Menthol and initiation of cigarette smoking

Abstract

The use of tobacco products would not continue without the initiation of their use by youth and adults. Since the vast majority of cigarette smokers begin smoking by age 25, understanding the role of menthol cigarettes in the initiation of smoking in youth (under the age of 18) and young adults (aged 18-25) is especially relevant. Data demonstrate that menthol cigarettes are disproportionately used by youth and young adults. This review seeks to examine what role, if any, menthol plays in the initiation of cigarette smoking. Overall, there is a paucity of data on this topic. The data that do exist suggests that youth who have smoked for less than 1 year are more likely to smoke menthol cigarettes than youth who have smoked for more than 1 year. A lack of data prevents further conclusions on the role of menthol cigarettes in the initiation of smoking.

Full text

REVIE W Open Access
Menthol and initiation of cigarette smoking
Joshua Rising
1*
, Kristina Wasson-Blader
2
Abstract
The use of tobacco products would not continue without the initiation of their use by youth and adults. Since the
vast majority of cigarette smokers begin smoking by age 25, understanding the role of menthol cigarettes in the
initiation of smoking in youth (under the age of 18) and young adults (aged 18–25) is especially relevant. Data
demonstrate that menthol cigarettes are disproportionately used by youth and young adults. This review seeks to
examine what role, if any, menthol plays in the initiation of cigarette smoking. Overall, there is a paucity of data on
this topic. The data that do exist suggests that youth who have smoked for less than 1 year are more likely to
smoke menthol cigarettes than youth who have smoked for more than 1 year. A lack of data prevents further
conclusions on the role of menthol cigarettes in the initiation of smoking.
Review
Introduction
Initiation of cigarette smoking in the United States has
continued at a high rate. According to a 2008 report
from the Substance Abuse and Mental Health Adminis-
tration, around 4,000 youth try their first cigarette each
day [1] and approximately 1,000 youth become daily
smokers. [2] Additionally, 2,800 young adults try their
first cigarette each day. [1] Other data have also demon-
strated high rates of smoking initiation among youth
and young adults. A report from the Surgeon General in
1994 [3] reviewed data from the National Household
Surveys on Drug Abuse, which surveyed persons aged
30–39 about their recollections of the age of first cigar-
etteandfirstregularsmoking,andfoundthat62.2%of
persons who had ever smoked daily tried their first
cigarettebeforetheageof16.Inaddition,morethan
half of those who ever smoked daily began smoking
dailybeforetheageof18[3].Astudythatusedaggre-
gated data from the 1990s examined the age at smoking
initiation as recalled by individuals aged 26–50 years;
this study revealed significant racial/ethnic disparities
[4]. The authors found that the majority of White and
Latino smokers began smoking by the age of 18, while
the majority of Black/African American and Asian/Paci-
fic Islander smokers began smoking between the ages of
18 and 25. While these reports do not distinguish
between menthol and non-menthol cigarette smokers,
they do provide data that demonstrate that the majority
of smokers begin smoking as youth and young adults.
Despite acknowledgement of the importance of under-
standing why individuals initiate cigarette smoking,
there is limited literature on the impact of menthol on
the initiation of cigarette smoking. This article reviews
the available literature on menthol and the initiation of
cigarette smoking and explores the following questions:
•Do menthol cigarette smokers start smoking earlier
in life than non-menthol cigarette smokers?
○Does this vary by race/ethnicity?
•Is there a higher use of menthol cigarettes among
recent initiations (e.g., youth who have been smoking
for less than 1 year)?
○Does this vary by age or race/ethnicity?
•Does the smoking of menthol cigarettes alter pro-
gression from first cigarette(s) toward becoming a regu-
lar smoker?
•Did current smokers initiate smoking with menthol
cigarettes and then switch to non-menthol cigarettes?
•What information do published reports on publicly
available internal tobacco industry documents contain
on this topic?
Summarized in this review are 10 articles found to
have either direct relevance to these questions, or were
used to provide relevant background information. Many
ofthesearticleswereidentifiedthroughareviewofthe
literature conducted by the National Cancer Institute in
2009, published as “Bibliography of literature on
menthol and tobacco”(http://cancercontrol.cancer.gov/
* Correspondence: Joahua.Rising@fda.hhs.gov
1
Center for Tobacco Products, U.S. Food and Drug Administration, Rockville,
MD, USA
Full list of author information is available at the end of the article
Rising and Wasson-Blader Tobacco Induced Diseases 2011, 9(Suppl 1):S4
http://www.tobaccoinduceddiseases.com/content/9/S1/S4
© 2011 Rising and Wasson-Blader; licensee BioMed Central Ltd. This is an open access ar ticle distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by /2.0), which permits unr estricted use, distribution, and
reproductio n in any medium, provided the original work is properly cited.

