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Abstract
Introduction Menthol-flavoured cigarettes remain unregulated in the USA and in many low- and middle-income countries (LMICs) despite their known impacts on smoking uptake and reduced cessation. Yet, evidence about whether menthol cigarettes are associated with higher disease risks than non-menthol cigarettes is inconclusive, and the industry has used this argument to lobby against regulation.
Methods All-cause and cause-specific mortality risk was assessed according to baseline smoking status (current, former and never) and menthol flavour status (menthol and non-menthol) of the cigarette brand smoked for the longest period among 969 349 persons from Cancer Prevention Study-II, a population-based prospective cohort study enrolled in 1982–1983 with mortality follow-up of 6 years.
Results 73 486 and 281 680 persons reported menthol brands and non-menthol brands, respectively, among whom 4071 and 20 738 deaths occurred, respectively. Currently smoking cigarettes, whether menthol or non-menthol brands, was associated with highest mortality risks (eg, all causes: about two times higher risk vs never smoking) but quitting substantially reduced risks for both types. Among persons who formerly smoked, menthol versus non-menthol smoking was associated with an elevated mortality risk of 12% from all-causes, 16% from all cardiovascular diseases, 13% from ischaemic heart disease, and 43% from other heart diseases Among individuals currently smoking, there was no difference in mortality risks for menthol versus non-menthol cigarettes except for elevated risk among those smoking≥40 cigarettes per day. Black persons currently smoking menthol versus non-menthol brands had an 88% elevated mortality risk for other heart diseases.
Conclusion Findings of a unique excess mortality risk associated with menthol cigarettes provide additional scientific evidence—apart from their known impacts on initiation and cessation—in support of menthol flavour regulation in the USA and similar policies in LMICs. Public communication efforts must reiterate that quitting all cigarette types is the only safe option to reduce disease risk.
- Smoking Caused Disease
- Public policy
- Tobacco industry
Data availability statement
Data are available on reasonable request. Not applicable.
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Data availability statement
Data are available on reasonable request. Not applicable.
Footnotes
X @samasares2, @NigarNargis2, @ahjemal
Contributors PB conceptualised and designed the work, contributed to the analysis and interpreted the data for the work, drafted and revised the manuscript for important intellectual content, and will serve as a guarantor of the overall content. CN analysed and interpreted the CPS-II data, contributed to the design of the work and revised the manuscript for important intellectual content. ZX acquired cigarette brand name data from various sources to code menthol brand status in CPS-II data and drafted and revised the manuscript for important intellectual content. BT, SA, MP, FI, NN and AJ interpreted the data for the work and revised the manuscript for important intellectual content. AVP and JLW contributed to acquiring and interpreting the data for the work and revised the manuscript for important intellectual content. WRD contributed to acquiring and interpreting the data for the work, contributed to the design of the work and drafted and revised the manuscript for important intellectual content. All authors have given final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The American Cancer Society funds the creation, maintenance, and updating of the Cancer Prevention Study-II cohort.
Disclaimer The study protocol was approved by the Institutional Review Boards of Emory University, and those of participating registries as required. The authors assume full responsibility for all analyses and interpretation of results. The views expressed here are those of the authors and do not necessarily represent the American Cancer Society or the American Cancer Society—Cancer Action Network.
Competing interests No, there are no competing interests.
Provenance and peer review Not commissioned; externally peer reviewed.
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