Nicotine & Tobacco Research, 2015, 1286–1287 doi:10.1093/ntr/ntv021 Letter Advance Access publication January 29, 2015
Letter Switching to E-Cigarettes in the Event of a Menthol Cigarette Ban
Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ; 2Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC
1
Corresponding Author: Olivia A. Wackowski, PhD, MPH, Center for Tobacco Studies, Rutgers School of Public Health, 335 George Street, Suite 2100, New Brunswick, NJ 08901, USA. Phone: 732-235-9731; Fax: 732-235-9777; E-mail: [email protected]
Three recent nationally representative survey studies have asked smokers what they might do if menthol cigarettes were banned, an action under consideration by the Food and Drug Administration.1–3 Two of these, both general population studies conducted in 2010, found that about 39% of American adult menthol smokers indicated that they would quit smoking altogether rather than the presented alternative options of switching to non-menthol cigarettes1,2 or to some other tobacco product.1 A third study, which Drs. Wackowski and Delnevo previously published in Nicotine & Tobacco Research, surveyed a national sample of young adults (ages 18–34) in 2011 and found that intentions to quit smoking if menthol cigarettes were banned were even higher in this age group: 65.7% of young adult menthol smokers said they would quit tobacco use altogether rather than switch to non-menthol cigarettes (18.4%) or to some other tobacco product (16.0%).3 While these previous studies suggest the potential positive impact of a menthol cigarette ban, a limitation is that they did not present switching to menthol electronic cigarettes (e-cigarettes) as a response option. It is not clear to what extent, if any, respondents may have considered “e-cigarettes” as being a type of “other tobacco product” without being named in the response. This is significant given the growth in sales, use and acceptability of e-cigarettes as a cigarette alternative.4,5 Additionally, the response options in all three studies were not randomized and thus potentially susceptible to a response order effect. We inquired about behavioral intention under a menthol ban in a new online survey of 519 adult current smokers administered in April 2014. We expanded on previous research by including an e-cigarette response option. The question asked menthol cigarette smokers (i.e., those who indicated the brand they usually smoke is mentholated): “If menthol cigarettes were no longer sold, which of the following would you most likely do?” Response options were “switch to non-menthol cigarettes”; “switch to menthol electronic cigarettes”; “switch to some other tobacco product (e.g., cigars, spit tobacco, snus);” “quit smoking and not use any other tobacco
product”; and “other.” The order of these response options was randomized. This survey was limited to current smokers (i.e., have ever smoked 100 cigarettes and now smoke “some days” or “everyday”), recruited from GFK’s nationally representative Knowledge Networks (KN) research panel. GFK contacted 1,042 panel members ages 18+ who identified as current smokers at panel recruitment; 609 (58.4%) took the study screener, and 519 (85.2%) were confirmed to be current smokers and completed the survey. Descriptive statistics and Wald chi-square tests were conducted using Sudaan (Version 11.0), applying a post-stratification weight to adjust for non-coverage and nonresponse. The most comparable of the three previous studies in terms of both the measure and target population is Hartman 20111, though lack of 95% CIs from Hartman 2011 precludes us from making statistical comparisons with the current study. Among the 519 current smoker respondents in our study, 36.3% were menthol cigarette smokers. Almost half of menthol smokers (45.9%) indicated that they would switch to non-menthol cigarettes if menthol cigarettes were no longer sold, which was qualitatively higher than this response reported in Hartman1 (36.2%). In the current survey, 28.4% of menthol smokers said they would quit smoking and not use any other product, an estimate which was qualitatively lower than that found by Hartman (39%). In this study, older smokers (ages 45 and up) (40.1%, 95% CI = 27.7–54.0) and Black menthol smokers (47.4%, 95% CI = 29.9–65.5) had a significantly higher prevalence of choosing quitting altogether than younger (20.0%, 95% CI = 10.5–34.6) (p = .03) and White menthol smokers (17%; 95% CI = 8.6–30.9) (p = .01), respectively. Few (3.9%) menthol smokers in our study said they would switch to some other tobacco product (e.g., cigars, smokeless tobacco) or do something else (i.e., “other” response, 6.7%). In the Hartman study, 7.7% said they would switch to some other tobacco product and 9.4% said they would do something else (i.e., “none of the above” response).1
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1286
Downloaded from http://ntr.oxfordjournals.org/ at Washington University School of Medicine Library on November 14, 2015
Olivia A. Wackowski PhD, MPH1, Cristine D. Delnevo PhD, MPH1, Jennifer L. Pearson PhD, MPH2
Nicotine & Tobacco Research, 2015, Vol. 17, No. 10
Funding This study was supported by a grant from the New Jersey Health Foundation and in part by the National Cancer Institute (through the Rutgers Cancer Institute of New Jersey, P30CA072720) and the Food and Drug Administration
Center for Tobacco Products (K01CA189301). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organizations.
