Perceptions of Use Patterns and Health Consequences Associated With Mentholated Cigarettes Among U.S. Adults

Abstract

Despite declines in overall cigarette smoking in the United States, menthol cigarette smoking prevalence has increased among young adults (18-25 years) and remains constant among older adults (26 years and older). Disparities in menthol cigarette use exist, with higher prevalence among younger adult smokers and among racial/ethnic minority populations. Menthol in cigarettes has been shown to play a role in increasing smoking initiation and making it more difficult to quit smoking. Little research focuses on perceptions of the addictive potential and health consequences of menthol cigarette use. This analysis uses data from a national panel of U.S. adults (n = 1,303) surveyed in 2016. Participants were asked to what extent they agreed with various statements regarding menthol use among demographic and tobacco use subgroups. These data reveal disparities in perceptions of the impact of menthol use, with Black, non-Hispanic, and Hispanic adults and adults with lower income and less education misperceiving the health effects and addiction potential of menthol in cigarettes. Determining how and to what extent population subgroups understand the effect of menthol cigarette use can inform public education strategies and, in turn, policy efforts to ban or restrict menthol cigarette availability.

Keywords

cigarettes health disparities menthol tobacco control

Findings from this study reveal disparities in perceptions of the impact of menthol use and can inform public education strategies and policy efforts to ban or restrict menthol cigarette availability.

Despite declines in overall cigarette smoking in the United States, menthol cigarette smoking prevalence has increased. From 2004 to 2014, past 30-day nonmenthol cigarette smoking among U.S. young adults (18-25 years) declined from 26.9% to 14.0%, while menthol cigarette smoking among young adults increased from 12.9% to 14.8% (Villanti et al., 2016). Similar trends were seen over the same time frame among adults 26 years and older but at a much lower rate (nonmenthol: 4% decline; menthol: 0.7% increase; Villanti et al., 2016). Menthol cigarette smoking surpassed nonmenthol cigarette smoking in 2008-2009 among U.S. youth and in 2013-2014 among young adults (Villanti et al., 2016). About 60% of current smoking youth smoked menthol cigarettes in 2013-2014, compared to just over a third of current cigarette smoking U.S. adults (Villanti, Johnson, et al., 2017). Additionally, in a recent study of U.S. adult smokers, Black adults were 22 times more likely to smoke a menthol versus nonmenthol cigarette brand (Cohn, Rose, Ilakkuvan, et al., 2019).

Menthol cigarettes may continue to be a popular product among smokers since menthol is the only characterizing flavor in cigarettes not banned at the federal level (U.S. Food & Drug Administration [FDA], 2018a). The FDA (2018b, 2018c) has issued an advance notice of proposed rulemaking to address the role of flavors in tobacco use and has specifically announced proposals to ban menthol in cigarettes. However, the timing of these policy changes remains uncertain, and menthol remains on the market despite public support for a menthol ban (Rath et al., 2018). Given these delays, states and localities are taking action to ban menthol cigarette sales at the local level ahead of federal actions. The Tobacco Products Scientific Advisory Committee (TPSAC) in 2011 published a report that concluded that menthol in cigarettes likely increases initiation and tobacco dependence, increases progression to regular cigarette smoking, and decreases success in smoking cessation, especially among Black menthol smokers.

A more recent systematic review conducted by Villanti, Collins, Niaura, Gagosian, and Abrams (2017) found additional evidence to support the TPSAC’s conclusions regarding increased difficulty in quitting menthol cigarettes. A mixture of cross-sectional, cohort, and randomized controlled studies included in this review demonstrated that menthol smokers were less successful in quitting than nonmenthol smokers despite increased quit attempts or intentions to quit (Villanti, Collins, et al., 2017). Among both youth and adults, numerous studies in the systematic review demonstrated significantly higher endorsement of dependence symptoms among menthol smokers compared with nonmenthol smokers (Kasza et al., 2014; Villanti, Collins, et al., 2017; Wackowski & Delnevo, 2007). In addition, a 3-year longitudinal study of youth showed that those who initiated with menthol cigarettes were more likely to progress to established smoking (≥100 cigarettes lifetime and smoked 20-30 days in the past 30 days) compared with those who initiated with nonmenthol cigarettes (Nonnemaker et al., 2013; Villanti, Collins, et al., 2017).

