A menthol cigarette ban may influence smokers to quit

(Reuters Health) - One month after Ontario fully banned menthol in cigarettes, twice as many menthol smokers attempted to quit compared to how many had predicted they would do so in the months leading up to the ban, according to a small study in the Canadian province.

Of 325 menthol cigarette smokers interviewed before and after the ban went into effect on January 1, 2017, 29 percent had tried to quit by the February 1 survey whereas only 14.5 percent thought they would do so when asked in late 2016.

“We would actually expect the impact of this study to be even greater in the U.S. given the higher use and regularity of (menthol cigarette) use,” lead author Michael Chaiton of the Ontario Tobacco Research Unit and the Dalla Lana School of Public Health at the University of Toronto said in an email.

He added that there was little controversy in Canada over this ban, which meant that the level of awareness of it was low.

“What this showed is that getting menthol out of cigarettes is not only possible, but it has a way bigger health benefit than anyone thought it would,” Stanton Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco and coauthor of an accompanying commentary in JAMA Internal Medicine said in a phone interview.

Menthol’s cooling effect decreases airway irritation in the lungs, which is thought to make it easier for menthol smokers to inhale deeper and longer. Some research also suggests that menthol may enhance absorption of nicotine, adding to the addictive potential of cigarettes.

According to the Centers for Disease Control and Prevention, 26 percent of all cigarettes sold in the U.S. in 2015 were mentholated. In contrast, menthol cigarettes made up just 5 percent of Ontario’s market before the ban, the study team notes.

For the new analysis, Chaiton’s team recruited smokers aged 16 or older from September 12, 2016 through December 31, 2016. All the participants said they had smoked within the past month and had smoked at least one menthol cigarette within the past year.

In the lead up to the ban, researchers asked participants if they planned to switch to non-menthol cigarettes after the ban took effect, as well as if they would quit smoking or switch to other types of tobacco products.

Before the ban, 123 participants (60 percent) said they would switch to, or only use, non-menthol cigarettes. Only 51 people (28 percent) had done so at follow-up.

In contrast, 60 smokers attempted to quit compared with only 30 who said they would do so. Twenty-five participants succeeded.

Quit attempts were more common among those who primarily smoked menthol cigarettes before the ban. Sixteen of them (80 percent) indicated that the ban affected their decision to quit “at least a little,” compared with 10 (26 percent) of those who had smoked menthol cigarettes only occasionally.

Researchers found that more people (29 percent) than predicted (6 percent) switched to other flavored tobacco products including e-cigarettes.

This is the first study comparing menthol smokers’ actual behavior to predicted behavior, said Vaughan Rees, director of the Center for Global Tobacco Control at the Harvard T.H. Chan School of Public Health in Boston.

“This is an important finding and one that I hope will be closely watched by the FDA,” said Rees, who wasn’t involved in the study.

The U.S. Food and Drug Administration (FDA) has been deliberating an outright ban of menthol cigarettes since 2009 when the Tobacco Control Act was signed into law. It gave the FDA the power to regulate the manufacturing, distribution and marketing of tobacco products.

Canada imposed a nationwide ban on menthol cigarettes that took effect in October 2017. The European Union’s Tobacco Products Directive law will ban menthol cigarettes by 2020.

Among the study’s limitations, Chaiton noted, is that the follow-up was done very shortly after the implementation of the ban. He said he expects the impacts may change over time, especially as the availability of menthol cigarettes through normal retail outlets diminished. The participants in this study were also recruited using telephone sampling and may not be fully representative of the population.

SOURCE: JAMA Internal Medicine, online March 5, 2018.