Declaration of Interests None declared.
References 1. Hartman A. What Menthol Smokers Report They Would do if Menthol Cigarettes Were no Longer Sold. Tobacco Products Scientific Advisory Committee, Food & Drug Administration; 2011. http://www.fda. gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/ TobaccoProductsScientificAdvisoryCommittee/UCM240176.pdf. Accessed November 5, 2014. 2. Pearson J, Abrams D, Niaura R, Richardson A, Vallone D. A ban on menthol cigarettes: impact on public opinion and smokers’ intention to quit. Am J Public Health. 2012;102:e107–e114. 3. Wackowski O, Manderski M, Delnevo C. Young adults’ behavioral intentions surrounding a potential menthol cigarette ban. Nicotine Tob Res. 2014;16:876–880. 4. King B, Alam S, Promoff G, Arrazola R, Dube S. Awareness and ever use of electronic cigarettes among U.S. Adults, 2010–2011. Nicotine Tob Res. 2013;15:1623–1627. 5. Morrison M. Big three’s e-cig play: with cash at ready, Altria, Reynolds, Lorillard to increase investments, Herzog tells NATO. CSP Daily News. 2014. http://www.cspnet.com/category-news/tobacco/articles/big-threes-ecig-play. Accessed November 5, 2014. 6. Fiore M, Schroeder S, Baker T. Smoke, the chief killer–strategies for targeting combustible tobacco use. N Engl J Med. 2014;370:297–299. 7. Hajek P. Electronic cigarettes have a potential for huge public health benefit. BMC Med. 2014;12:225. 8. Statement from Specialists in Nicotine Science and Public Health Policy. Letter to Dr Margaret Chan. Reducing the toll of death and disease from tobacco—tobacco harm reduction and the Framework Convention on Tobacco Control. 2014. http://nicotinepolicy.net/documents/letters/ MargaretChan.pdf. Accessed November 5, 2014. 9. Delnevo C, Gundersen D, Hrywna M, Echeverria S, Steinberg M. Smokingcessation prevalence among U.S. smokers of menthol versus non-menthol cigarettes. Am J Prev Med. 2011;41:357–365. 10. Levy DT, Pearson JL, Villanti AC, et al. Modeling the future effects of a menthol ban on smoking prevalence and smoking-attributable deaths in the United States. Am J Public Health. 2011;7:1236–1240.
Downloaded from http://ntr.oxfordjournals.org/ at Washington University School of Medicine Library on November 14, 2015
New to this study was the finding that 15.1% of menthol smokers said they would switch to menthol e-cigarettes. No significant differences were found by gender, age or current e-cigarette use. An association did exist for race, where higher percentages of Black (23%; 95% CI = 10.6–42.7) and White (18.3%; 95% CI = 10.7– 29.5) menthol smokers said they would switch to mentholated e-cigarettes compared to Hispanic menthol smokers (0.7%; 95% CI = 0.1–5.0, p ≤ .02). Although these data are based on a relatively small sample size, they suggest that intentions to quit smoking and not switch to any other product in the event of a menthol cigarette ban may be somewhat lower than what previous general population studies of smokers have found,1,2 which were conducted when e-cigarettes were less popular and did not include switching to menthol e-cigarettes as a response option. Indeed, in just the 3–4 years between the three previous surveys (2010, 2011) and this one (2014), a period in which action on menthol cigarette regulation stalled, the tobacco environment changed and e-cigarettes became a more popular smoking alternative. However, while quitting all tobacco products would be an ideal policy effect, switching to e-cigarettes could still provide a public health benefit from a harm reduction perspective.6–8 Furthermore, given the cessation difficulty associated with menthol cigarettes,9 it is possible that menthol e-cigarettes may make quitting menthol tobacco cigarettes easier and help prevent switching to some more harmful form of tobacco (e.g., menthol cigars or non-menthol cigarettes). This study is limited in not asking about other plausible responses, such as switching to tobacco products in other attractive flavors (which might negatively maintain tobacco use), and pursuing “black market” or “homemade” menthol cigarettes. As with all these studies, it is not known to what extent smokers’ responses might correlate with their actual behavior if menthol cigarettes were banned. However, if even a small percentage of menthol smokers were to truly quit, numerous lives could potentially be saved.2,10 Overall, in today’s evolved tobacco environment, we continue to believe that regulation of menthol cigarettes could provide significant public health gains.