Two cross-sectional studies from the Villanti, Collins, et al. (2017) review demonstrated the particular vulnerability and prevalence of menthol use among Black smokers: One study of adult daily smokers found that nearly 80% of Black smokers smoked menthol cigarettes, the highest prevalence across racial/ethnic groups; the other found that Black youth, who smoke at lower rates than White youth, reported higher cigarette consumption than their White counterparts when the cigarettes contained menthol (Muilenburg & Legge, 2008; Villanti, Collins, et al., 2017). In addition, almost half (47%) of adult Hispanic smokers during 2012 to 2014 in the United States smoked menthol (Villanti et al., 2016). Historically, tobacco industry documents reveal that tobacco companies developed and marketed their menthol products primarily to youth and Blacks, as well as to Hispanics (Landrine et al., 2005). Strategies included price promotions (Mills et al., 2018) and tailored marketing toward Black and youth culture (Cruz, Wright, & Crawford, 2010; Rising & Alexander, 2011). These documents also revealed that youth were a purposeful target for menthol products because menthol’s flavor facilitates trial and initiation of smoking (Klausner, 2011). A systematic review suggested that the influence of preexisting culturally based beliefs (e.g., the medicinal effects of menthol) along with targeted marketing interacted to produce almost universal (85%) menthol cigarette use among Black smokers that still exists today (Castro, 2004; Villanti et al., 2016).

Marketing by tobacco companies shapes public perception of the harms of menthol, which in turn could affect menthol smoking behavior. Longitudinal studies suggest that low perceived harm and addictiveness of various tobacco products are associated with subsequent initiation of those products (Brose, Brown, Hitchman, & McNeill, 2015; Cooper, Loukas, Case, Marti, & Perry, 2018; Parker et al., 2018). Misperception that menthol cigarettes are less harmful than regular cigarettes may lead to menthol cigarette smoking (Anderson, 2011; Sutton & Robinson, 2004). For example, youth menthol cigarette smokers in the Population Assessment of Tobacco and Health study believed that menthol was easier to smoke than nonmenthol (Cohn, Rose, D’Silva, & Villanti, 2019). This is consistent with the Risk Perception Attitude framework, which posits that low perceived risk of a behavior results in continuing that behavior (Rimal & Real, 2003).

However, research on public perception of the harm of menthol cigarettes is mixed, among not only nonsmokers and nonmenthol smokers but also menthol smokers themselves. While some findings suggest that the groups most likely to use menthol are aware of the associated harms of menthol smoking, other studies report that menthol users are not aware of the associated harms. Focus groups of New Jersey youth in 2015 revealed that many believed that menthol cigarettes were more harmful than nonmenthol cigarettes (Wackowski et al., 2018), primarily because they were believed to contain more additives, and among New Jersey adults in 2005, Blacks and young adults were more likely to believe that menthol cigarettes are riskier than nonmenthol cigarettes compared with White respondents and older adults (Wackowski, Delnevo, & Lewis, 2010). Baseline data (2013/2014) from the Population Assessment of Tobacco and Health study showed that adult menthol smokers were more likely than nonmenthol smokers to believe that their preferred brand was more harmful than other brands (Cohn, Rose, Ilakkuvan, et al., 2019).

Rath et al. (2018) studied how menthol-related perceptions are associated with support for a menthol ban among current smokers. They found that current menthol smokers were significantly less knowledgeable about the health effects of menthol products than nonmenthol smokers and that more accurate health-related perceptions about menthol in cigarettes were associated with increased odds of supporting a national menthol ban among menthol smokers. Another study of a large national sample of U.S. adults found that support for a menthol ban was significantly lower for smokers compared with nonsmokers (Rose et al., 2015). However, these studies did not examine how differences in perceptions of menthol may vary by demographic factors. In addition, published studies have not examined perceptions related to the addiction potential of menthol. Understanding how different demographic subgroups of people perceive the addiction potential and the health impact of menthol cigarettes can help inform counter-tobacco public education and policy efforts to dispel myths or misperceptions that may exist. Therefore, the purpose of this study was to explore perceptions regarding how menthol cigarettes may affect health and addiction among a national sample of U.S. adults.

