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REVIEWOpenAccessMentholandinitiationofcigarettesmokingJoshuaRising1*,KristinaWasson-Blader2AbstractTheuseoftobaccoproductswouldnotcontinuewithouttheinitiationoftheirusebyyouthandadults.
Sincethevastmajorityofcigarettesmokersbeginsmokingbyage25,understandingtheroleofmentholcigarettesintheinitiationofsmokinginyouth(undertheageof18)andyoungadults(aged18–25)isespeciallyrelevant.
Datademonstratethatmentholcigarettesaredisproportionatelyusedbyyouthandyoungadults.
Thisreviewseekstoexaminewhatrole,ifany,mentholplaysintheinitiationofcigarettesmoking.
Overall,thereisapaucityofdataonthistopic.
Thedatathatdoexistsuggeststhatyouthwhohavesmokedforlessthan1yeararemorelikelytosmokementholcigarettesthanyouthwhohavesmokedformorethan1year.
Alackofdatapreventsfurtherconclusionsontheroleofmentholcigarettesintheinitiationofsmoking.
ReviewIntroductionInitiationofcigarettesmokingintheUnitedStateshascontinuedatahighrate.
Accordingtoa2008reportfromtheSubstanceAbuseandMentalHealthAdminis-tration,around4,000youthtrytheirfirstcigaretteeachday[1]andapproximately1,000youthbecomedailysmokers.
[2]Additionally,2,800youngadultstrytheirfirstcigaretteeachday.
[1]Otherdatahavealsodemon-stratedhighratesofsmokinginitiationamongyouthandyoungadults.
AreportfromtheSurgeonGeneralin1994[3]revieweddatafromtheNationalHouseholdSurveysonDrugAbuse,whichsurveyedpersonsaged30–39abouttheirrecollectionsoftheageoffirstcigar-etteandfirstregularsmoking,andfoundthat62.
2%ofpersonswhohadeversmokeddailytriedtheirfirstcigarettebeforetheageof16.
Inaddition,morethanhalfofthosewhoeversmokeddailybegansmokingdailybeforetheageof18[3].
Astudythatusedaggre-gateddatafromthe1990sexaminedtheageatsmokinginitiationasrecalledbyindividualsaged26–50years;thisstudyrevealedsignificantracial/ethnicdisparities[4].
TheauthorsfoundthatthemajorityofWhiteandLatinosmokersbegansmokingbytheageof18,whilethemajorityofBlack/AfricanAmericanandAsian/Paci-ficIslandersmokersbegansmokingbetweentheagesof18and25.
Whilethesereportsdonotdistinguishbetweenmentholandnon-mentholcigarettesmokers,theydoprovidedatathatdemonstratethatthemajorityofsmokersbeginsmokingasyouthandyoungadults.
Despiteacknowledgementoftheimportanceofunder-standingwhyindividualsinitiatecigarettesmoking,thereislimitedliteratureontheimpactofmentholontheinitiationofcigarettesmoking.
Thisarticlereviewstheavailableliteratureonmentholandtheinitiationofcigarettesmokingandexploresthefollowingquestions:Domentholcigarettesmokersstartsmokingearlierinlifethannon-mentholcigarettesmokersDoesthisvarybyrace/ethnicityIsthereahigheruseofmentholcigarettesamongrecentinitiations(e.
g.
,youthwhohavebeensmokingforlessthan1year)Doesthisvarybyageorrace/ethnicityDoesthesmokingofmentholcigarettesalterpro-gressionfromfirstcigarette(s)towardbecomingaregu-larsmokerDidcurrentsmokersinitiatesmokingwithmentholcigarettesandthenswitchtonon-mentholcigarettesWhatinformationdopublishedreportsonpubliclyavailableinternaltobaccoindustrydocumentscontainonthistopicSummarizedinthisrevieware10articlesfoundtohaveeitherdirectrelevancetothesequestions,orwereusedtoproviderelevantbackgroundinformation.
ManyofthesearticleswereidentifiedthroughareviewoftheliteratureconductedbytheNationalCancerInstitutein2009,publishedas"Bibliographyofliteratureonmentholandtobacco"(http://cancercontrol.
cancer.
gov/*Correspondence:Joahua.
