Menthol cigarettes will be removed from shelves in the UK this Wednesday (20 May 2020), yet new research has found that tobacco companies failed to use the four-year phasing-in period (from 2016) to prepare for this week’s ban.
Instead they continued to sell and promote menthol products and to develop new products which circumvent the ban.
The University of Bath researchers behind the study – which is out today (Monday 18 May 0001 GMT) in the BMJ’s Tobacco Control – argue this highlights how tobacco companies have exploited a delay in the ban to develop new products, keeping menthol products on the market for as long as possible, rather than phasing them out.
A menthol ban was first agreed in 2014 and originally due to be implemented in 2016, alongside accompanying measures such as standardised packaging.
However, after intense lobbying, its implementation was put back four years, until this week when it will be implemented in the midst of Covid-19.
For the new study, the researchers from the Tobacco Control Research Group analysed industry analyst data to track menthol market cigarette share from legislation agreement through to 2018.
They also analysed documentary evidence – industry documents, websites and retail publications – to understand tobacco industry activities.
Their results show that during the grace period the tobacco industry was given to prepare, the UK market share of menthol cigarettes grew rapidly from 14% of cigarette sales in 2014 to over a fifth (21%) in 2018.
With one in six menthol smokers stating they would quit after the menthol ban, an impact which potentially could reduce UK cigarette sales overall by 3%, the researchers say the menthol ban will be an important driver in the fight against deaths and illness from cigarette smoking.
Dr. Rosemary Hiscock, lead author, explains: “Our findings suggest the tobacco industry was driving sales of menthol cigarettes right up to the ban – a product whose serious health implications had led to the ban in the first place.”
In the paper, the authors argue that the tobacco industry used the delay to develop and introduce new menthol products that will circumvent the ban once it is implemented: menthol filters and flavour cards which smokers can add to cigarette packs or roll-your-own tobacco pouches to make them minty.
Due to a loophole in the tobacco display ban legislation, these accessories, unlike cigarettes, can be promoted to customers near the cash till in England and Wales (but not Scotland).
They also find that two tobacco companies have introduced cigarette-like ‘cigarillos’ (small cigars) with a flavour capsule. Although cigarillos have a small market share of UK tobacco sales at the moment, Euromonitor forecasts that this market will grow, not least because they are subject to lower taxes than cigarettes and are mostly exempt from plain packaging legislation.
Dr. Hiscock added: “We recommend loopholes in legislation be closed as soon as possible to prevent tobacco companies undermining the intended public health impacts of the legislation.
This includes preventing the display of tobacco accessories and extending the menthol ban to all tobacco products, including cigarillos and heated tobacco products.
“In Canada, the menthol ban stops menthol being used at all, whereas UK legislation only stops menthol’s use as a characterising flavour. Banning menthol’s use would stop menthol masking the harsh effects of smoking when it is present at undetectable levels.”
Finally, the researchers highlight how big tobacco companies have created new websites and sponsored retail industry pieces which effectively undermine the intended public health benefit of the ban.
These websites push consumers to switch to other products rather than quitting: a key concern is that they promote new heated tobacco products, such as IQOS, which are still allowed to have a menthol flavour.
Professor Anna Gilmore, Director of the Tobacco Control Research Group, explains: “The way tobacco companies are using the ban on menthol cigarettes to promote new menthol tobacco products which are heated rather than burned undermines the very purpose of this ban.
It also flies in the face of tobacco company claims that they wish to reduce the harm from smoking. They realise the menthol ban will trigger smokers to quit.
Instead they seek to move the smokers onto new tobacco products which independent evidence indicates are as dangerous as smoking and from which they make even more profit.”
The team conclude that the tobacco industry’s exploitation of the phase-in of the menthol ban repeats what happened during the 12-month phase-in period of standardised packaging, revealed by previous TCRG work.
In both cases, tobacco companies misused the phase-in period to find ways to circumvent legislation and to shore up profits at the expense of public health, say the researchers.
The addition of menthol to cigarettes takes away some of the harsh sensations of smoking. Public health experts suggest this can make them more appealing to younger people and could lead them to become more quickly dependent on nicotine in comparison with non-menthol products.
A menthol flavour can be added to cigarettes during the manufacturing process or smokers can add it themselves by crushing a menthol capsule.
