in five countries and cheaper in one country (p < 0.05). There was no pattern found in the pricing of capsule or menthol non-capsule cigarettes, suggesting variability in the tobacco industry's pricing strategies across countries. Tailoring tobacco control policies to match national market conditions, particularly in countries with significant market shares of capsule and menthol non-capsule cigarettes could help address the public health threat posed by the tobacco epidemic.

Reactions to using other nicotine and tobacco products instead of menthol cigarettes: A qualitative study of people who smoke menthol cigarettes in the United States.

The US Food and Drug Administration is considering banning menthol cigarettes, which could result in some people who smoke menthol cigarettes switching to other tobacco products (OTPs). This qualitative study explored reactions to using OTPs instead of menthol cigarettes. People who smoke menthol cigarettes (N=40) completed a behavioral economic assessment of the effects of menthol cigarette price increases on OTP purchasing. At the highest price, most participants could not afford menthol cigarettes. Instead, they could purchase non-menthol cigarettes, little cigars/cigarillos (LCCs), e-cigarettes, smokeless tobacco, or medicinal nicotine, or they could abstain from tobacco use. Participants used the OTPs they purchased for three days. During follow-up sessions, participants (n=35) completed semi-structured interviews discussing their purchasing-decisions and experiences using OTPs instead of menthol cigarettes. Interviews were analyzed using reflexive thematic analysis methods. Factors influencing purchasing decisions included flavor, price, prior use of OTPs, interest in trying new OTPs, and perceived ability to satisfy nicotine cravings. Participants described positive experiences using e-cigarettes including the "refreshing" menthol flavor, ability to use in places where cigarettes are prohibited, and convenience of use relative to smoking. Among those using non-menthol cigarettes, many reported they were acceptable but less satisfying products compared to menthol cigarettes while others reported negative reactions to them such as tasting like "cardboard". Reactions to smoking LCCs were mostly unfavorable but participants said it gave them "something to light". Multiple considerations may affect switching to OTPs in light of pending menthol cigarette regulation including the availability of menthol-flavored alternatives and (dis)satisfaction with OTPs.

Reactions to a Hypothetical Menthol Cigarette Ban among Sexual- and Gender-Minoritized Communities: A Concept Mapping Study.

Menthol cigarette use is disproportionately higher among sexual- and gender-minoritized (SGM; 36%) individuals compared to cisgender, heterosexual (29%), individuals. The FDA has announced intentions to ban menthol in cigarettes, citing these use and health disparities as partial motivation. This study identified potential outcomes of a menthol cigarette ban among SGM individuals who smoke menthol cigarettes (N = 72). Potential outcomes were identified via concept mapping using the prompt: "If menthol in cigarettes was banned, a specific action I would take related to my tobacco use is…" Participants generated 82 response statements, sorted them, and rated them on personal relevance. Eight thematic clusters were identified: (1) Thoughtful Consideration of the Ban, (2) Negative Reactions to the Ban, (3) Positive Aspects of the Ban, (4) Strategies to Reduce Cravings, (5) Intent to Quit and Cessation Strategies, (6) Support-Seeking and Engagement in Positive Behaviors, (7) Strategies to Maintain Menthol-Flavored Product Use, and (8) Substance Use Alternatives to Menthol Cigarettes. Cluster differences based on sociodemographic factors, smoking behavior, and quitting interest were identified. Results provide insight into potential responses to a menthol cigarette ban and can contribute to public health prevention and intervention efforts, messaging campaigns, and support services for SGM people who smoke menthol cigarettes, specifically.

A Longitudinal Study of Perceptions of the Massachusetts Menthol Ban and Its Impact on Smoking Behaviors among Marginalized Individuals.