Rising@fda.
hhs.
gov1CenterforTobaccoProducts,U.
S.
FoodandDrugAdministration,Rockville,MD,USAFulllistofauthorinformationisavailableattheendofthearticleRisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S42011RisingandWasson-Blader;licenseeBioMedCentralLtd.
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
tcrb/documents/menthol_bibliography_508.
pdf).
Searchtermsusedwerementholcigarette(s);mentholatedcigarette(s);mentholtobacco;mentholatedtobacco;mentholsmoker(s);mentholANDthefollowingterms:addiction,nicotine,marketing,cancer,biomarkers,asthma,cardiovasculardisease,heartdisease,vasculardisease,chronicobstructivelungdisease,respiratory,environmentaltobaccosmoke,nationalhealth,healthdisparities,andminorityhealth.
Additionalsearchesandsources,suchasthoseidentifiedthroughreviewarticles,identifiedadditionalarticlesthatwereincludedasappropriate.
OfthosearticlesthatareintheNCIBibliographybutwerenotincluded,mostwerenotdirectlyrelevanttothistopic(e.
g.
,theystudiedmentholasachemicalinde-pendentfromtobaccosmokeexposure,didnotevaluatementholasaseparatevariable).
Someofthosearticles,however,wereusedtoprovidebackgroundinformation.
Animalorinvitroresearchwasincludedonlytohelpexplainhumanfindings.
Althoughafewreviewarticleswereusedtomakegeneralstatementsand/orprovidebackgroundinformation,mostwerenotincludedindeferencetooriginalsources.
Publishedabstractswerenotincludedoutofconcernthat,duetothelackofdetails,thosestudiescouldnotadequatelybeassessed.
NewyouthandyoungadultsmokersAstudybyHerseyetal[5]examineddatafromthe2002NationalYouthTobaccoSurveyregardingthedurationofsmokingandmentholcigaretteuse.
Middleschoolstudents(grades6–8)whohadbeensmokinglessthan1yearweresignificantlymorelikelytosmokementholcigarettesthanweremiddleschoolstudentswhohadbeensmokingmorethan1year(62.
4%vs.
53.
3%,p=1YearNationalSurveyonDrugUse&HealthSubstanceAbuseandMentalHealthServicesAdministrationFigure1Mentholcigaretteusebynewsmokers(age:12-21).
RisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S4Page2of4dizziness,relaxation,irritation)tothefirstcigarette[9].
Nostudiesexaminedwhethertheearlyuseofmentholcigarettesaffectedanindividual'strajectorytoregularsmoking.
Switchingbetweenmentholandnon-mentholcigarettesNostudieswereidentifiedthatdirectlyaddressedwhethercurrentsmokersstartedsmokingwithmentholcigarettesandthenswitchedtonon-mentholcigarettes.
A1989study,however,examinedtheswitchingbeha-viorof29,037currentsmokerswhoattendedtheKaiserPermanenteMedicalCareProgrambetween1979and1986.
Studyparticipantswerefollowedforameanof4.
5years[10].
Ofthe1,688Black/AfricanAmericansmo-kersundertheageof40forwhomfollow-updatawereavailable,thepercentageofthosewhoswitchedfromnon-mentholcigarettestomentholcigarettes(14.
6%)wasmuchhigherthanthepercentageofmentholcigar-ettesmokerswhoswitchedtonon-mentholcigarettes(3.
6%).
Usingaproportionalhazardsmodeladjustingforageandsex,theresearchersfoundthatnon-mentholcigarettesmokerswere4.
2timesmorelikelytoswitchtomentholcigarettesthanformentholcigarettesmo-kerstoswitchtonon-mentholcigarettes.
Oneotherstudydescribedswitchingbehavior.
Pletcheretal[8]foundnodifferenceinthepercentageofyoungadultsmokerswhohadswitchedtypesofpro-ductsatthe15-yearfollow-upintheCARDIAstudy;12%ofthosewhooriginallypreferredmentholcigaretteshadswitchedtonon-mentholcigarettes,and11%ofthosewhooriginallypreferrednon-mentholcigaretteshadswitchedtomentholcigarettes.
ResearchonpubliclyavailableinternaltobaccoindustrydocumentsonmentholandinitiationTworeviewsofinternaltobaccocompanydocumentsonthetopicofmentholcigaretteswereperformedbyKre-slakeetal[11,12].