Significantly however, menthol can mask early respiratory disease symptoms, so menthol smokers may carry on smoking after they start to become ill, at a time when smokers of other products might be prompted to quit.
Cigarette sensory characteristics (eg, taste, smell, visual stimuli) can reinforce smoking behavior and enhance nicotine self-administration.1–4
Menthol as a cigarette additive is more than just a flavor; menthol is involved with neurobiological processes that trigger reward pathways in the brain through quick dopamine release.5,6
Menthol also exerts a range of sensory effects on the airways such as anesthesia and cooling, helping mask and smooth the harshness of tobacco smoke while increasing appeal, and ease of smoking among naïve smokers.3,7–10
Menthol cigarettes increase the likelihood of smoking initiation and nicotine addiction and are also harder to quit.10–15
Moreover, the proportion of menthol use among youth smokers is higher than adult smokers, which is concerning, as it may facilitate progression to more established smoking.16
The menthol cigarette market share in the United States increased from 32% in 2011 to 36% in 2017,17 while the overall US cigarette smoking prevalence decreased over the past decade.18,19
In the past two decades, youth menthol smoking prevalence has been higher than non-menthol smoking, suggesting that menthol cigarette use may be slowing overall youth smoking reductions.12,20
Findings from the National Survey on Drug Use and Health (NSDUH) indicated that youth menthol smoking prevalence decreased from 4.6% in 2004 to 2.5% in 2014, while non-menthol smoking decreased from 6.3% to 2.2% during this period.20
Youth cigarette smoking prevalence from Wave 1 (2013–2014) of the Population Assessment of Tobacco and Health (PATH) Study showed that 4.6% of youth were past 30-day cigarette smokers,21 of whom 59.5% smoked menthol cigarettes22,23; of the 13.4% of youth who reported ever smoking a cigarette, 43% reported their first cigarette was a menthol cigarette,23 and 50.1% reported that their first tobacco product used was flavored.22
Menthol cigarette smoking may also play a role in smoking and tobacco use transitions in youth. Studies have reported an association between first use of menthol cigarettes and established cigarette smoking the following year,15,24 and that menthol smoking increases the likelihood of other tobacco use, including non-cigarette flavored tobacco use and use of multiple products.25–30
Youth cigarette smokers who initiate with menthol cigarettes are more likely to progress to smoking ≥20 out of the past 30 days and to report smoking ≥100 cigarettes in their lifetime, compared to smokers who initiate with non-menthol.15
Furthermore, youth who initiate cigarette smoking with menthol display more nicotine dependence symptoms than youth who initiate with non-menthol,15 including a shorter time to smoking their first cigarette of the day and more withdrawal and craving symptoms.13,31–33
Demographic characteristics, cigarette brand familiarity, and popularity and availability of menthol cigarettes in the social environment are important factors associated with youth menthol smoking.
Youth aged 12–17 years have three to four times higher odds of smoking menthol cigarettes than adults aged 35 years or older,12,20 and female smokers have nearly two times higher odds of menthol smoking compared to males.12,20
Regarding differences by race/ethnicity, non-Hispanic black smokers traditionally have had higher odds of smoking menthol cigarettes compared to non-Hispanic white smokers,20 and racial differences have been noted in cigarette brand identification.34
In a study examining three major cigarette brands (two menthol, one non-menthol), recognition of menthol brands predicted cigarette smoking at 12-month follow-up for high school nonsmokers at baseline; non-Hispanic black students were more likely to identify menthol brands compared to white students.34
For cigarettes specifically, non-Hispanic black youth smokers tend to increase the number of cigarettes smoked and accelerate their cigarette consumption when the brand of choice is menthol.35
From the social environment perspective, menthol cigarettes are advertised extensively in neighborhoods that are low-income or have a high proportion of minority residents.36 A 2012 study reported that schools in California with a higher proportion of black students and in areas with more school-age youth had more retail tobacco advertising, including menthol cigarette advertising.37
While previous studies have examined trends and factors associated with menthol cigarette smoking in adults,11,20,23,25,38 the most recent US study focusing on youth trends in menthol use utilized data through 2014.20
This study provides updated estimates and trends in youth menthol and non-menthol smoking from 2011 to 2018. Using nationally representative data from the National Youth Tobacco Survey (NYTS), this study assessed: (1) trends in the prevalence of past 30-day cigarette smoking by menthol status among US middle and high school students from 2011 to 2018; (2) trends in the proportion of past 30-day menthol smoking among youth smokers, overall and stratified by race/ethnicity, sex, and school level; and (3) factors associated with menthol cigarette use among youth smokers during 2016–2018.