tcrb/documents/menthol_bibliography_508.pdf). Search
terms used were menthol cigarette(s); mentholated
cigarette(s); menthol tobacco; mentholated tobacco;
menthol smoker(s); menthol AND the following terms:
addiction, nicotine, marketing, cancer, biomarkers,
asthma, cardiovascular disease, heart disease, vascular
disease, chronic obstructive lung disease, respiratory,
environmental tobacco smoke, national health, health
disparities, and minority health. Additional searches and
sources, such as those identified through review articles,
identified additional articles that were included as
appropriate.
Of those articles that are in the NCI Bibliography but
were not included, most were not directly relevant to
this topic (e.g., they studied menthol as a chemical inde-
pendent from tobacco smoke exposure, did not evaluate
menthol as a separate variable). Some of those articles,
however, were used to provide background information.
Animal or in vitro research was included only to help
explain human findings. Although a few review articles
were used to make general statements and/or provide
background information, most were not included in
deference to original sources. Published abstracts were
not included out of concern that, due to the lack of
details, those studies could not adequately be assessed.
New youth and young adult smokers
A study by Hersey et al [5] examined data from the
2002 National Youth Tobacco Survey regarding the
duration of smoking and menthol cigarette use. Middle
school students (grades 6–8) who had been smoking
less than 1 year were significantly more likely to smoke
menthol cigarettes than were middle school students
who had been smoking more than 1 year (62.4% vs.
53.3%, p < .002). A similar, though not statistically sig-
nificant, pattern was found for high school students
(grades 9–12); 46% of the high school students who had
been smoking for less than 1 year smoked menthol
cigarettes, compared with 42% of students who had
been smoking more than 1 year.
In National Survey on Drug Use and Health aggre-
gated data from 2004 to 2008, among smokers who had
been smoking less than 1 year, the proportion who
smoked menthol cigarettes was greater than the propor-
tion who smoked non-menthol cigarettes for both youth
(49.2% vs. 43.8%) and young adult smokers (40.2% vs.
36.4%), providing further indications of greater use of
menthol cigarettes among recent initiators; however, sta-
tistical significance was not reported [6].
Unpublished data from the years 2004 to 2008 on the
use of menthol cigarettes by young smokers (aged 12–
21 years) from the National Survey on Drug Use and
Health [6] show a similar pattern (see Figure 1), with
menthol cigarettes being used more among new
smokers (smokers for less than 1 year) than among
experienced smokers (smokers for more than 1 year).
Although this pattern reversed in 2008, more data
points will be needed to assess whether this is an aber-
ration or the beginning of a new pattern.
Age of initiation
The age at which cigarette smoking (menthol or non-
menthol) was initiated has been evaluated in two studies
[7,8]. Hymowitz et al [7] reported on the baseline char-
acteristics of the cohort enrolled in the National Cancer
Institute–funded Community Intervention Trial for
Smoking Cessation (COMMIT) trial. Enrollment for the
COMMIT trial occurred in 1988. The researchers
reported that there was no difference in the ages at
which menthol cigarette smokers and non-menthol
smokers started smoking. The Coronary Artery Risk
Development in Young Adults (CARDIA) study also
found both non-menthol smokers (n = 563) and
menthol smokers (n = 972) smoked their first cigarette
at an average age of 16 [8]. Both the Hymowitz et al
and Pletcher et al studies used retrospective questions
to assess “age started smoking”(Hymowitz et al) and
“age smoked first cigarette”(Pletcher et al).
Early menthol cigarette use and subsequent cigarette use
and dependence
Only one study was identified that looked at whether
early menthol cigarette use is predictive of nicotine
dependence. A longitudinal study by DiFranza et al [9]
followed seventh graders for 30 months and then ana-
lyzed data on the 237 individuals who had either inhaled
a cigarette before the start of the study or who first
inhaled a cigarette during the study period. Approxi-
mately half of these youth were able to report if their
first cigarette had been a menthol one (among those
who could remember, 42% reported that it was). There
were no differences in reported reactions (nausea,
Menthol cigarette use by
new smokers (age: 12-21)
0
10
20
30
40
50
60
2004 2005 2006 2007 2008
Year s
Percent
<1 Year
>=1Year
National Survey on Drug Use & Health
Substa
n
ce
A
buse
a
n
d
M
e
n
ta
l H
ea
l
t
h
Se
rvi
ces
A
d
mini
st
r
at
i
o
n
Figure 1 Menthol cigarette use by new smokers (age: 12-21).
Rising and Wasson-Blader Tobacco Induced Diseases 2011, 9(Suppl 1):S4
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dizziness, relaxation, irritation) to the first cigarette [9].
No studies examined whether the early use of menthol
cigarettes affected an individual’s trajectory to regular
smoking.
Switching between menthol and non-menthol cigarettes
No studies were identified that directly addressed
whether current smokers started smoking with menthol
