Virginia Tech researchers find menthol restrictions may drive smokers to healthier alternatives

Nationwide, fewer people smoke than did a decade ago, but the proportion who smoke menthol-flavored cigarettes is on the rise.

More than 9 million adults, or about 32 percent of all smokers, use menthol cigarettes, according to the Centers for Disease Control and Prevention. In Virginia, the proportion stands higher, at 38 percent.

A team of researchers including Roberta Freitas-Lemos, assistant professor at Virginia Tech’s Fralin Biomedical Research Institute at VTC, found that if menthol products were unavailable, smokers found replacement therapies such as nicotine gum and lozenges were practical alternatives, potentially improving health outcomes for people who use menthol cigarettes.

The findings come from a study that examined what products adult smokers purchased in an experimental marketplace that adjusted prices and availability of tobacco and nicotine products.

“We were trying to understand how different flavor policies interact, the role of cigarette filter ventilation, and how different types of smokers would respond to those policies,” said Freitas-Lemos, who is with both the institute’s Center for Health Behaviors Research and Cancer Research Center in Roanoke. “We wanted to understand the effect of restrictions on purchases.”

The study, which published in the October issue of Drug and Alcohol Dependence, analyzed preferences for menthol-flavored cigarettes and e-cigarettes and the effect of filter ventilation options on purchase decisions.

What they did

Researchers analyzed data from 172 people who exclusively smoke cigarettes — 76 of whom smoke menthol and 96 non-menthol cigarettes — and 91 people who use multiple tobacco products. Participants were older than 21, smoked at least 10 cigarettes daily, and had smoked a minimum of 100 cigarettes in their lifetime.

The volunteers were asked to complete trial purchases in the Experimental Tobacco Marketplace, a tool addiction recovery research expert Warren Bickel created to study the effects of tax and regulatory policies on health behaviors. Bickel, who died in September, was a professor at the Fralin Biomedical Research Institute, director of its Addiction Recovery Research Center and Center for Health Behaviors Research, and one of the study’s principal investigators.

In the marketplace, participants used an account in an online platform to purchase tobacco and nicotine products, including replacement therapies. Options were tailored to each participant’s preferred flavors and nicotine concentrations, and they were given an account balance designed to reflect their personal budget constraints.

Research participants shopped for products under different market conditions — with varying prices and restricted or unrestricted cigarette or e-cigarette flavors.

What they found

When menthol cigarettes were not available, smokers who preferred menthol cigarettes were less willing to purchase any type of cigarettes and more willing to purchase products such as nicotine gum and other replacement therapies.

In addition, cigarette smokers who prefer menthol products were less likely to substitute e-cigarettes when menthol flavored e-cigarettes were also restricted.

For individuals in the study who use multiple tobacco products, restricting flavors had no impact on their purchases.

The study also found higher demand for cigarettes among smokers who preferred high-ventilation cigarettes — cigarettes with filter holes for airflow.

Why it matters

Menthol, a compound found in plants such as peppermint, is added to tobacco products to make them more appealing. In addition, menthol enhances nicotine’s effects and can make them more addictive.

Tobacco product design features, including flavors and cigarette filter ventilation, are subject to regulation by the Food and Drug Administration, which is why the study examined the effects of cigarette and e-cigarette flavors on demand and substitution by preferred cigarette flavor and ventilation.

An area that requires more investigation, Freitas-Lemos said, is the relationship between cigarette filter ventilation and smoking behavior, which could be connected to smokers’ perception of their cigarettes.

“Cigarettes with ventilation are milder and people think they are less harmful, but it is a false perception,” said Freitas-Lemos, who also holds an appointment as an assistant professor of psychology in the College of Science. One study showed higher rates of lung adenocarcinoma among people who smoke ventilated cigarettes. 

“It could be that people who smoke ventilated cigarettes are more responsive to one ban than another,” said Freitas-Lemos, who noted that more research is needed to better understand how perception and ventilation influence behavior.

“I think the most important conclusion from this study is that we can improve health outcomes by emphasizing policies that reduce sales of flavored products and increase accessibility of nicotine replacement therapies,” Freitas-Lemos said.