Trends in Overall Cigarette Smoking and Menthol Cigarette Smoking: 2011–2018
Table 1 provides estimates of the trends of youth current cigarette smoking from 2011 to 2018, including by menthol use status. From 2011 to 2014, the prevalence of all current cigarette smoking among youth significantly decreased (10.8% to 6.3%, APC1: −17.0% [95% CI: −23.5, −10.0]), while not significantly changing from 2014 to 2018 (6.3% to 5.4%, APC2: −5.7% [95% CI: −11.5, 0.6]). Similarly, the prevalence of youth current menthol smoking significantly decreased from 2011 to 2016 (6.2% to 2.6%, APC1: −16.0% [95% CI: −21.3, −10.4]), but did not significantly change from 2016 to 2018 (2.6% to 2.5%, APC2: −1.8% [95% CI: −23.3, 25.8]). Pairwise parallel tests show differences between prevalence trends in menthol and non-menthol (p ≤ .001).
Table 1. -Percentage and Trend of Current Menthol Cigarette Smokingab During the Preceding 30 Days, by School Level, Sex, and Race/Ethnicity—National Youth Tobacco Survey, United States, 2011–2018
| 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | Joinpoint regression trendsc | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| % (95% CI)d | % (95% CI)d | % (95% CI)d | % (95% CI)d | % (95% CI)d | % (95% CI)d | % (95% CI)d | % (95% CI)d | Year | APC1 (95% CI)d,e | Year | APC2 (95% CI)d,e | ||
| Estimated number of smokersf (N) | |||||||||||||
| Total smokers | 2 880 000 | 2 510 000 | 2 260 000 | 1 680 000 | 1 660 000 | 1 450 000 | 1 390 000 | 1 410 000 | — | — | — | — | |
| Menthol smokers | 1 650 000 | 1 370 000 | 1 200 000 | 900 000 | 850 000 | 690 000 | 680 000 | 640 000 | — | — | — | — | |
| Non-menthol smokers | 1 090 000 | 1 030 000 | 940 000 | 700 000 | 710 000 | 660 000 | 630 000 | 660 000 | — | — | — | — | |
| Unknown menthol status | 130 000 | 110 000 | 110 000 | 80 000 | 80 000 | 90 000 | 80 000 | 90 000 | — | — | — | — | |
| Prevalence of smoking by menthol status among all youth | |||||||||||||
| Overall smoking | 10.8 (9.3, 12.6) | 9.4 (8.4, 10.6) | 8.5 (7.5, 9.5) | 6.3 (5.7, 7.0) | 6.2 (5.2, 7.4) | 5.5 (4.7, 6.4) | 5.3 (4.6, 6.0) | 5.4 (4.7, 6.1) | 2011–2014 | −17.0 (−23.5, −10.0) | 2014–2018 | −5.7 (−11.5, 0.6) | |
| Menthol smoking | 6.2 (5.2, 7.4) | 5.2 (4.5, 5.9) | 4.5 (3.9, 5.3) | 3.4 (2.9, 4.0) | 3.2 (2.7, 3.9) | 2.6 (2.2, 3.1) | 2.6 (2.2, 3.1) | 2.5 (2.1, 2.8) | 2011–2016 | −16.0 (−21.3, −10.4) | 2016–2018 | −1.8 (−23.3, 25.8) | |
| Non-menthol smoking | 4.1 (3.5, 4.8) | 3.9 (3.2, 4.7) | 3.5 (3.0, 4.2) | 2.6 (2.3, 3.0) | 2.7 (2.1, 3.5) | 2.5 (1.9, 3.2) | 2.4 (2.0, 2.8) | 2.5 (2.2,3.0) | 2011–2018 | −7.6 (−10.9, −4.1) | — | — | |
| Unknown menthol status | 0.5 (0.4, 0.6) | 0.4 (0.3, 0.5) | 0.4 (0.3, 0.6) | 0.3 (0.2, 0.4) | 0.3 (0.2, 0.5) | 0.4 (0.3, 0.5) | 0.3 (0.2, 0.4) | 0.4 (0.3, 0.5) | 2011–2014 | −13.5 (−37.4, 19.5) | 2014–2018 | 7.4 (−9.2, 27.1) | |
| Proportion by menthol status among all youth smokers | |||||||||||||
