Addiction Potential of Combustible Menthol Cigarette Alternatives: A Randomized Crossover Trial
Authors: Wagener Theodore L. , Mehta Toral , Hinton Alice , Schulz Jonathan , Erath Tyler , Tidey Jennifer W. , Villanti Andrea C. 
Published: June 2022

Introduction

The FDA announced its intention to issue proposed product standards banning menthol as a characterizing flavor in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared to usual brand menthol cigarettes (UBMC).

Methods

Eighty adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and 3 menthol cigarette alternatives in random order at the subsequent visits: 1) a pre-assembled menthol roll-your-own cigarette using menthol pipe tobacco and mentholated cigarette tube (mRYO), 2) a menthol filtered little cigar (mFLC), and 3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects, and behavioral economic demand indices were assessed.

Results

Compared to UBMC, menthol cigarette alternatives resulted in similar topography and CO exposure but significantly lower levels of positive subjective experience and behavioral economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase, and use the mRYO product regularly compared with mFLC and NMC.

Conclusions and Relevance

mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA’s proposed ban.

What is already known on this topic

Menthol cigarettes are associated with increased smoking initiation, higher nicotine dependence, and decreased adult cessation, particularly among vulnerable populations. To address this public health issue, the FDA announced in April 2021 its intention to issue product standards banning menthol as a characterizing flavor in both cigarettes and cigars within a year. However, the public health benefits of these product standards may be attenuated by the role of plausible substitutes available in the marketplace

What this study adds

In this randomized cross-over design study that included 80 adult menthol cigarette smokers, each of the alternative products demonstrated the ability to significantly reduce nicotine craving and withdrawal symptoms, but the combination of mentholated pipe tobacco and tubes in a menthol roll-your-own cigarette, resulted in the highest behavioral economic demand and positive subjective experience.

How this study may affect policy

To maximize the benefits of a menthol cigarette ban, restrictions should extend to plausible substitutes, particularly menthol pipe tobacco and cigarette tubes.