Method

Sample

Data used for this study were collected from the NORC (formerly National Opinion Research Center) AmeriSpeak® address-based panel. The U.S. national cross-sectional survey was conducted among adults aged 18 years and older, including an oversample of 300 Black participants. Data collection took place both online and via telephone (for those with limited Internet access) from June 21, 2016, through July 18, 2016. A total of 1,303 respondents completed the survey, resulting in a study completion rate of 38%. This rate is comparable to other studies using the AmeriSpeak panel (Bye, Ghirardelli, & Fontes, 2016). Study protocols were reviewed and approved for human participant research by the Chesapeake Institutional Review Board (now Advarra).

Measures

Menthol Knowledge and Perceptions

Knowledge and perceptions of menthol use disparities (Table 1) were measured using seven items drawn from the FDA’s TPSAC (2011) report. Participants were asked to rate their agreement with the items on a scale from 1 to 4, with 1 indicating strongly disagree and 4 indicating strongly agree. A “don’t know” response was an option for each statement. Based on previous analyses with these data (Rath et al., 2018), the seven items were combined to create two separate scales: health effects (five items, α = .83) and addiction (two items, α = .80). Two mean scale scores were created for each participant, one for their mean scores on the health effects scale and the other for their mean score on the addiction scale, which includes all items on that scale (either 5 or 7) excluding “don’t know” responses. These created a continuous measure, with higher scores indicating more correct knowledge (Table 1) across items. A “don’t know” index was created for each participant as the count of “don’t know” responses to the seven items (range 0-7). Supplementary analyses of individual items did not show differences by age or race/ethnicity.

Table 1.

Health Effects and Addiction Scale Items and Correct Responses.

Item no.	Health effects scale	Correct response
1	Menthol cigarettes make it easier to quit smoking, especially among African Americans.	Disagree or strongly disagree
2	There are health benefits of menthol cigarettes compared with nonmenthol cigarettes.	Disagree or strongly disagree
3	Menthol cigarettes are healthier than nonmenthol cigarettes.	Disagree or strongly disagree
4	Menthol cigarettes are more natural than nonmenthol cigarettes.	Disagree or strongly disagree
5	Menthol cigarettes contain less nicotine than nonmenthol cigarettes.	Disagree or strongly disagree
	Addiction scale	Correct response
6	Menthol in cigarettes is linked to becoming a regular smoker.	Agree or strongly agree
7	Youth smoking menthol cigarettes are more likely to become addicted to smoking.	Agree or strongly agree

Covariates

Demographic variables included respondents’ age (18-24 years, 25-44 years, 45-64 years, 65 years and older), gender (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic “other” race), educational attainment (less than high school, high school, some college, bachelor’s degree or higher), and income (<$25,000, $25,000-$49,999, $50,000-$99,999, ≥$100,000).

Cigarette smoking status was derived from the following items: “Have you ever smoked at least 100 cigarettes in your entire life?” and if “yes,” “Do you now smoke cigarettes every day, some days, or not at all?” Those who replied “no” to the first item were defined as never smokers, whereas those who reported smoking “every day” or “some days” were defined as current smokers, and those who reported smoking “not at all” (but met the 100 cigarette lifetime threshold) were defined as former smokers. Those who reported “yes” to “Are menthol cigarettes the product you have always used?” were defined as always users of menthol cigarettes.