| Menthol smoking | 57.3 (53.7, 60.9) | 54.6 (49.5, 59.5) | 53.2 (47.9, 58.4) | 53.6 (47.9, 59.1) | 51.7 (45.8, 57.4) | 47.8 (41.1, 54.6) | 48.6 (43.6, 53.8) | 45.7 (42.1, 49.4) | 2011–2018 | −3.0 (−3.6, −2.4) | — | — | |
| Non-menthol smoking | 38.2 (34.5, 41.9) | 41.0 (36.1, 46.2) | 41.8 (36.7, 47.2) | 41.7 (36.4, 47.2) | 43.1 (37.3, 49.0) | 45.6 (39.0, 52.3) | 45.4 (40.4, 50.4) | 47.3 (43.5, 51.1) | 2011–2018 | +2.9 (2.3, 3.4) | — | — | |
| Unknown menthol status | 4.5 (3.5, 5.8) | 4.4 (3.5, 5.5) | 5.0 (3.6, 6.9) | 4.8 (3.5, 6.5) | 5.3 (4.1, 6.8) | 6.7 (5.0, 8.8) | 6.0 (4.5, 8.0) | 7.0 (5.6, 8.7) | 2011–2018 | +7.1 (4.5, 9.8) | — | — | |
| Proportion of menthol use among current smokers by demographic characteristicsg | |||||||||||||
| School level | Middle School | 53.2 (47.3, 59.0) | 41.6 (33.6, 50.0) | 49.1 (42.4, 55.9) | 48.4 (38.1, 58.8) | 48.8 (39.4, 58.3) | 45.7 (35.8, 55.9) | 43.3 (33.0, 54.2) | 42.0 (33.4, 51.1) | 2011–2018 | −2.6 (−5.2, 0.1) | — | — |
| High School | 58.2 (54.0, 62.3) | 56.9 (51.7, 62.0) | 54.1 (48.0, 60.1) | 54.5 (48.4, 60.4) | 52.2 (45.7, 58.7) | 48.0 (40.7, 55.4) | 49.0 (43.6, 54.4) | 46.1 (41.9, 50.3) | 2011–2018 | −3.2 (−3.8, −2.6) | — | — | |
| Sex | Female | 62.2 (56.4, 67.6) | 56.9 (50.6, 63.0) | 56.1 (50.8, 61.3) | 55.8 (48.7, 62.7) | 56.2 (48.8, 63.3) | 50.4 (40.3, 60.5) | 48.2 (41.6, 54.9) | 45.9 (39.7, 52.2) | 2011–2018 | −3.8 (−5.0, −2.5) | — | — |
| Male | 54.0 (49.4, 58.5) | 52.9 (48.0, 57.8) | 51.0 (44.7, 57.2) | 51.8 (45.4, 58.1) | 48.7 (42.7, 54.7) | 46.0 (39.6, 52.5) | 48.3 (41.9, 54.8) | 45.4 (40.7, 50.2) | 2011–2018 | −2.4 (−3.1, −1.7) | — | — | |
| Race/ ethnicityh | NH white | 55.4 (51.0, 59.6) | 50.0 (43.9, 56.1) | 46.0 (39.6, 52.5) | 51.4 (43.8, 59.0) | 44.4 (36.4, 52.8) | 42.2 (34.2, 50.7) | 43.7 (36.9, 50.7) | 42.8 (37.9, 47.8) | 2011–2018 | −3.6 (−5.2, −1.9) | — | — |
| NH black | 80.5 (73.6, 86.0) | 76.9 (65.0, 85.6) | 70.2 (59.7, 78.9) | 70.5 (60.1, 79.1) | 81.8 (74.9, 87.2) | 64.7 (53.6, 74.5) | 71.9 (55.5, 84.0) | 51.4 (32.8, 69.7) | 2011–2018 | −1.7 (−5.5, 2.3) | — | — | |
| Hispanic | 52.4 (47.0, 57.8) | 54.3 (47.7, 60.8) | 59.3 (52.0, 66.2) | 52.3 (44.3, 60.1) | 54.9 (48.6, 61.1) | 56.0 (43.9, 67.4) | 54.6 (48.1, 60.9) | 50.6 (44.1, 57.0) | 2011–2018 | −0.3 (−2.1, 1.6) | — | — | |
| NH Other Race | 60.1 (51.4, 68.1) | 57.5 (47.7, 66.7) | 63.3 (54.1, 71.5) | 58.1 (48.9, 66.8) | 56.7 (45.2, 67.4) | 51.9 (39.7, 63.9) | 51.0 (39.4, 62.5) | 44.8 (35.0, 54.9) | 2011–2013 | +2.8 (−7.3, 13.9) | 2013–2018 | −5.7 (−8.4, −3.0) |
bMenthol cigarette status was determined by asking, “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” and “During the past 30 days, what brand of cigarettes did you usually smoke?” Among past 30-day cigarette smokers, those responding “Yes” to the menthol question, or who reported “Newport” or “Kool” as the usual cigarette brand, were classified as menthol smokers; those who reported “No” to the menthol question, or who did not report “Newport” or “Kool” brands, were classified as non-menthol smokers; all other past 30-day cigarette smokers were classified as missing menthol smoking status.