Menthol cigarettes have had a profound adverse effect on public health. On 1 June 2020, Massachusetts became the first state to ban the sale of menthol cigarettes. We explored how perceptions of the ban and smoking behaviors changed over time among a group of 27 individuals who smoked menthol cigarettes at our safety-net hospital. In a convergent mixed methods study, we administered questionnaires and interviews simultaneously at two timepoints: 1 month pre-ban and 6 months post-ban. Pre-ban, we assessed perceptions of the ban and anticipated smoking behaviors after the ban. Post-ban, we assessed participants' actual smoking behaviors and elicited suggestions to avoid unintended consequences that might undermine intended policy effects. Several respondents perceived the Massachusetts ban as positive because it could promote smoking cessation, prevent youth initiation, and mitigate unfair targeting of socioeconomically disadvantaged populations. Others perceived the ban as an overreach of government policy, financially motivated, and unfairly targeting the Black community. Many continued to smoke menthol cigarettes obtained outside Massachusetts. Individuals suggested promoting tobacco treatment for people affected by the ban and a national ban to circumvent out-of-state purchasing of menthol cigarettes. Our findings suggest that in order to be most effective, healthcare systems must promote tobacco treatment and ensure that treatment is accessible to all individuals affected by the ban.

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study.

PURPOSE: Describe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies. METHODS: Using data on US young adults (ages 18-34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users. RESULTS: Any flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users. DISCUSSION: Racial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

"I think it's a good idea for the people that's young, the kids, but for someone like me it's a bad idea." - Interviews about a U.S. menthol cigarette ban with people who smoke menthol cigarettes.

OBJECTIVE: The US Food and Drug Administration recently announced its intention to pursue a federal ban on menthol cigarettes. This qualitative study assessed reactions to a potential menthol cigarette ban among people who smoke menthol cigarettes. METHODS: As part of a laboratory study examining menthol flavor regulations, we conducted follow-up interviews with participants who smoke menthol cigarettes (N = 35). We explored the following topics: (1) menthol cigarette risk perceptions; (2) knowledge, attitudes, and perceptions of menthol cigarette regulations; and (3) anticipated behavior if menthol cigarettes were banned. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. RESULTS: Many participants thought menthol cigarettes carried more health risks than non-menthol cigarettes. Some participants said regulators wanted to ban menthol cigarettes because they appeal to youth. Others thought a ban would be good for public health because fewer people, particularly youth, would smoke. Several voiced skepticism about banning only menthol cigarettes rather than all cigarettes. Most said they would use other products, including electronic cigarettes or non-menthol cigarettes, but many also thought a menthol ban could motivate them or others to quit smoking. CONCLUSIONS: Banning menthol cigarettes could lead some people who smoke menthol cigarettes to switch to potentially less harmful products, like e-cigarettes, or quit smoking, which would likely benefit public health; however, others may simply transition to non-menthol cigarettes. As regulators move forward with banning menthol cigarettes, communication campaigns explaining the public health benefits, potentially focusing on the benefits for youth, should be part of the policy implementation plan.

Substitution of flavored cigarillos with menthol cigarettes among young adults in the U.S.

BACKGROUND: Young adult cigarillo users often cite flavor as a primary reason for initiating and sustaining product use and are more likely to concurrently use other tobacco products such as menthol cigarettes. This study examines substitution with menthol cigarettes among cigarillo users facing a hypothetical ban on flavored cigarillos. METHODS: Current young adult (21-28 years) cigarillo users were recruited from October 2020 to April 2021 for an online survey about cigarillo and other tobacco use behaviors. Participants (n = 500) self-reported past or current menthol cigarette experience, and if they would switch to menthol cigarettes if they could not get flavored cigarillos. Logistic regression was used to test differences in switching behaviors by level of experience with menthol cigarettes. RESULTS: Most young adult cigarillo users (76.8 %) had ever used a menthol cigarette and 46.6 % reported current use of menthol cigarettes. No participant who had never used menthol cigarettes reported they would switch to menthol cigarettes. Current users were 4.2 times as likely to say they would switch after controlling for demographic characteristics and nicotine dependence. CONCLUSION: Most young adult cigarillo users reported they would not switch to menthol cigarettes if flavored cigarillos became unavailable. However, participants who currently use or have used menthol cigarettes were more likely to report their intention to switch products than those who had never used menthol cigarettes. There may be a subsequent increase in menthol cigarette use among past menthol cigarette users if policies restricting flavored tobacco products exclude menthol cigarettes, diluting these policies' intended population health impact.