Analyses

Of the full sample of 1,303 observations, four were omitted from the analysis for missing at least one covariate (n = 1,299). If participants responded “don’t know” to all items on a scale, they were excluded from analyses for the respective scale. These scale-specific exclusions resulted in three analytic samples: the health scale sample (n = 1,009), the addiction scale sample (n = 884), and the don’t know index sample (n = 1,299). Multivariable linear regression analyses were conducted separately for health effects, addiction, and don’t know indices to examine the relationship between demographic and smoking characteristics and menthol cigarette knowledge and perceptions. The relationship between each index and smoking status together with menthol use among current and former smokers, adjusting for all other demographic variables, was also examined. Models used poststratification weights to generalize to the national adult population. All analyses were performed using Stata 15.1.

Results

Table 2 presents unweighted frequencies and weighted percentages of demographic variables, smoking behavior, and the three outcome scales in the full analytic sample. Overall, participants were evenly distributed across the four age categories, and a little more than half were female. The majority of the sample identified as non-Hispanic White, followed by Hispanic, non-Hispanic Black, and non-Hispanic “other” race. Less than a quarter of the sample did not graduate high school (11%), and each of the remaining three education categories constituted about 30% of the sample. The sample was relatively evenly split across the household income categories. About half of the respondents are never smokers, 26% are current smokers, and 20% are former smokers. About 25% of current and former smokers currently always use or have always used menthol cigarettes.

Table 2.

Sample Characteristics for Each Analytic Sample.

Covariates	Full sample, n (weighted %), N = 1,299
Age, years
18-24	238 (21.3)
25-44	317 (25.3)
45-64	380 (26.3)
≥65	364 (27.2)
Sex
Male	574 (48.4)
Female	725 (51.6)
Race/ethnicity
White, non-Hispanic	700 (64.4)
Black, non-Hispanic	405 (11.8)
Hispanic	110 (15.8)
Other, non-Hispanic	84 (8.0)
Education
<High school	124 (11.4)
High school diploma/GED	346 (29.0)
Some college	421 (29.0)
≥Bachelor’s degree	408 (30.7)
Income, $
<25,000	349 (22.2)
25,000-49,999	364 (28.2)
50,000-99,999	361 (28.8)
100,000+	225 (20.8)
Smoker status
Never	721 (53.6)
Former	262 (20.2)
Current	316 (26.1)
Always smoked menthol cigarettes
No	338 (75.8)
Yes	157 (24.2)
Always smoked menthol by smoking status
Former/nonmenthol	194 (43.2)
Current/nonmenthol	143 (32.5)
Former/menthol	73 (12.4)
Current/menthol	84 (11.9)
Outcomes
Health effects scale (n = 1,009)
M (SE)	3.31 (0.02)
Addiction scale (n = 884)
M (SE)	2.75 (0.04)
Don’t know scale (n = 1,229)
M (SE)	2.89 (0.09)

Figure 1 presents the distribution of responses for the largest analytic sample (“don’t know” index sample). Among those who responded with something other than “don’t know,” the majority selected the correct response for that statement (all z statistics > 1.96, p < .05). Item 3 (“Menthol cigarettes are healthier than nonmenthol cigarettes”) yielded the largest percentage of correct responses (about 95%), and Item 6 (“Menthol in cigarettes is linked to becoming a regular smoker”) yielded the smallest percentage of correct answers (about 60%). Item 1 (“Menthol cigarettes make it easier to quit smoking especially among African Americans”) yielded the largest proportion of “don’t know” responses (about 55%). The averages for each outcome index were as follows: health effects (M = 3.31, SE = 0.02); addiction (M = 2.25, SE = 0.04); and the don’t know index (M = 2.89, SE = 0.09; Table 2).

Figure 1.

Overall prevalence of menthol perceptions/knowledge (N = 1,299).

There were disparities by demographic variables and tobacco use characteristics among those who misperceived or did not know how to respond to the statements. Table 3 presents results from linear regression analyses examining the association between health effects and addiction perceptions and demographic variables among all adults in the sample. Table 4 presents additional results among only current/former smokers.

Table 3.

The Association Between Health Effects and Addiction Indices and Demographic Variables.