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Letter Switching to E-Cigarettes in the Event of a Menthol Cigarette Ban
Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, NJ; 2Schroeder Institute for Tobacco Research and Policy Studies, Legacy, Washington, DC
1
Corresponding Author: Olivia A. Wackowski, PhD, MPH, Center for Tobacco Studies, Rutgers School of Public Health, 335 George Street, Suite 2100, New Brunswick, NJ 08901, USA. Phone: 732-235-9731; Fax: 732-235-9777; E-mail: [email protected]
Three recent nationally representative survey studies have asked smokers what they might do if menthol cigarettes were banned, an action under consideration by the Food and Drug Administration.1–3 Two of these, both general population studies conducted in 2010, found that about 39% of American adult menthol smokers indicated that they would quit smoking altogether rather than the presented alternative options of switching to non-menthol cigarettes1,2 or to some other tobacco product.1 A third study, which Drs. Wackowski and Delnevo previously published in Nicotine & Tobacco Research, surveyed a national sample of young adults (ages 18–34) in 2011 and found that intentions to quit smoking if menthol cigarettes were banned were even higher in this age group: 65.7% of young adult menthol smokers said they would quit tobacco use altogether rather than switch to non-menthol cigarettes (18.4%) or to some other tobacco product (16.0%).3 While these previous studies suggest the potential positive impact of a menthol cigarette ban, a limitation is that they did not present switching to menthol electronic cigarettes (e-cigarettes) as a response option. It is not clear to what extent, if any, respondents may have considered “e-cigarettes” as being a type of “other tobacco product” without being named in the response. This is significant given the growth in sales, use and acceptability of e-cigarettes as a cigarette alternative.4,5 Additionally, the response options in all three studies were not randomized and thus potentially susceptible to a response order effect. We inquired about behavioral intention under a menthol ban in a new online survey of 519 adult current smokers administered in April 2014. We expanded on previous research by including an e-cigarette response option. The question asked menthol cigarette smokers (i.e., those who indicated the brand they usually smoke is mentholated): “If menthol cigarettes were no longer sold, which of the following would you most likely do?” Response options were “switch to non-menthol cigarettes”; “switch to menthol electronic cigarettes”; “switch to some other tobacco product (e.g., cigars, spit tobacco, snus);” “quit smoking and not use any other tobacco
product”; and “other.” The order of these response options was randomized. This survey was limited to current smokers (i.e., have ever smoked 100 cigarettes and now smoke “some days” or “everyday”), recruited from GFK’s nationally representative Knowledge Networks (KN) research panel. GFK contacted 1,042 panel members ages 18+ who identified as current smokers at panel recruitment; 609 (58.4%) took the study screener, and 519 (85.2%) were confirmed to be current smokers and completed the survey. Descriptive statistics and Wald chi-square tests were conducted using Sudaan (Version 11.0), applying a post-stratification weight to adjust for non-coverage and nonresponse. The most comparable of the three previous studies in terms of both the measure and target population is Hartman 20111, though lack of 95% CIs from Hartman 2011 precludes us from making statistical comparisons with the current study. Among the 519 current smoker respondents in our study, 36.3% were menthol cigarette smokers. Almost half of menthol smokers (45.9%) indicated that they would switch to non-menthol cigarettes if menthol cigarettes were no longer sold, which was qualitatively higher than this response reported in Hartman1 (36.2%). In the current survey, 28.4% of menthol smokers said they would quit smoking and not use any other product, an estimate which was qualitatively lower than that found by Hartman (39%). In this study, older smokers (ages 45 and up) (40.1%, 95% CI = 27.7–54.0) and Black menthol smokers (47.4%, 95% CI = 29.9–65.5) had a significantly higher prevalence of choosing quitting altogether than younger (20.0%, 95% CI = 10.5–34.6) (p = .03) and White menthol smokers (17%; 95% CI = 8.6–30.9) (p = .01), respectively. Few (3.9%) menthol smokers in our study said they would switch to some other tobacco product (e.g., cigars, smokeless tobacco) or do something else (i.e., “other” response, 6.7%). In the Hartman study, 7.7% said they would switch to some other tobacco product and 9.4% said they would do something else (i.e., “none of the above” response).1
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1286
Downloaded from http://ntr.oxfordjournals.org/ at Washington University School of Medicine Library on November 14, 2015
Olivia A. Wackowski PhD, MPH1, Cristine D. Delnevo PhD, MPH1, Jennifer L. Pearson PhD, MPH2
Nicotine & Tobacco Research, 2015, Vol. 17, No. 10
Funding This study was supported by a grant from the New Jersey Health Foundation and in part by the National Cancer Institute (through the Rutgers Cancer Institute of New Jersey, P30CA072720) and the Food and Drug Administration
Center for Tobacco Products (K01CA189301). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organizations.
