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Association of Ontario's Ban on Menthol Cigarettes with Smoking

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Association of Ontario's Ban on Menthol Cigarettes with Smoking Letters Medicine, Chicago, Illinois (Levine); Rush University Medical Center, Chicago, random-digit dialing was 44.1%, with a 6.7% refusal rate Illinois (O’Mahony, Fitchett). among known eligible participants, consistent with an Corresponding Author: Aoife C. Lee, DMin, BCC, Spiritual Care Department, established provincial health monitoring survey. Partici- Rush Oak Park Hospital, 520 S Maple Ave, Oak Park, IL 60304 (aoife_lee@rush .edu). pants were contacted for follow-up beginning 1 month Accepted for Publication: November 18, 2017. (February 1, 2017) after the implementation of the Published Online: January 16, 2018. doi:10.1001/jamainternmed.2017.7961 ban (January 1, 2017) through an online survey Author Contributions: Drs Lee and Fitchett had full access to all of the data in (206 recontacted [63.4%]). Those who were unavailable for the study and take responsibility for the integrity of the data and the accuracy follow-up did not differ by level of menthol smoking, age, of the data analysis. sex, income, educational level, or smoking characteristics. Study concept and design: Lee, McGinness, Fitchett. Acquisition, analysis, or interpretation of data: All authors. Planned reaction to the ban, actual behavior at 1 month Drafting of the manuscript: Lee, Fitchett. after the ban, and planned future reaction beyond 1 month Critical revision of the manuscript for important intellectual content: All authors. after the ban were compared. Oral consent was obtained Statistical analysis: Lee, Fitchett. from all participants, and the analytic data set was deidenti- Administrative, technical, or material support: Lee, McGinness, O'Mahony, Levine. fied. This study was approved by the research ethics board Study supervision: Lee, Fitchett. of the University of Toronto, Toronto, Ontario, Canada. Conflict of Interest Disclosures: None reported. Additional Contributions: This project was conducted while Board-Certified Chaplain Aoife Lee was a fellow in the Coleman Palliative Medicine Training Results | A total of 325 participants participated in the study Program, Chicago, Illinois–Cohort 2, 2015 to 2017. Chaplain Lee is grateful for (181 [55.7%] male; 143 [44.0%] female; mean [SD] age, 47.1 the support of the coauthors. [0.9] years). Before the ban, most menthol smokers (123 1. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of [59.7%]) said that they surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. would switch to or only use Invited Commentary page 711 2. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare nonmenthol cigarettes, but beneficiaries: site of death, place of care, and health care transitions in 2000, only 51 (28.2%) had done so 2005, and 2009. JAMA. 2013;309(5):470-477. at follow-up (Table). In contrast, a larger proportion (60 3. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver [29.1%]) attempted to quit compared with only 30 (14.5%) bereavement adjustment. JAMA. 2008;300(14):1665-1673. who said they would do so. Similarly, a larger proportion 4. Houben CHM, Spruit MA, Groenen MTJ, Wouters EFM, Janssen DJA. (60 [29.1%]) reported using other flavored tobacco or Efficacy of advance care planning: a systematic review and meta-analysis. JAm e-cigarette products (menthol was not banned in e-cigarette Med Dir Assoc. 2014;15(7):477-489. products) compared with their preban plans (12 [5.8%]). 5. Jones CA, Acevedo J, Bull J, Kamal AH. Top 10 tips for using advance care After the ban, participants were less likely to anticipate planning codes in palliative medicine and beyond. J Palliat Med. 2016;19(12): using other flavored products. Of those who made a quit 1249-1253. attempt, 16 (80.0%; 95% CI, 56.3%-92.5%) of those who pri- 6. Tsai G, Taylor DH. Advance care planning in Medicare: an early look at the marily smoked menthol cigarettes at baseline suggested impact of new reimbursement on billing and clinical practice [published online June 21, 2017]. BMJ Support Palliat Care. doi:10.1136/bmjspcare-2016-001181 that the ban affected their decision to quit at least a little compared with 10 (25.6%; (95% CI, 14.1%-41.0%) of those who smoked menthol cigarettes only occasionally. Before HEALTH CARE POLICY AND LAW the ban, 1 individual (0.3%) suggested trying to switch to Association of Ontario’s Ban on Menthol Cigarettes marijuana and 4 (1.2%) suggested adding menthol to ciga- With Smoking Behavior rettes separately using flavor cards, oils, or papers as substi- 1 Month After Implementation tutes for the lack of menthol, but none reported planning to The