Covariates	Health effects scale, N = 1,009, $\hat{β}$ [95% CI]	Addiction scale, N = 884, $\hat{β}$ [95% CI]	Don’t know index, N = 1,299, $\hat{β}$ [95% CI]
Age, years
18-24	0.17** [0.04, 0.29]	0.07 [−0.12, 0.26]	−0.10 [−0.59,0.40]
25-44	0.28*** [0.16, 0.40]	−0.22* [−0.42, −0.01]	0.01 [−0.46,0.48]
45-64	0.25*** [0.14, 0.35]	−0.01 ([−0.19, 0.18]	−0.21 [−0.65, 0.24]
≥65	Reference	Reference	Reference
Sex
Male	Reference	Reference	Reference
Female	0.01 [−0.08, 0.09]	0.03 [−0.11, 0.18]	0.06 [−0.27, 0.38]
Race/ethnicity
White, non-Hispanic	Reference	Reference	Reference
Black/African American, non-Hispanic	−0.34*** [−0.44, 0.24]	0.23** [0.08, 0.38]	−0.69*** [−1.06, −0.32]
Hispanic	−0.22** [−0.38, −0.06]	−0.05 [−0.28, 0.18]	−0.13 [−0.65, 0.39]
Other non-Hispanic	−0.08 [−0.22, 0.05]	0.29* [0.04, 0.54]	−0.77** [−1.33, −0.21]
Education
<High school	−0.18* [−0.33, −0.04]	−0.13 [−0.37, 0.11]	0.54 [−1.12, 0.05]
High school diploma/GED	−0.11 [−0.24, 0.01]	−0.13 [−0.32, 0.07]	−0.03 [−0.51, 0.44]
Some college	0.04 [−0.07, 0.15]	−0.10 [−0.29, 0.09]	0.21 [−0.22, 0.64]
≥Bachelor’s degree	Reference	Reference	Reference
Income, $
<25,000	−0.06 [−0.21, 0.08]	0.10 [−0.12, 0.32]	−0.94** [−1.52, −0.36]
25,000-49,999	−0.03 [−0.17, 0.10]	−0.07 [−0.29, 0.15]	−0.59* [−1.12, −0.06]
50,000-99,999	−0.00 [−0.13, 0.12]	0.04 [−0.19, 0.27]	−0.28 [−0.78, 0.22]
100,000+	Reference	Reference	Reference
Smoker status
Never	Reference	Reference	Reference
Former	0.15** [0.04, 0.25]	−0.37*** [−0.56, −0.18]	−1.55*** [−1.95, −1.14]
Current	0.18*** [0.08, 0.28]	−0.42*** [−0.60, −0.23]	−1.28*** [−1.69, −0.87]

Note. F test of overall significance: bold formatting indicates p < .05.

t-test significance: *p < .05. **p < .01. ***p < .001.

Table 4.

Association Between Health Effects and Addiction Indices and Menthol Smoking Among Current/Former Smokers^a (N = 578).

Always smoked menthol by smoking status	Health effects index, N = 450, $\hat{β}$ [95% CI]	Addiction index, N = 382, $\hat{β}$ [95% CI]	Don’t know index, N = 494, $\hat{β}$ [95% CI]
Former/nonmenthol	—	—
Current/nonmenthol	−0.06 [−0.19, 0.07]	0.15 [−0.12, 0.43]	−0.15 [−0.78, 0.47]
Former/menthol	−0.07 [−0.26, 0.12]	0.31 [−0.05, 0.67]	−0.19 [−0.94, 0.57]
Current/menthol	−0.18 [−0.39, 0.03]	0.26 [−0.12, 0.64]	−0.15 [−0.86, 0.56]

Adjusted for age, gender, race/ethnicity, education, and income.

t-test significance: *p < .05. **p < .01. ***p < .001.