Theauthorsciteatobaccocompanydocumentthatfoundabenefittoincludingmentholincigarettesinordertomakethesmokingexperiencemorepalatableforinexperiencedsmokers.
"First-timesmokerreactionisgenerallynegative…Initialnegativescanbealleviatedwithalowlevelofmenthol"[12].
Theyalsofoundavailabledocumentationthattobaccocompa-nieswereawarethatnewersmokerspreferredmentholcigaretteswithalowerlevelofmentholthanestablishedsmokers.
AccordingtoKreslakeetal,"theauthorofaninternalBrownandWilliamsonmemoobservedthatKool'smenthollevelmaybeconsideredtoohighfornewsmokers,andthatasuccessful'starter'cigarettewouldneedtoincludealowtobaccotaste,lowimpactandirritation,lowtobaccoaftertasteandlowmentholcontent"[11].
ConclusionsLimiteddataexistregardingtheroleofmentholintheinitiationofsmoking.
Furthermore,therearesignificantlimitationstotheexistingstudies.
Someofthestudiesthatusedretrospectivedataandadultrecollectionsofsmokinginitiationmaynotprovideanaccuraterepre-sentationoftheproductused.
Onlythreestudiesfol-lowedindividualsprospectively,andtwoofthesestudiesbeganfollowingindividualsaftersmokinghadbeeninitiated.
Thethirdofthesestudies[9]hadasmallsam-plesize.
However,Herseyetal[5]specificallyaddressedtheissueofpotentialincompleteknowledgeofmentholsta-tusofcigarettesusedbyyoungersmokers.
Theseresearchersexaminedthedatabasedonseveraldifferentdefinitionsof"mentholcigarettesmoker"andfoundthattheresultsweresimilarregardlessofthedefinition,indicatingthattherateofmisclassificationofmentholstatusofcigarettesbynewuserswaslow[5].
Evenwiththeabovelimitations,however,theexistingliteraturedoessupportthefollowingconclusions:Thevastmajorityofindividualswhobecomeregularsmokersbeginsmokingasyouthoryoungadults.
Mentholcigarettesarewidelyusedamongyouthwhohavesmokedforlessthanoneyearandareusedlessfrequentlybyyouthwhohavesmokedformorethanoneyear.
Althoughlimiteddataareavailable,thereappearstobenodifferencesinageofinitiationbetweenthosewhostartsmokingwithmentholcigarettesandthosewhostartsmokingwithnon-mentholcigarettes;however,becausethedataareretrospective,theyreflectinitiationrates16-30yearsago,notcurrentpatterns.
Resultsareinconsistentregardingthefrequencyanddirectionofswitchingbetweenmentholandnon-mentholcigarettes.
Nodataexistonwhethermentholcigaretteusealtersthetrajectoryfrominitiatingcigaretteusetoregu-larsmoking.
Reviewsofpubliclyavailableinternaltobaccoindus-trydocumentssuggestanindustryawarenessoftheappealofmentholcigarettestonewersmokers.
AcknowlegdementDisclaimer:ThisarticlereflectstheviewsoftheauthorsandshouldnotbeconstruedtorepresentFDA'sviewsorpolicies.
ThisarticlehasbeenpublishedaspartofTobaccoInducedDiseasesVolume9Supplement1,2011:Mentholatedcigarettesandpublichealth.
PublicationofthissupplementhasbeensupportedbytheCenterforTobaccoProducts,FoodandDrugAdministration.
Thefullcontentsofthesupplementareavailableonlineathttp://www.
tobaccoinduceddiseases.
com/supplements/9/S1Authordetails1CenterforTobaccoProducts,U.
S.
FoodandDrugAdministration,Rockville,MD,USA.
2KWBHealthCommunications,Inc,USA.
RisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S4Page3of4CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Published:23May2011References1.
SubstanceAbuseandMentalHealthAdministration:Resultsfromthe2008NationalSurveyonDrugUseandHealth.
DetailedTablesRockville(MD):OfficeofAppliedStudies;,[accessed2010August9]Availableathttp://oas.
samhsa.
gov/NSDUH/2K8NSDUH/tabs/Sect4peTabs1to4.
pdf.