cJoinpoint regression is used to identify statistically significant trend change points and the APC in each trend segment using a Monte Carlo permutation method allowing for a maximum of 1 joinpoint. For example, this is reflected in the proportion of male menthol smokers among all youth smokers where an inflection point was found in 2015. No inflection points were found for any other covariates.
d95% CI = 95% confidence interval.
eAPC = Annual Percent Change. Bold indicates significance at the p < .05 level.
fThe estimated number of cigarette smokers were rounded down to the nearest 10 000.
gProportions reflect the percentage of youth menthol smokers among youth current smokers among each covariate.
h“NH” refers to “non-Hispanic”.
The proportion of menthol smoking among youth current cigarette smokers significantly decreased (57.3% to 45.7%, APC: −3.0% [95% CI: −3.6, −2.4]) from 2011 to 2018, while the proportion of non-menthol smoking (38.2% to 47.3%, APC: 2.9% [95% CI: 2.3, 3.4]) and those with unknown menthol smoking status (4.5% to 7.0%, APC: 7.1% [95% CI: 4.5, 9.8]) significantly increased.
Pairwise parallel tests for the proportion of youth smokers by menthol status showed differences in trends between menthol and non-menthol (p = .004), menthol and unknown menthol status (p = .007), and non-menthol and unknown menthol status (p = .007).
While current menthol smoking generally decreased among all youth from 2011 to 2018, some differences were observed by demographic subgroup. The proportion of menthol use among high school cigarette smokers significantly declined (58.2% to 46.1%, APC: −3.2% [95% CI: −3.8, −2.6]) whereas the proportion of menthol use among middle school cigarette smokers did not significantly change (53.2% to 42.0%, APC: −2.6% [95% CI: −5.2, 0.1]).
For both female and male cigarette smokers, the proportion of menthol use significantly declined (females: 62.2% to 45.9%, APC: −3.8% [95% CI: −5.0, −2.5]; males: 54.0% to 45.4%, APC: −2.4% [95% CI: −3.1, −1.7]). Pairwise parallel tests for the proportion of menthol use by sex show similar trends between male and female youth menthol smokers (p = .243).
By race and ethnicity, the proportion of menthol use among non-Hispanic white youth cigarette smokers significantly decreased (55.4% to 42.8%, APC: −3.6% [95% CI: −5.2, −1.9]); however, menthol use did not significantly change among non-Hispanic blacks (80.5% to 51.4%, APC: −1.7% [95% CI: −5.5, 2.3]) and Hispanics (52.4% to 50.6%, APC: −0.3% [95% CI: −2.1, −1.6]).
Among non-Hispanic Other Race smokers, the proportion of menthol use did not significantly change from 2011 to 2013 (60.1% to 63.3%, APC1: 2.8% [95% CI: −7.3, 13.9]), but then significantly declined from 2013 to 2018 (63.3% to 44.8%, APC2: −5.7% [95% CI: −8.4, −3.0]).