Health Effects

Several significant factors were associated with level of accuracy on the health effects of menthol scale (Table 3). Adults younger than 65 years scored on average higher on the scale than adults 65 years or older, indicating greater knowledge about menthol (p < .01). Former ( $\hat{β}$ = 0.15, p < .01) and current smokers ( $\hat{β}$ = 0.18, p < .001) were also more knowledgeable about the health effects of menthol compared with never smokers. Compared with White respondents, Black ( $\hat{β}$ = −0.34, p < .001) and Hispanic ( $\hat{β}$ = −0.22, p < .01) adults scored lower on the health effects scale, indicating more misperceptions of menthol’s health effects. Compared to adults with a bachelor’s degree, those who did not complete high school were less knowledgeable about health effects of menthol ( $\hat{β}$ = −0.18, p < .05).

Addiction

Race/ethnicity and smoking status were significantly associated with scores on the addiction scale (Table 3). Non-Hispanic Black ( $\hat{β}$ = 0.23, p < .01) and other non-Hispanic adults ( $\hat{β}$ = 0.29, p < .05) were significantly more knowledgeable about addiction potential of menthol than non-Hispanic White adults. Current ( $\hat{β}$ = −0.42, p < .001) and former smokers ( $\hat{β}$ = −0.37, p < .01) were less knowledgeable about addiction compared with never smokers. In addition, adults ages 25 to 44 years scored lower ( $\hat{β}$ = −0.22, p < .05) on the scale compared with those ages 65 years and older, but age overall was not a significant predictor of menthol addiction knowledge.

Don’t Know

Race/ethnicity, smoking status, and income were significantly associated with scores on the “don’t know” index (Table 3). Compared with non-Hispanic White adults, non-Hispanic Black ( $\hat{β}$ = −0.69, p < .001) and other non-Hispanic adults ( $\hat{β}$ = -0.77, p<0.01) had lower mean scores on the don’t know index, indicating more certainty, that is, they more often agreed or disagreed with statements about menthol rather than not giving an opinion. Former and current smokers also scored on average significantly lower compared to never smokers on the don’t know index (p < .001). The model estimated significantly lower mean scores on the scale for adults making <$50,000 per year compared with those making $100,000 or more (p < .05).

Subgroup Analysis

A subanalysis among only current and former smoking adults (Table 4) found that menthol use together with smoking status was not significantly associated with the health effects, addiction, or don’t know indices.

Discussion

The goal of this study was to examine demographic variations in perceptions related to the health and addiction effects of mentholated cigarette use among a national sample of adults in the United States. Much of the prior research on perceptions of menthol has been solely examined differences between menthol or nonmenthol smokers (Cohn, Rose, Ilakkuvan, et al., 2019; Rath et al., 2018). However, given that tobacco industry advertising has been historically targeted to youth and Black audiences, which have high prevalence rates of menthol cigarette smoking, it is important to specifically understand their perceptions of the effects of menthol so that appropriate education and community-based and policy interventions can be implemented.

A large proportion of adults in this sample did not know if they agreed with many statements about menthol cigarette use. This finding indicates a lack of knowledge and understanding in the general population about the relative effects of these products compared with nonmenthol cigarettes. While menthol cigarettes are still available on the market, it is important that public education efforts aim to provide clarity about the impact of menthol on patterns of use and subsequent harm exposure. However, current smokers not only were more certain about menthol (reported fewer don’t know responses) but also had fewer misperceptions about the health effects of menthol (reported fewer incorrect responses). As smokers, they may be more attentive to information about the products they use and about the types of tobacco products available compared to people who have never smoked cigarettes (Pfeffer, Wigginton, Gartner, & Morphett, 2018). However, smokers in this study were less knowledgeable about the addiction potential of menthol. In addition, among current and former smokers, menthol smoking status was not related to any of the indices. Since this subgroup was relatively small, these findings suggest that more research is needed to understand the nuances of these perceptions.

