In the cigarette market in the United States, one quarter of cigarettes are labeled “menthol”. Over 70% of African American smokers use menthol cigarettes, compared with 30% of White smokers
[1, 2]. Further, menthol cigarettes are disproportionately preferred by adolescents, adult women, and those with low income
Menthol as an additive to cigarettes has been a topic of scientific and public health attention for the past 20 years. As a result of the Master Settlement Agreement in 1998 between five major tobacco companies in the U.S. and Attorneys General in 46 states, tobacco industry internal documents regarding product design and development have become available to researchers and have shed light on the effect of cigarette additives. Menthol is hypothesized to be a factor that contributes to higher dependence and increased difficulty in quitting. This may lead to a higher lifetime exposure to tobacco and its by-products and a subsequent higher prevalence of tobacco-related morbidity and mortality. Review articles that have looked at the health effects comprehensively suggest that the relevant biological systems, namely the cardiovascular and respiratory systems, may be themselves affected by the menthol additive
The significance of menthol as a cigarette additive was recognized in 2009 with The Family Smoking Prevention and Tobacco Control Act, giving the Food and Drug Administration (FDA) the authority to regulate tobacco products
. The Tobacco Products Scientific Advisory Committee for the FDA has stated that menthol is not simply a flavoring additive. Because of its ability to mask smoke harshness and irritation from nicotine, menthol has become a popular cigarette choice, especially among African Americans and youth. While menthol cigarettes are not widely used in Europe, the EU Scientific Committee on Emerging and Newly Identified Health Risks is also reviewing menthol as a harmful additive in tobacco products.
While there are no current regulations in place regarding menthol, research has continued to point to its contribution to tobacco use initiation, dependence and related morbidity. Tobacco Induced Diseases published a supplement in May 2011, consisting of seven papers reviewing the literature. It concluded that menthol is a biologically active compound which has primary actions, as well as secondary effects in conjunction with nicotine. However, much of the data on related topics were inconclusive
[3, 4, 7–11].
Some studies have shown African Americans to be more nicotine-dependent than White smokers
[12–15]. African Americans have lower cessation rates even after accounting for socioeconomic and demographic factors
. One study found that African Americans are more likely than Whites to report both strong motivation to quit and unsuccessful quit attempts in the past year
, suggesting that they experience more difficulty quitting. This study also found that African Americans are more likely to smoke their first cigarette within ten minutes of waking up, indicating greater tobacco dependence. Finally, despite lighter smoking patterns, African Americans have higher blood serum levels of cotinine, a nicotine metabolite that serves as an indicator of nicotine exposure and dependence
[13, 17–19]. Research specifically on cigarette mentholation and tobacco dependence, independent of race, is limited and has generated mixed results. To better understand the relationship between tobacco use and dependence, other measures in addition to CPD, such as time to first cigarette, number and length of previous quit attempts, and salivary or blood biomarkers, need to be assessed
When gender is considered as a factor, the data on menthol cigarettes, dependence, and morbidity becomes even less clear, as women smokers in the US are more likely than male smokers to choose menthol
[2, 3, 21]. Further research examining the relationship between salivary cotinine levels and CPD among African Americans, Whites, men and women has shown differences between the races and genders. Kinnunen and colleagues found a positive correlation between salivary cotinine levels and CPD among men and women, both African American and White, but this relationship was restricted to non-menthol smokers. Among menthol smokers, there was only a significant positive correlation between salivary cotinine and CPD for White men. Thus, menthol may have a differential effect on smokers depending on their race and gender
Research around tobacco use and dependence is important because tobacco-attributable illnesses account for approximately 440,000 deaths in the United States
 and 5.4 million deaths worldwide each year
. Tobacco use is the leading preventable cause of morbidity and mortality. In the United States, African Americans bear a disproportionate burden of smoking-related illnesses. It has been speculated that cigarette mentholation may increase health risks by enhancing tobacco dependence in menthol smokers
[15, 24–26]. Even though African Americans smoke fewer cigarettes per day than Whites, they have higher rates of tobacco-related cancers, heart disease, and stroke
[14, 27, 28] and may be more nicotine-dependent
[12–15]. Alternatively, menthol may affect the metabolism of nicotine and other cigarette smoke constituents, thus altering smoking habits or the toxicity of cigarette compounds
. Although menthol itself may be broken down into harmful products during combustion
[29–31], one review of the scientific literature concluded that cigarette mentholation confers only limited toxicological effects that do not increase smoking-related health risks
. A systematic review regarding lung cancer found that among African American male smokers, lung cancer could not be attributed to menthol cigarettes
. In contrast, another review suggested that cardiovascular health outcomes may be worse for those smoking menthol cigarettes
. More specific examination of menthol and its effects among women and their health issues is warranted.
The aim of this study was to determine whether women menthol smokers have higher tobacco dependence than women non-menthol smokers, while accounting for the influence of White and African American race.