We examined four measures of past cessation experiences: lifetime number of quit attempts, time since most recent quit attempt, and duration of abstinence for both longest-ever and most recent quit attempts. While both groups did not differ in their lifetime number of quit attempts, menthol smokers on average had a nonsignificantly (20%) higher number of more recent quit attempts compared to nonmenthol smokers. A more interesting finding, however, is that menthol smokers reported shorter periods of abstinence for both their longest-ever and most recent quit attempts compared to nonmenthol smokers. While these differences did not reach statistical significance, the consistency and direction of the three measures of success with smoking cessation suggest that menthol smokers were less success ful in past quit attempts compared to nonmenthol smokers. Lack of statistical significance could be due in part to a relatively small sample of nonmenthol smokers and wide ranges (minimum to maximum) of these measures. To demonstrate a 0.05 level of statistical significance with 0.8 power will require samples of up to 300 nonmenthol and 180 menthol smokers.
Our findings are consistent with findings from a recent, randomized clinical trial that reported that African-American nonmenthol smokers were twice as likely as menthol smokers to quit smoking at six weeks post target quit day. However, two other studies have reported findings different from the present study. In the first study, which was based on data from the Community Intervention Trial for Smoking Cessation, use of mentholated cigarettes was found to be unrelated to cessation. The other, a cross-sectional study, found that African Americans and whites who smoked mentholated cigarettes were more likely to be current smokers. However, the differences were not statistically significant. With regards to why menthol smokers may be less successful with smoking cessation, we found in the current study that compared to nonmenthol smokers, menthol smokers were more likely to smoke cigarettes that have longer rod lengths and are higher in nicotine and tar contents. Since nicotine is the main addictive component of cigarette, it is reasonable to expect that smoking of cigarettes higher in nicotine would lead to greater level of addiction. More addicted smokers are known to be less likely to quit. Although this explanation is consistent with a recent study that reported that African-American menthol smokers are more likely to smoke their first cigarette of the day within 30 minutes of awakening the current study did not find differences in addiction between menthol and nonmenthol smokers. However, in one study, menthol smokers rated cigarette taste and satisfaction more favorably than nonmenthol smokers. Although cigarette taste has not been shown to be predictive of smoking cessation, we believe that a more favorable rating of cigarette taste may make menthol smokers less willing to give up smoking. If smokers of mentholated cigarettes (either because of taste preference or greater nicotine addiction) are less likely to quit, a longer duration of smoking among menthol smokers who are predominantly African Americans may contribute to the excess cigarette-related morbidity and mortality experienced by African-American smokers.
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Our study has limitations. First, menthol classification and measures of past smoking cessation experiences were obtained by self-report and subject to false reporting and recall bias. Second, being a cross-sectional study, causal relationship between menthol and smoking cessation cannot be implied. Sample size was also limited to that of the primary data. Third, our study was also limited to African-American smokers, and findings may not apply to smokers of other ethnic groups as there are well-documented differences in smoking patterns among various ethnic groups.
Despite these limitations, the present study makes an important contribution to the scientific literature by showing that African-American smokers of mentholated cigarettes tend to be less successful in smoking cessation. Understanding the differences in smoking patterns and smoking cessation experiences between menthol and nonmenthol smokers is an important contribution for defining the role of menthol in the excess morbidity and mortality among African Americans.
There is a need to better understand the relationship between smoking of mentholated cigarettes and the excess smoking morbidity and mortality among African-American smokers. Prospective studies are needed to examine this relationship as well as studies that include menthol smokers of different ethnic backgrounds. It is quite possible that other factors associated with smoking menthol cigarettes (e.g., age, length, and nicotine/tar content of cigarettes smoked) rather than menthol itself are responsible for the effects being attributed to menthol. Even if menthol is found not to be an independent factor, factors, such as smoking of cigarettes with high tar and higher nicotine addiction, would likely increase the health risks of smoking mentholated cigarettes.
Future studies should also examine the role of various pharmacotherapies in possible differences in smoking cessation between menthol and nonmenthol smokers. One study already reported lower cessation rates among African-American smokers treated with bupropion. Whether this effect is specific for bupropion or also applies to other smoking pharmacotherapies should be examined. In summary, our study shows that African-American smokers of mentholated cigarettes tend to be less successful in previous cessation experiences. If smoking of mentholated cigarettes is confirmed to be associated with lower cessation rates, then the lower cessation rates among African Americans could be partially explained by their predominantly smoking mentholated cigarettes, which may, in turn, explain the excess smoking-relat-ed morbidity among African Americans.
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