In contrast to other findings that demonstrate that cigarette smokers are aware of menthol’s harmful consequences, this study found that misperceptions are still prevalent, particularly among some subgroups including among racial/ethnic minority adults. Non-Hispanic Black and Hispanic respondents were less knowledgeable about the health effects of menthol product use and yet, based on their fewer “don’t know” responses, were more confident in these perceptions. This finding is in contrast to research that suggests that “don’t know” responses are more common among racial/ethnic minorities (Waters, Hay, Orom, Kiviniemi, & Drake, 2013). However, because we assessed perceptions of a product that has been marketed directly to Blacks and Hispanics (as opposed to perceived risk of cancer), this finding could indicate that Black and Hispanic respondents “know” the harm of menthol smoking, but their perceived knowledge is a result of incorrect information conveyed by tobacco companies. This finding implies that the effects of the historic targeted marketing of menthol products to Blacks and Hispanics persists (Landrine et al., 2005; Lee, Henriksen, Rose, Moreland-Russell, & Ribisl, 2015). This may also reflect more normative acceptance of menthol cigarettes given the higher prevalence rates among these subgroups. Nonetheless, non-Hispanic Black adults were more knowledgeable about the addictive nature of menthol cigarettes as compared to non-Hispanic White adults. As a previous study has noted, given that the vast majority of Black smokers smoke menthol cigarettes, it is not possible to determine whether the participants distinguished between menthol and nonmenthol cigarettes when taking the survey but rather responded about cigarettes in general (Cohn, Rose, Ilakkuvan, et al., 2019).

Younger and middle-aged adults were more knowledgeable about the health effects of menthol, which is consistent with some evidence, including qualitative research showing that young adults perceived menthol cigarettes to be at least equally as harmful as nonmenthol cigarettes (Wackowski et al., 2018). This finding may be due to more recent attempts to dispel myths about menthol (National Association for the Advancement of Colored People, 2019). It could also relate to younger adults being more proactive about finding information about menthol on the Internet (Wartella, Rideout, Zupancic, Beaudoin-Ryan, & Lauricella, 2015).

Despite the study’s strengths, there are several limitations. First, there is the potential in this study for nonresponse bias or measurement error. However, when the sample demographics were compared with nationwide averages, differences were found to be small (0% to 3.6% for age, race, and sex; Rath et al., 2018). Second, the addition of a small telephone data collection subsample to the primary sample where data were collected online may have resulted in some mode differences. Responses relied on self-reported data, and there may have been differences in how questions were interpreted. Third, youth and sexual minorities are also targeted by the tobacco industry and have higher prevalence of menthol cigarette smoking (Fallin, Goodin, Lee, & Bennett, 2015; Kreslake, Wayne, Alpert, Koh, & Connolly, 2008), but this survey focused on adults and did not measure sexual orientation, so perceptions of menthol among these vulnerable groups should be examined in future studies. Last, this study did not assess the reasons why there are disparities in menthol cigarette perceptions, so more research is needed to examine whether marketing exposure, social norms regarding menthol cigarettes, or another reason predicts incorrect menthol cigarette perceptions.

This study provides further evidence that disparities exist related to the misperceptions of the health and addiction effects of menthol, with adults with lower levels of education as well as Black and Hispanic adults misperceiving the impact of menthol use. Unfortunately, these subpopulations are also at highest risk of menthol use. Findings from the current study can inform targeted messaging to these subpopulations to correct their misperceptions, such as revealing tobacco industry advertising practices or communicating that menthol could be making it harder for smokers to quit (Lewandowsky, Ecker, Seifert, Schwarz, & Cook, 2012). According to the Risk Perception Attitude framework, behavior change cannot occur unless risk perceptions are corrected and efficacy is increased, so messaging should also use evidence-based strategies to increase efficacy in order to avoid menthol cigarettes (Rimal & Real, 2003). In addition, recent efforts by localities in the United States to ban the sales of menthol cigarettes in their jurisdiction can help to reduce tobacco use among these vulnerable groups who are most at risk of menthol use (Innocent, 2018; Rose et al., 2020). Modeling studies indicate that banning menthol in 2011 would have saved over half a million lives by 2050, with 37% of those among Blacks (Levy et al., 2011). Differences in the awareness of the impact of menthol use can inform the implementation of antitobacco public education campaigns and policy approaches in an effort to reduce the deadly toll of menthol cigarettes within some of our most vulnerable communities.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was internally funded by Truth Initiative.

ORCID iD

Allison M. Glasser

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