province of Ontario, Canada, implemented a full men- use these substitutes in the future. thol cigarette ban on January 1, 2017. To date, there has been no population-wide, systematic evaluation of the associa- tion of the implementation of a menthol ban Discussion | This study is, to our knowledge, the first evalua- with smoker behavior. Assessments of perceived behavioral tion of the immediate association of a menthol cigarette ban responses to hypothetical menthol flavor bans are useful1; with behavior change. Actual behaviors contrast sharply however, there is no guarantee that individuals will follow with planned behaviors. Although a substantial decrease in through with their planned behaviors. This study compares menthol cigarette use was observed, there was a consider- respondents’ planned behavior before the ban with actual able increase in use of flavored e-cigarettes and cigars. Fur- behavior 1 month after the ban. thermore, 29.1% of menthol smokers attempted to quit smoking shortly after ban implementation. Because previ- ous studies2,3 have found an expected rate of 0.5 quit Methods | Eligible participants were residents of Ontario 16 attempts and a 7.7% abstinence rate during a 6-month years or older who had smoked at least 1 menthol cigarette period in this population, this finding suggests that the ban in the past year and were past-month smokers. A total of substantially increased quit attempts. Few smokers used 325 participants were recruited using random-digit dialing aftermarket additive flavorings, and there was no increase of residential telephone numbers from September 12 in the use of contraband tobacco. Limitations of this study through December 31, 2016. Participation rate for the include the unique demographics of menthol cigarette 710 JAMA Internal Medicine May 2018 Volume 178, Number 5 (Reprinted) jamainternalmedicine.com © 2018 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Letters Table. Expected, Short-term Actual, and Long-term Planned Reactions to the Ban on Menthol in Tobacco, Ontario, Canada No. (%; 95% CI) (n = 206) Reaction Expected Reaction Before Ban Actual Short-term Reactiona Long-term Planned Reaction Use of nonmenthol cigarettes onlyb 123 (59.7; 52.8-66.2) 51 (28.2; 22.0-35.2) 102 (49.5; 42.7-56.4) Quit 30 (14.5; 10.3-20.1) 60 (29.1; 23.3-35.8)c 35 (17.0; 12.4-22.3) Use of alternative flavored products (e-cigarettes, 12 (5.8; 3.3-10.2) 60 (29.1; 23.3-35.8) 6 (2.9; 1.3-6.4) cigars, and other flavored tobacco products) Use of contraband menthol 23 (11.2; 7.5-16.3) 29 (14.1; 10.0-19.6)d 34 (16.5; 12.0-22.3) Adding menthol or other reaction 4 (1.9; 0.7-5.1) 29 (14.1; 10.0-19.6) NR Don’t know 14 (6.8; 4.1-11.2) 6 (2.9; 1.3-6.4) 29 (14.1; 10.0-19.6) Abbreviation: NR, not reported. smoking by follow-up was 25 (12.1%; 95% CI, 8.3%-17.4%). a Column does not total 100% because actual behaviors were not mutually d Purchasing menthol cigarettes from a First Nations reserve, other province, exclusive. other country, or online. Does not include stockpiled cigarettes, cigarettes b Continued or new users of nonmenthol cigarettes who did not try to quit, use bought from existing stocks that enforcement allowed stores to sell out, or any menthol product, use any other flavored product, or add flavor to those provided by friends. A total of 72 individuals (35.1%; 95% CI, nonmenthol cigarettes. 28.9%-42.0%) used menthol from all sources in the past month. c Quit or made serious quit attempt. The number (percentage) not currently smokers in Canada, where menthol cigarettes comprise 5% Role of the Funder/Sponsor: The funding source had no role in the design and of cigarette sales4,5 compared with 30% in the United conduct of the study; collection, management, analysis, and interpretation of 6 the data; preparation, review, or approval of the manuscript; and the decision to States and use is not concentrated among black submit the manuscript for publication. Canadians.5 The initial results suggest that removing men- Disclaimer: The content is solely the responsibility of the authors and does not thol tobacco from the market is a feasible strategy that may necessarily represent the views of the National Institutes of Health or the US influence cessation behavior, although differences between Food and Drug Administration. menthol users in Ontario, Canada, and other jurisdictions 1. O’Connor RJ, Bansal-Travers M, Carter LP, Cummings KM. What would may affect the potential influence of a ban. menthol smokers do if menthol in cigarettes were banned? behavioral intentions and simulated demand. Addiction. 2012;107(7):1330-1338. Michael Chaiton, PhD 2. Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of Robert Schwartz, PhD smokers.
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