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Menthol Cigarettes and Smoking Cessation Behaviour: a Review of Tobacco Industry Documents Stacey J Anderson1,2

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Menthol Cigarettes and Smoking Cessation Behaviour: a Review of Tobacco Industry Documents Stacey J Anderson1,2 View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by PubMed Central Research paper Menthol cigarettes and smoking cessation behaviour: a review of tobacco industry documents Stacey J Anderson1,2 1Department of Social and ABSTRACT The concentration of menthol in tobacco prod- Behavioral Sciences, University Objective To determine what the tobacco industry knew ucts varies according to the product and the flavour of California, San Francisco about menthol’s relation to smoking cessation behaviour. desired, but is present in 90% of all tobacco prod- (UCSF), San Francisco, ‘ ’ ‘ ’ 2 3 California, USA Methods A snowball sampling design was used to ucts, mentholated and non-mentholated . 2Center for Tobacco Control systematically search the Legacy Tobacco Documents Studies in the peer-reviewed academic literature of Research and Education, Library (LTDL) (http://legacy.library.ucsf.edu) between 15 the association of menthol smoking and cessation University of California, San May to 1 August 2010. Of the approximately 11 million have yielded conflicting findings. One reason for Francisco (UCSF), San Francisco, California, USA documents available in the LTDL, the iterative searches inconsistencies is differences in study design (eg, returned tens of thousands of results. A final collection of clinical treatment studies, population-based Correspondence to 509 documents relevant to 1 or more of the research studies), and another is differences in cessation Stacey J Anderson, Department questions were qualitatively analysed, as follows: (1) outcomes (eg, length of time abstinent, length of of Social and Behavioral perceived sensory and taste rewards of menthol and time to relapse, number of quit attempts) across Sciences, Box 0612, University fi of California, San Francisco potential relation to quitting; and (2) motivation to quit studies. Some studies yielded null ndings for effect (UCSF), San Francisco, CA among menthol users. of menthol on amount smoked, quitting, or time to 94143-0612, USA; stacey. Results Menthol’s cooling and anaesthetic effects mask first cigarette in the morning,4 or smoking absti- [email protected] the short-term negative physiological effects of smoking nence.5 Other studies showed mixed results, with such as throat pain, burning and cough. This provides no difference in number of past quit attempts Received 17 November 2010 Accepted 3 February 2011 superficial physical relief as well as psychological between menthol and non-menthol smoking assurance against concerns about the health dangers of groups, but shorter duration since most recent quit smoking that would otherwise motivate smokers to quit. attempt (shorter time to relapse, a measure of Menthol smokers, particularly women, perceive the difficulty quitting) among menthol smokers,6 and minty aroma of menthol cigarettes to be more socially significantly greater risk of relapse among menthol acceptable than non-menthol cigarettes. smokers than non-menthol smokers.7 However, Discussion Consumers believe menthol’s sensory other studies revealed significant associations of effects equate to health protections and that menthol menthol with lower smoking cessation rates89and cigarettes are more socially acceptable than lowered confidence in ability to quit,10 and less non-menthol cigarettes. Menthol in cigarettes may likelihood of quitting particularly among younger encourage experimenters who find non-mentholated AfricaneAmerican menthol smokers than their cigarettes too harsh, including young or inexperienced non-menthol smoking counterparts.11 users, to progress to regular smoking rather than The tobacco companies monitored the independent quitting, and may lessen the motivation to quit among biomedical literature but seem to have conducted established menthol smokers. The perception of menthol very little in-house research on the direct role of cigarettes as more socially acceptable lessens the menthol in quitting smoking and relapse (ie, the impact of smoking denormalisation on quitting possibility that menthol itself addicts smokers or motivation. Menthol makes cigarettes easier and more otherwise makes it biologically more difficult to palatable to smoke and less desirable to quit among quit smoking). The tobacco industry documents, established smokers. Fewer smokers quitting contributes however, reveal considerable interest in menthol’s to the incidence of tobacco-related diseases. indirect role in keeping smoking attractive enough to dissuade cessation (ie, the possibility that menthol either enhances some aspects of smoking INTRODUCTION that make it pleasant or diminishes some aspects The