Characteristics of Current Cigarette Smoking by Menthol Status: 2016–2018
Table 2 presents the proportion of menthol and non-menthol use among youth smokers for each demographic characteristic. In 2016–2018, 50.7% of youth smokers reported using menthol cigarettes. Proportions of menthol and non-menthol use were nearly equal among males (53.6% vs. 55.3%, respectively; p = .499) and by school level (84.2% of menthol and non-menthol smokers were in high school; p = .999); however, a significantly higher proportion of menthol smokers were either non-Hispanic black, Hispanic, or non-Hispanic Other Race (43.3% of menthol smokers and 30.4% of non-menthol smokers were a race other than non-Hispanic white; p < .001).
Table 2. – Characteristics of Past 30-Day Cigarette Smokers by Menthol Smoking Statusa—National Youth Tobacco Survey, United States, 2016–2018
| Menthola | Non-menthola | pe | ||||||
|---|---|---|---|---|---|---|---|---|
| nb | % (95% CI)c | Weighted Nd | nb | % (95% CI)c | Weighted Nd | |||
| Overall | 1529 | 50.7 (47.5, 53.9) | 670 000 | 1304 | 49.3 (46.1, 52.5) | 650 000 | ||
| Sex | Male | 829 | 53.6 (50.1, 57.1) | 350 000 | 730 | 55.3 (51.5, 59.1) | 350 000 | |
| Female | 677 | 46.4 (42.9, 49.9) | 300 000 | 564 | 44.7 (41.0, 48.5) | 290 000 | .499 | |
| School levels | Middle school | 256 | 15.8 (13.1, 18.9) | 100 000 | 224 | 15.8 (13.0, 19.0) | 100 000 | |
| High school | 1239 | 84.2 (81.2, 86.9) | 550 000 | 1072 | 84.2 (81.0, 87.0) | 540 000 | .999 | |
| Race/ethnicity | Non-Hispanic white | 713 | 56.7 (52.4, 60.8) | 360 000 | 773 | 69.6 (65.4, 73.6) | 440 000 | |
| Non-Hispanic black | 151 | 8.3 (6.4, 10.6) | 50 000 | 54 | 3.4 (2.4, 4.8) | 20 000 | ||
| Hispanic | 448 | 26.1 (22.9, 29.6) | 160 000 | 288 | 18.3 (15.3, 21.8) | 110 000 | ||
| Non-Hispanic Other Race | 145 | 9.0 (7.2, 11.1) | 50 000 | 145 | 8.7 (7.0, 10.7) | 50 000 | <.001 | |
| Number of days smoked in the past 30 days | 1–5 days (infrequent) | 729 | 48.2 (44.7, 51.7) | 320 000 | 769 | 57.6 (54.1, 61.2) | 370 000 | |
| 6–19 days (moderate) | 328 | 21.9 (19.3, 24.7) | 147 000 | 267 | 20.0 (17.4, 22.9) | 130 000 | ||
| ≥20 days (frequent) | 427 | 30.0 (27.0, 33.0) | 202 000 | 268 | 22.3 (18.6, 26.5) | 140 000 | <.001 | |
| Number of cigarettes smoked per dayf | <1 cigarette/day | 304 | 19.7 (17.2, 22.5) | 130 000 | 371 | 27.8 (24.7, 31.2) | 180 000 | |
| 1 cigarettes/day | 294 | 20.6 (17.8, 23.7) | 130 000 | 284 | 22.2 (19.3, 25.3) | 140 000 | ||
| 2–5 cigarettes/day | 562 | 38.9 (35.3, 42.7) | 250 000 | 427 | 32.5 (29.2, 36.0) | 210 000 | ||
| More than 5 cigarettes/day | 345 | 20.7 (17.9, 23.8) | 130 000 | 204 | 17.5 (14.3, 21.2) | 110 000 | <.001 | |
| Lifetime number of cigarettes | 5 or less | 265 | 16.1 (13.9, 18.7) | 100 000 | 332 | 24.1 (21.0, 27.4) | 150 000 | |
| 6–25 | 328 | 21.4 (19.0, 24.1) | 140 000 | 314 | 23.1 (20.3, 26.2) | 150 000 | ||
| 26–99 | 245 | 17.4 (14.7, 20.6) | 110 000 | 195 | 15.9 (13.5, 18.6) | 100 000 | ||
| ≥100 | 683 | 45.0 (41.6, 48.4) | 300 000 | 452 | 36.9 (33.0, 41.1) | 230 000 | <.001 | |
| E-cigarette use | Current userg | 857 | 61.4 (56.9, 65.7) | 395 000 | 717 | 58.0 (53.7, 62.2) | 367 000 | |