cigarettes and then switched to non-menthol cigarettes.
A 1989 study, however, examined the switching beha-
vior of 29,037 current smokers who attended the Kaiser
Permanente Medical Care Program between 1979 and
1986. Study participants were followed for a mean of 4.5
years [10]. Of the 1,688 Black/African American smo-
kers under the age of 40 for whom follow-up data were
available, the percentage of those who switched from
non-menthol cigarettes to menthol cigarettes (14.6%)
was much higher than the percentage of menthol cigar-
ette smokers who switched to non-menthol cigarettes
(3.6%). Using a proportional hazards model adjusting for
age and sex, the researchers found that non-menthol
cigarette smokers were 4.2 times more likely to switch
to menthol cigarettes than for menthol cigarette smo-
kers to switch to non-menthol cigarettes.
One other study described switching behavior.
Pletcher et al [8] found no difference in the percentage
of young adult smokers who had switched types of pro-
ducts at the 15-year follow-up in the CARDIA study;
12% of those who originally preferred menthol cigarettes
had switched to non-menthol cigarettes, and 11% of
those who originally preferred non-menthol cigarettes
had switched to menthol cigarettes.
Research on publicly available internal tobacco industry
documents on menthol and initiation
Two reviews of internal tobacco company documents on
the topic of menthol cigarettes were performed by Kre-
slake et al [11,12]. The authors cite a tobacco company
document that found a benefit to including menthol in
cigarettes in order to make the smoking experience
more palatable for inexperienced smokers. “First-time
smoker reaction is generally negative…Initial negatives
can be alleviated with a low level of menthol”[12]. They
also found available documentation that tobacco compa-
nies were aware that newer smokers preferred menthol
cigarettes with a lower level of menthol than established
smokers. According to Kreslake et al, “the author of an
internal Brown and Williamson memo observed that
Kool’s menthol level may be considered too high for
new smokers, and that a successful ‘starter’cigarette
would need to include a low tobacco taste, low impact
and irritation, low tobacco aftertaste and low menthol
content”[11].
Conclusions
Limited data exist regarding the role of menthol in the
initiation of smoking. Furthermore, there are significant
limitations to the existing studies. Some of the studies
that used retrospective data and adult recollections of
smoking initiation may not provide an accurate repre-
sentation of the product used. Only three studies fol-
lowed individuals prospectively, and two of these studies
began following individuals after smoking had been
initiated. The third of these studies [9] had a small sam-
ple size.
However, Hersey et al [5] specifically addressed the
issue of potential incomplete knowledge of menthol sta-
tus of cigarettes used by younger smokers. These
researchers examined the data based on several different
definitions of “menthol cigarette smoker”and found
that the results were similar regardless of the definition,
indicating that the rate of misclassification of menthol
status of cigarettes by new users was low [5].
Even with the above limitations, however, the existing
literature does support the following conclusions:
•The vast majority of individuals who become regular
smokers begin smoking as youth or young adults.
•Menthol cigarettes are widely used among youth
who have smoked for less than one year and are used
less frequently by youth who have smoked for more
than one year.
•Although limited data are available, there appears to
be no differences in age of initiation between those who
start smoking with menthol cigarettes and those who
start smoking with non-menthol cigarettes; however,
because the data are retrospective, they reflect initiation
rates 16-30 years ago, not current patterns.
•Results are inconsistent regarding the frequency and
direction of switching between menthol and non-
menthol cigarettes.
•No data exist on whether menthol cigarette use
alters the trajectory from initiating cigarette use to regu-
lar smoking.
•Reviews of publicly available internal tobacco indus-
try documents suggest an industry awareness of the
appeal of menthol cigarettes to newer smokers.
Acknowlegdement
Disclaimer:This article reflects the views of the authors and should not be
construed to represent FDA’s views or policies.
This article has been published as part of Tobacco Induced Diseases Volume 9
Supplement 1, 2011: Mentholated cigarettes and public health. Publication of
this supplement has been supported by the Center for Tobacco Products, Food
and Drug Administration. The full contents of the supplement are available
online at http://www.tobaccoinduceddiseases.com/supplements/9/S1
Author details
1
Center for Tobacco Products, U.S. Food and Drug Administration, Rockville,
MD, USA.
2
KWB Health Communications, Inc, USA.
Rising and Wasson-Blader Tobacco Induced Diseases 2011, 9(Suppl 1):S4
http://www.tobaccoinduceddiseases.com/content/9/S1/S4
Page 3 of 4

Competing interests
The authors declare that they have no competing interests.
Published: 23 May 2011
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doi:10.1186/1617-9625-9-S1-S4
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