Declaration of Interests None declared.
References 1. Hartman A. What Menthol Smokers Report They Would do if Menthol Cigarettes Were no Longer Sold. Tobacco Products Scientific Advisory Committee, Food & Drug Administration; 2011. http://www.fda. gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/ TobaccoProductsScientificAdvisoryCommittee/UCM240176.pdf. Accessed November 5, 2014. 2. Pearson J, Abrams D, Niaura R, Richardson A, Vallone D. A ban on menthol cigarettes: impact on public opinion and smokers’ intention to quit. Am J Public Health. 2012;102:e107–e114. 3. Wackowski O, Manderski M, Delnevo C. Young adults’ behavioral intentions surrounding a potential menthol cigarette ban. Nicotine Tob Res. 2014;16:876–880. 4. King B, Alam S, Promoff G, Arrazola R, Dube S. Awareness and ever use of electronic cigarettes among U.S. Adults, 2010–2011. Nicotine Tob Res. 2013;15:1623–1627. 5. Morrison M. Big three’s e-cig play: with cash at ready, Altria, Reynolds, Lorillard to increase investments, Herzog tells NATO. CSP Daily News. 2014. http://www.cspnet.com/category-news/tobacco/articles/big-threes-ecig-play. Accessed November 5, 2014. 6. Fiore M, Schroeder S, Baker T. Smoke, the chief killer–strategies for targeting combustible tobacco use. N Engl J Med. 2014;370:297–299. 7. Hajek P. Electronic cigarettes have a potential for huge public health benefit. BMC Med. 2014;12:225. 8. Statement from Specialists in Nicotine Science and Public Health Policy. Letter to Dr Margaret Chan. Reducing the toll of death and disease from tobacco—tobacco harm reduction and the Framework Convention on Tobacco Control. 2014. http://nicotinepolicy.net/documents/letters/ MargaretChan.pdf. Accessed November 5, 2014. 9. Delnevo C, Gundersen D, Hrywna M, Echeverria S, Steinberg M. Smokingcessation prevalence among U.S. smokers of menthol versus non-menthol cigarettes. Am J Prev Med. 2011;41:357–365. 10. Levy DT, Pearson JL, Villanti AC, et al. Modeling the future effects of a menthol ban on smoking prevalence and smoking-attributable deaths in the United States. Am J Public Health. 2011;7:1236–1240.
Downloaded from http://ntr.oxfordjournals.org/ at Washington University School of Medicine Library on November 14, 2015
New to this study was the finding that 15.1% of menthol smokers said they would switch to menthol e-cigarettes. No significant differences were found by gender, age or current e-cigarette use. An association did exist for race, where higher percentages of Black (23%; 95% CI = 10.6–42.7) and White (18.3%; 95% CI = 10.7– 29.5) menthol smokers said they would switch to mentholated e-cigarettes compared to Hispanic menthol smokers (0.7%; 95% CI = 0.1–5.0, p ≤ .02). Although these data are based on a relatively small sample size, they suggest that intentions to quit smoking and not switch to any other product in the event of a menthol cigarette ban may be somewhat lower than what previous general population studies of smokers have found,1,2 which were conducted when e-cigarettes were less popular and did not include switching to menthol e-cigarettes as a response option. Indeed, in just the 3–4 years between the three previous surveys (2010, 2011) and this one (2014), a period in which action on menthol cigarette regulation stalled, the tobacco environment changed and e-cigarettes became a more popular smoking alternative. However, while quitting all tobacco products would be an ideal policy effect, switching to e-cigarettes could still provide a public health benefit from a harm reduction perspective.6–8 Furthermore, given the cessation difficulty associated with menthol cigarettes,9 it is possible that menthol e-cigarettes may make quitting menthol tobacco cigarettes easier and help prevent switching to some more harmful form of tobacco (e.g., menthol cigars or non-menthol cigarettes). This study is limited in not asking about other plausible responses, such as switching to tobacco products in other attractive flavors (which might negatively maintain tobacco use), and pursuing “black market” or “homemade” menthol cigarettes. As with all these studies, it is not known to what extent smokers’ responses might correlate with their actual behavior if menthol cigarettes were banned. However, if even a small percentage of menthol smokers were to truly quit, numerous lives could potentially be saved.2,10 Overall, in today’s evolved tobacco environment, we continue to believe that regulation of menthol cigarettes could provide significant public health gains.
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