| Ever, but not current userh | 400 | 26.4 (22.7, 30.4) | 170 000 | 333 | 28.6 (24.9, 32.6) | 181 000 | ||
| Never user | 199 | 12.3 (10.1, 14.8) | 79 000 | 206 | 13.5 (11.1, 16.2) | 85 000 | .465 | |
| Cigar use | Current userg | 819 | 55.2 (51.0, 59.4) | 351 000 | 547 | 45.4 (41.9, 48.9) | 279 000 | |
| Ever, but not current userh | 394 | 28.3 (25.3, 31.6) | 180 000 | 370 | 31.1 (27.9, 34.4) | 191 000 | ||
| Never user | 217 | 16.4 (13.9, 19.3) | 104 000 | 312 | 23.5 (21.0, 26.3) | 145 000 | <.001 | |
| Hookah use | Current userg | 431 | 30.6 (27.0, 34.5) | 194 000 | 246 | 19.1 (16.1, 22.5) | 118 000 | |
| Ever, but not current userh | 336 | 24.0 (21.3, 27.0) | 152 000 | 269 | 24.8 (21.8, 28.1) | 153 000 | ||
| Never user | 656 | 45.4 (41.5, 49.3) | 287 000 | 704 | 56.1 (52.0, 60.1) | 346 000 | <.001 | |
| Smokeless tobacco usei | Current userg | 627 | 44.1 (40.6, 47.7) | 288 000 | 531 | 41.6 (38.4, 44.8) | 267 000 | |
| Ever, but not current userh | 256 | 18.1 (15.5, 21.2) | 119 000 | 243 | 20.4 (17.8, 23.2) | 131 000 | ||
| Never user | 589 | 37.8 (34.2, 41.4) | 247 000 | 506 | 38.1 (35.1, 41.2) | 245 000 | .417 | |
| Other tobacco usej | Current userg | 430 | 34.3 (30.9, 37.9) | 204 000 | 343 | 32.2 (26.8, 38.1) | 189 000 | |
| Ever, but not current userh | 292 | 20.7 (18.1, 23.6) | 123 000 | 260 | 22.0 (19.1, 25.1) | 129 000 | ||
| Never user | 620 | 45.0 (41.1, 48.9) | 267 000 | 563 | 45.8 (41.0, 50.8) | 269 000 | .709 | |
| Current, non-cigarette tobacco use, by flavor use statusk | Does not use a non- cigarette tobacco product | 222 | 13.4 (11.4, 15.7) | 90 000 | 221 | 16.7 (14.3, 19.5) | 109 000 | |
| Flavored, non-cigarette tobacco use | 938 | 64.0 (60.6, 67.2) | 429 000 | 707 | 55.8 (52.0, 59.6) | 364 000 | ||
| Non-flavored, non-cigarette tobacco use | 166 | 9.7 (8.0, 11.7) | 65 000 | 219 | 15.0 (12.7, 17.6) | 97 000 | ||
| Non-cigarette tobacco use, flavor unknown | 191 | 12.9 (10.8, 15.4) | 87 000 | 149 | 12.5 (10.0, 15.5) | 87 000 | .008 | |
| Household tobacco use | Yes | 977 | 75.4 (71.2, 79.2) | 290 000 | 809 | 67.6 (63.6, 71.4) | 270 000 | |
| No | 365 | 24.6 (20.8, 28.8) | 90 000 | 386 | 32.4 (28.6, 36.4) | 130 000 | .008 | |
| Speak English at home | Yes | 949 | 71.1 (67.1, 74.8) | 430 000 | 905 | 77.1 (73.8, 80.0) | 460 000 | |
| No | 431 | 28.9 (25.2, 32.9) | 170 000 | 309 | 22.9 (20.0, 26.2) | 130 000 | .004 | |
| Ease of buying tobacco | Easy/Somewhat easy | 1117 | 78.6 (75.6, 81.3) | 490 000 | 985 | 78.1 (74.8, 81.0) | 480 000 | |
| Not easy | 309 | 21.4 (18.7, 24.4) | 130 000 | 245 | 20.5 (21.9, 25.2) | 130 000 | .830 | |
| Believe cigarettes are harmful | Some/A lot | 894 | 65.9 (62.1, 74.4) | 400 000 | 841 | 71.3 (68.0, 74.4) | 430 000 | |
| No/Little | 487 | 34.1 (30.5, 37.9) | 200 000 | 370 | 28.7 (25.6, 32.0) | 170 000 | .024 | |
| Believe tobacco products are harmful | Strongly disagree/Disagree | 454 | 30.6 (27.3, 34.0) | 190 000 | 340 | 25.6 (22.9, 28.5) | 150 000 | |
| Strongly agree/Agree | 950 | 69.4 (66.0, 72.7) | 430 000 | 888 | 74.4 (71.5, 77.1) | 450 000 | .026 | |
| Craving tobacco | Yes | 812 | 56.4 (53.1, 59.6) | 360 000 | 623 | 51.5 (47.8, 55.3) | 320 000 | |