2.
SubstanceAbuseandMentalHealthAdministration:Resultsfromthe2008NationalSurveyonDrugUseandHealth.
DetailedTablesRockville(MD):OfficeofAppliedStudies;,[accessed2010August9]Availableathttp://oas.
samhsa.
gov/NSDUH/2K8NSDUH/tabs/Sect4peTabs10to11.
pdf.
3.
OfficeoftheSurgeonGeneral:YouthandTobacco:PreventingTobaccoUseamongYoungPeople.
AReportoftheSurgeonGeneral.
Washington,D.
C:USDeptofHealthandHumanServices;1994.
4.
TrinidadDR,GilpinEA,LeeL,etal:DothemajorityofAsian-AmericanandAfrican-AmericansmokersstartasadultsAmericanJournalofPreventiveMedicine2004,26(2):156-158.
5.
HerseyJC,NgSW,NonnemakerJM,etal:ArementholcigarettesastarterproductforyouthNicotineandTobaccoResearch2006,8(3):403-413.
6.
SubstanceAbuseandMentalHealthServicesAdministration,OfficeofAppliedStudies:TheNSDUHReport:UseofMentholCigarettes.
Rockville,MD:OfficeofAppliedStudies;2009.
7.
HymowitzN,CorleD,RoyceJ,etal:Smokers'baselinecharacteristicsinthecommittrial.
PreventiveMedicine1995,24(5):503-508.
8.
PletcherMJ,HulleyBJ,HoustonT,etal:Mentholcigarettes,smokingcessation,atherosclerosis,andpulmonaryfunction:theCoronaryArteryRiskDevelopmentinYoungAdults(CARDIA)study.
ArchivesofInternalMedicine2006,166(17):1915-1922.
9.
DiFranzaJR,SavageauJA,FletcherK,etal:Recollectionsandrepercussionsofthefirstinhaledcigarette.
AddictiveBehaviors2004,29:261-272.
10.
SidneyS,TekawaI,FriedmanGD:Mentholatedcigaretteuseamongmultiphasicexaminees,1979–86.
AmericanJournalofPublicHealth1989,79(10):1415-1416.
11.
KreslakeJM,WayneGF,ConnollyGN:Thementholsmoker:Tobaccoindustryresearchonconsumersensoryperceptionofmentholcigarettesanditsroleinsmokingbehavior.
NicotineandTobaccoResearch2008,10(4):705-715.
12.
KreslakeJM,WayneGF,etal:Tobaccoindustrycontrolofmentholincigarettesandtargetingofadolescentsandyoungadults.
AmericanJournalofPublicHealth2008,98(9):1685-1692.
doi:10.
1186/1617-9625-9-S1-S4Citethisarticleas:RisingandWasson-Blader:Mentholandinitiationofcigarettesmoking.
TobaccoInducedDiseases20119(Suppl1):S4.
SubmityournextmanuscripttoBioMedCentralandtakefulladvantageof:ConvenientonlinesubmissionThoroughpeerreviewNospaceconstraintsorcolorgurechargesImmediatepublicationonacceptanceInclusioninPubMed,CAS,ScopusandGoogleScholarResearchwhichisfreelyavailableforredistributionSubmityourmanuscriptatwww.
biomedcentral.
com/submitRisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S4Page4of4
Sincethevastmajorityofcigarettesmokersbeginsmokingbyage25,understandingtheroleofmentholcigarettesintheinitiationofsmokinginyouth(undertheageof18)andyoungadults(aged18–25)isespeciallyrelevant.
Datademonstratethatmentholcigarettesaredisproportionatelyusedbyyouthandyoungadults.
Thisreviewseekstoexaminewhatrole,ifany,mentholplaysintheinitiationofcigarettesmoking.
Overall,thereisapaucityofdataonthistopic.
Thedatathatdoexistsuggeststhatyouthwhohavesmokedforlessthan1yeararemorelikelytosmokementholcigarettesthanyouthwhohavesmokedformorethan1year.
Alackofdatapreventsfurtherconclusionsontheroleofmentholcigarettesintheinitiationofsmoking.
ReviewIntroductionInitiationofcigarettesmokingintheUnitedStateshascontinuedatahighrate.