Family Smoking Prevention and Tobacco that make it undesirable, apart from the physical addiction issue). ‘Quitting’ is not consistently Control Act (FSPTCA) gave the US Food and Drug fi Administration (FDA) regulatory authority over de ned in the internal industry documents (and is often not defined at all), so a formal definition of tobacco products. On 22 September 2009, the FDA ‘ ’ exercised this authority when it announced a rule quitting could not be obtained from the docu- banning cigarette flavourings specified in the Act. ments. Quitting can be understood as cessation of This ban did not include menthol, however, smoking in general terms only. because it was excluded from the list of banned Menthol and non-menthol smokers can experi- flavourings in the Act because of opposition by the ence similar potential motivations to quit, tobacco industry. The fact that menthol was not including having smoking-related illnesses and included in the original list of banned flavours holding beliefs regarding smoking-related health 12 13 e This paper is freely available concerned many in the public health arena who harms. Unger et al found that African online under the BMJ Journals argued that menthol is used by the tobacco American smokers in the Los Angeles area who unlocked scheme, see http:// smoked menthol cigarettes believed menthol has tobaccocontrol.bmj.com/site/ industry to attract young, inexperienced smokers about/unlocked.xhtml and/or AfricaneAmericans.1 medicinal effects, believed menthol cigarettes were Tobacco Control 2011;20(Suppl 2):ii49eii56. doi:10.1136/tc.2010.041947 ii49 Research paper less harmful than non-menthols, and preferred the menthol male smoker)), ‘psychographic’ segmentation reports (eg, the taste and sensation, relative to the beliefs and preferences of ‘Coolness’ segment referring to menthol users), identified non-menthol smokers. Such beliefs preferences raise questions motivations (eg, sensation, health, peer acceptance, offend, about the motivations to quit among menthol smokers relative smell), tobacco company project names (eg, Project GS, Project to non-menthol smokers. An interview study of Africane UT) and individuals and companies named in correspondences American smokers in Atlanta suggested the importance of beliefs and on research reports (eg, A Udow; Booz, Allen, & Hamilton, about menthol; group discussions revealed that participants Inc.). For each set of results, I reviewed the first 50e350 docu- thought smoking menthol cigarettes leads to fewer negative ments. If documents did not appear to be relevant to the health effects than smoking non-menthol cigarettes, and that research questions, or if there was a repetitive pattern of docu- switching from menthol to non-menthol would be a good way ments, I moved on to the next search term. A final collection of of attempting to quit smoking for habitual smokers.14 509 documents were deemed relevant to 1 or more of the The perceived health and sensory benefits of menthol may research questions and were qualitatively analysed. Memos were play an indirect role in discouraging cessation. In 2008, Kreslake written to summarise the relevant documents to further narrow et al15 identified two types of menthol smokers from their down to the 46 representative documents that are cited in this analysis of internal tobacco industry documents: (1) those who paper. find non-menthol smoke too harsh and irritating, and (2) those who specifically seek out menthol flavour and sensory effects. RESULTS For the first group, menthol functions to reduce the negative Perceived sensory and taste rewards of menthol and potential sensory experiences associated with smoking, suggesting relation to quitting menthol may inhibit cessation motivation in this group. In the Menthol styles of cigarettes were originally marketed as a remedy second group, some may have adopted menthol products to to the dryness and irritation smokers experience when smoking cover the unpleasant taste of tobacco and have grown accus- regular cigarettes.20 21 The first mentholated cigarette is credited to tomed to, and even desirous of, stronger menthol taste over Lloyd ‘Spud’ Hughes, when in the 1920s he added menthol crys- time, suggesting menthol eases the transition from experimental tals to his smoking tobacco tin while suffering a cold.22 23 Bearing to established smoking for this group of smokers, rather than Hughes’s nickname, Spud cigarettes in the 1920s became the first from experimentation to abstinence in the absence of menthol. commercial menthol brand to be marketed in the US. The Given that the literature that suggests the importance of anaesthetic and cooling qualities of menthol, along with the minty subjective experiences and health beliefs that may have indirect menthol taste, change the regular smoking experience and, to relations to menthol use and motivation to quit, this report some smokers, make
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