| No | 651 | 43.6 (40.4, 46.9) | 280 000 | 639 | 48.5 (44.7, 52.2) | 300 000 | .037 | |
| Want tobacco within 30 min of waking | Yes | 442 | 30.7 (27.8, 33.8) | 190 000 | 337 | 28.0 (24.2, 32.1) | 170 000 | |
| No | 1006 | 69.3 (66.2, 72.2) | 430 000 | 923 | 72.0 (67.9, 75.8) | 450 000 | .241 |
bUnweighted n for 2016–2018 combined.
c95% CI = 95% confidence interval.
dBecause 2016–2018 were combined for this analysis, the weights were averaged, producing averaged point estimates (including the proportions and estimated number of smokers). The estimated number of cigarette smokers were rounded down to the nearest 10 000 persons.
ep-value is chi-square testing differences between menthol status groups (menthol vs. non-menthol). Bold indicates significance at p < .05 level.
fCutoffs determined based on the distribution.
gUsed in the past 30 days.
hUsed in their lifetime, excluding those who used in the past 30 days.
iSmokeless tobacco use includes chewing tobacco, dip, snuff, snus, and dissolvable tobacco.
jOther tobacco includes bidis, pipe tobacco, and roll-your-own cigarettes.
kCurrent, non-cigarette flavored tobacco use status was assessed among youth who used any non-cigarette tobacco product at least one day in the past 30 days, utilizing the question: “Which of the following tobacco products that you used in the past 30 days were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate or any other flavors (Select one or more)?” Among current users, those who selected the corresponding product for the flavor question (eg, they smoked cigars more than one day in the past 30 days and selected “cigars, cigarillos, or little cigars” for the flavor product question) were defined as a “flavored, non-cigarette tobacco user” for that product. If a current user selected “I did not use any of the flavored tobacco products listed above in the past 30 days,” they were defined as a “non-flavored, non-cigarette tobacco user.” Lastly, if a current user did not provide a response to the flavor question (ie, missing), they were defined as a “non-cigarette tobacco user, flavor status unknown.” If a respondent did not use a non-cigarette tobacco product in the past 30 days, they were defined as a “does not use a non-cigarette tobacco product.”
For smoking pattern characteristics, higher proportions of menthol smokers reported smoking ≥20 in the past 30 days (menthol: 30.0%; non-menthol: 22.3%; p < .001), ≥2 cigarettes per day (menthol: 59.6%; non-menthol: 50.0%; p < .001), and ≥100 cigarettes in their lifetime (menthol: 45.0%; non-menthol: 36.9%; p < .001). A higher proportion of menthol smokers reported use of flavored, non-cigarette tobacco products (menthol: 64.0%; non-menthol: 55.8%, p < .001), whereas more non-menthol smokers reported current non-flavored, non-cigarette tobacco use (menthol: 9.7%; non-menthol: 15.0%, p < .001) or not using a non-cigarette tobacco product (menthol: 13.4%; non-menthol: 16.7%; p < .001).
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More information: Rosemary Hiscock et al, Tobacco industry tactics to circumvent and undermine the menthol cigarette ban in the UK, Tobacco Control (2020). DOI: 10.1136/tobaccocontrol-2020-055769