Accordingtoa2008reportfromtheSubstanceAbuseandMentalHealthAdminis-tration,around4,000youthtrytheirfirstcigaretteeachday[1]andapproximately1,000youthbecomedailysmokers.
[2]Additionally,2,800youngadultstrytheirfirstcigaretteeachday.
[1]Otherdatahavealsodemon-stratedhighratesofsmokinginitiationamongyouthandyoungadults.
AreportfromtheSurgeonGeneralin1994[3]revieweddatafromtheNationalHouseholdSurveysonDrugAbuse,whichsurveyedpersonsaged30–39abouttheirrecollectionsoftheageoffirstcigar-etteandfirstregularsmoking,andfoundthat62.
2%ofpersonswhohadeversmokeddailytriedtheirfirstcigarettebeforetheageof16.
Inaddition,morethanhalfofthosewhoeversmokeddailybegansmokingdailybeforetheageof18[3].
Astudythatusedaggre-gateddatafromthe1990sexaminedtheageatsmokinginitiationasrecalledbyindividualsaged26–50years;thisstudyrevealedsignificantracial/ethnicdisparities[4].
TheauthorsfoundthatthemajorityofWhiteandLatinosmokersbegansmokingbytheageof18,whilethemajorityofBlack/AfricanAmericanandAsian/Paci-ficIslandersmokersbegansmokingbetweentheagesof18and25.
Whilethesereportsdonotdistinguishbetweenmentholandnon-mentholcigarettesmokers,theydoprovidedatathatdemonstratethatthemajorityofsmokersbeginsmokingasyouthandyoungadults.
Despiteacknowledgementoftheimportanceofunder-standingwhyindividualsinitiatecigarettesmoking,thereislimitedliteratureontheimpactofmentholontheinitiationofcigarettesmoking.
Thisarticlereviewstheavailableliteratureonmentholandtheinitiationofcigarettesmokingandexploresthefollowingquestions:Domentholcigarettesmokersstartsmokingearlierinlifethannon-mentholcigarettesmokersDoesthisvarybyrace/ethnicityIsthereahigheruseofmentholcigarettesamongrecentinitiations(e.
g.
,youthwhohavebeensmokingforlessthan1year)Doesthisvarybyageorrace/ethnicityDoesthesmokingofmentholcigarettesalterpro-gressionfromfirstcigarette(s)towardbecomingaregu-larsmokerDidcurrentsmokersinitiatesmokingwithmentholcigarettesandthenswitchtonon-mentholcigarettesWhatinformationdopublishedreportsonpubliclyavailableinternaltobaccoindustrydocumentscontainonthistopicSummarizedinthisrevieware10articlesfoundtohaveeitherdirectrelevancetothesequestions,orwereusedtoproviderelevantbackgroundinformation.
ManyofthesearticleswereidentifiedthroughareviewoftheliteratureconductedbytheNationalCancerInstitutein2009,publishedas"Bibliographyofliteratureonmentholandtobacco"(http://cancercontrol.
cancer.
gov/*Correspondence:Joahua.
Rising@fda.
hhs.
gov1CenterforTobaccoProducts,U.
S.
FoodandDrugAdministration,Rockville,MD,USAFulllistofauthorinformationisavailableattheendofthearticleRisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S42011RisingandWasson-Blader;licenseeBioMedCentralLtd.
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.
org/licenses/by/2.
0),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
tcrb/documents/menthol_bibliography_508.
pdf).
Searchtermsusedwerementholcigarette(s);mentholatedcigarette(s);mentholtobacco;mentholatedtobacco;mentholsmoker(s);mentholANDthefollowingterms:addiction,nicotine,marketing,cancer,biomarkers,asthma,cardiovasculardisease,heartdisease,vasculardisease,chronicobstructivelungdisease,respiratory,environmentaltobaccosmoke,nationalhealth,healthdisparities,andminorityhealth.
Additionalsearchesandsources,suchasthoseidentifiedthroughreviewarticles,identifiedadditionalarticlesthatwereincludedasappropriate.
OfthosearticlesthatareintheNCIBibliographybutwerenotincluded,mostwerenotdirectlyrelevanttothistopic(e.
g.
,theystudiedmentholasachemicalinde-pendentfromtobaccosmokeexposure,didnotevaluatementholasaseparatevariable).
