1. Nicotine Dependence: Comparing Menthol and Non-Menthol Cigarette Smokers Qiang Li, MS Andrew Hyland, PhD Gary Giovino, MS, PhD Joseph Bauer, PhD Michael Cummings, PhD, MPH Roswell Park Cancer Institute 2005 NCTH Meeting Chicago, IL May, 2005 For more info: andrew.hyland@roswellpark.org

2. Menthol in Cigarettes Menthol is the chief constituent of peppermint oil. Menthol can be applied to tobacco in three different ways: –Adding it directly to the tobacco –Adding it to the cigarette filter –Adding it to the cigarette packaging Approximately 90% of all cigarettes contain a very small amount of menthol

3. Menthol in Cigarettes Menthol cigarettes contain from 0.3% to 0.7% of the tobacco weight in menthol A heavily menthol cigarette would have around 1% menthol. Menthol cigarettes account for one-fourth of the U.S. market Non-menthol cigarettes may contain subliminal levels (0.01- 0.03%)

4. How Menthol in Cigarettes Might Boost Dependence? Menthol in cigarettes Breath holding Airway anesthetic effects Airway “cooling” effects Absorption enhancement Possible central nervous system effects Altered puff parameter Increased nicotine intake and dependence

5. Study Objectives To describe the use rate of menthol cigarettes between 1988 and 2001 in a cohort of smokers To examine who is using menthol cigarettes To examine if menthol in cigarettes is associated with increased nicotine dependence

6. Data Source – COMMIT Study Community Intervention Trial for Smoking Cessation (COMMIT) Funded by NCI, conducted between 1988 and 1993 A match-pair, randomized trial of 22 small to medium communities in 10 states/provinces ~1,000 smokers from each community identified surveyed in 1988 and followed until 1993

7. Data Source – COMMIT Study In 1988, over 10,000 heavy smokers (25+ cpd) and more than 10,000 light to moderate smokers (<25 cpd) completed a 20 minute tobacco use telephone survey. In 1993, over 13,000 members of this cohort were re-interviewed to assess the quit rate in each community

8. COMMIT Communities

9. 2001 Follow-up Survey With NCI funding, we tried to re-interview all the U.S. participants who completed a 1993 survey in the summer of 2001 (n=13,544). 7,329 subjects were tracked and completed the telephone interview. Subjects included in this analysis were 4,488 continuous smokers between 1988 and 1993 who finished all the three surveys, reported whether their current cigarette brand was menthol or not both in 1988, 1993 and 2001.

10. Outcome Variables Smoking cessation by 2001 –Cessation was defined as “a person who had not smoked in the six months before the survey” Change of amount smoked daily from 1988 to 2001 Change of time to first cigarette after waking

11. Predictor Variable Use of menthol cigarettes in 1988 and 1993 among continuous smokers between 1988 and 1993. It was divided into 4 categories: –Menthol in both years (M-M) (N=973) –Non-menthol in both years (N-N) (N=3,183) –Menthol in 1988 and non-menthol in 1993 (M-N) (N=180) –Non-menthol in 1988 and menthol in 1993 (N-M) (N=152)

12. Control Variables Gender Age at baseline Race/ethnicity Education Cigarettes smoked per day in 1993 Time to first cigarette in the morning in 1988 History of past serious quit attempts Age started smoking Desire to stop smoking Frequency of alcohol consumption in 1988 Use a non-cigarette tobacco product in 1988 Pricing tier of cigarette smoked in 1988 The presence of another smoker in the household in 1988

13. Analysis Logistic regression models were used to examine factors associated with use of menthol cigarettes Logistic regression and linear regression techniques were used to examine if use of menthol cigarettes between 1988 and 1993 was associated with change of nicotine dependence between 1993 and 2001 Data were weighted to age, gender, race, and community to control for sttrition SUDAAN 8.0.2 was used to control for clustering effects

14. Baseline Characteristics of the Study Subjects (N=4,488)

15. Flow Chart of Mentholated Cigarette Use from 1988 to 2001 among COMMIT Cohort 25%, 25%, and 24% of the smokers in 1988, 1993 and 2001 smoked menthol cigarettes, respectively 15% of the menthol cigarette smokers and 5% of the non-menthol cigarette smokers in 1988 switched brands by 1993 12% of the menthol cigarette smokers and 3% of the non-menthol cigarette smokers in 1993 switched brands by 2001 26% and 42% of the non-menthol cigarette smokers in 1988 quitted by 1993 and 2001, respectively 24% and 41% of the menthol cigarette smokers in 1988 quitted by 1993 and 2001, respectively 40% of the ever menthol cigarette smokers in 1988 or 1993 quitted by 2001 42% of the ever non-menthol cigarette smokers in 1988 or 1993 quitted by 2001

16. In 1993, Female, Younger People, African Americans, and More Educated Smokers Were More Likely to Smoke Mentholated Cigarettes *: p<0.05 compared to the first category, logistic regression model controlled for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from the 1993 COMMIT survey (n=4,488)

17. Female, African American, and Less Dependent Non-menthol Cigarette Smokers Were More Likely to Switch to Menthol Cigarettes between 1988 and 1993 *: p<0.05 compared to the first category, logistic regression model controlled for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from the 1988 and 1993 COMMIT survey (n=6,521)

18. Younger, African American Menthol Cigarette Smokers Were Less Likely to Switch to Non-menthol Cigarettes between 1988 and 1993 *: p<0.05 compared to the first category, logistic regression model controlled for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from the 1988 and 1993 COMMIT survey (n=1,153)

19. By 2001, Quit Rates Were Similar among Smokers with Different Smoking Patterns of Menthol Cigarettes between 1988 and 1993 Note: N-P: 88 non-menthol, 93 non-menthol. N-M: 88 non-menthol, 93 menthol. M-N: 88 menthol, 93 non-menthol. M-M: 88 menthol, 93 menthol.

20. Odds Ratio for quitting in 2001 by use of mentholated cigarettes between 1988 and 1993 No statistically significant difference was detected in logistic regression controlled for for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from COMMIT data between 1988 and 2001 (n=4,488)

21. No Consistent Pattern Was Found on the Change of Amount Smoked between 1993 and 2001 by Use of Mentholated Cigarettes between 1988 and 1993 *: p<0.05 compared to N-N, linear regression model controlled for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from COMMIT data between 1988 and 2001 (n=3,216)

22. % Decreased Time to First Cigarette in the Morning from 1988 to 2001 by Use of Mentholated or Non-menthol Cigarettes in 1988 and 1993 No statistically significant difference was detected in logistic regression controlled for for gender, age, race, education, amount smoked in 1993, time to first cigarette after waking in 1988, number of past quit attempts, age started smoking, desire to quit in 1988, frequency of alcohol consumption in 1988, use non-cigarette tobacco products in 1988, pricing tier in 1988 and number of other smokers in the household. Data come from COMMIT data between 1988 and 2001 (n=3,216)

23. Discussion In this study, no consistent pattern was found when examining the association between use of menthol cigarettes and indicators of nicotine dependence. This finding is consistent with our previous study using COMMIT data between 1988 and 1993. Menthol switchers could compensate their smoking by reducing consumption to maintain the same nicotine level, which would possibly explain the results Further studies are needed to confirm the findings and reconcile the conflict between theories and actual findings

24. Conclusion About a quarter of smokers in this sample smoked menthol cigarettes A majority of African Americans smoked menthol cigarettes Other factors associated with use of menthol cigarettes include female gender, higher education, and younger age No consistent pattern was found between use of menthol cigarettes and nicotine dependence