Someofthosearticles,however,wereusedtoprovidebackgroundinformation.
Animalorinvitroresearchwasincludedonlytohelpexplainhumanfindings.
Althoughafewreviewarticleswereusedtomakegeneralstatementsand/orprovidebackgroundinformation,mostwerenotincludedindeferencetooriginalsources.
Publishedabstractswerenotincludedoutofconcernthat,duetothelackofdetails,thosestudiescouldnotadequatelybeassessed.
NewyouthandyoungadultsmokersAstudybyHerseyetal[5]examineddatafromthe2002NationalYouthTobaccoSurveyregardingthedurationofsmokingandmentholcigaretteuse.
Middleschoolstudents(grades6–8)whohadbeensmokinglessthan1yearweresignificantlymorelikelytosmokementholcigarettesthanweremiddleschoolstudentswhohadbeensmokingmorethan1year(62.
4%vs.
53.
3%,p=1YearNationalSurveyonDrugUse&HealthSubstanceAbuseandMentalHealthServicesAdministrationFigure1Mentholcigaretteusebynewsmokers(age:12-21).
RisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S4Page2of4dizziness,relaxation,irritation)tothefirstcigarette[9].
Nostudiesexaminedwhethertheearlyuseofmentholcigarettesaffectedanindividual'strajectorytoregularsmoking.
Switchingbetweenmentholandnon-mentholcigarettesNostudieswereidentifiedthatdirectlyaddressedwhethercurrentsmokersstartedsmokingwithmentholcigarettesandthenswitchedtonon-mentholcigarettes.
A1989study,however,examinedtheswitchingbeha-viorof29,037currentsmokerswhoattendedtheKaiserPermanenteMedicalCareProgrambetween1979and1986.
Studyparticipantswerefollowedforameanof4.
5years[10].
Ofthe1,688Black/AfricanAmericansmo-kersundertheageof40forwhomfollow-updatawereavailable,thepercentageofthosewhoswitchedfromnon-mentholcigarettestomentholcigarettes(14.
6%)wasmuchhigherthanthepercentageofmentholcigar-ettesmokerswhoswitchedtonon-mentholcigarettes(3.
6%).
Usingaproportionalhazardsmodeladjustingforageandsex,theresearchersfoundthatnon-mentholcigarettesmokerswere4.
2timesmorelikelytoswitchtomentholcigarettesthanformentholcigarettesmo-kerstoswitchtonon-mentholcigarettes.
Oneotherstudydescribedswitchingbehavior.
Pletcheretal[8]foundnodifferenceinthepercentageofyoungadultsmokerswhohadswitchedtypesofpro-ductsatthe15-yearfollow-upintheCARDIAstudy;12%ofthosewhooriginallypreferredmentholcigaretteshadswitchedtonon-mentholcigarettes,and11%ofthosewhooriginallypreferrednon-mentholcigaretteshadswitchedtomentholcigarettes.
ResearchonpubliclyavailableinternaltobaccoindustrydocumentsonmentholandinitiationTworeviewsofinternaltobaccocompanydocumentsonthetopicofmentholcigaretteswereperformedbyKre-slakeetal[11,12].
Theauthorsciteatobaccocompanydocumentthatfoundabenefittoincludingmentholincigarettesinordertomakethesmokingexperiencemorepalatableforinexperiencedsmokers.
"First-timesmokerreactionisgenerallynegative…Initialnegativescanbealleviatedwithalowlevelofmenthol"[12].
Theyalsofoundavailabledocumentationthattobaccocompa-nieswereawarethatnewersmokerspreferredmentholcigaretteswithalowerlevelofmentholthanestablishedsmokers.
AccordingtoKreslakeetal,"theauthorofaninternalBrownandWilliamsonmemoobservedthatKool'smenthollevelmaybeconsideredtoohighfornewsmokers,andthatasuccessful'starter'cigarettewouldneedtoincludealowtobaccotaste,lowimpactandirritation,lowtobaccoaftertasteandlowmentholcontent"[11].
ConclusionsLimiteddataexistregardingtheroleofmentholintheinitiationofsmoking.
Furthermore,therearesignificantlimitationstotheexistingstudies.
Someofthestudiesthatusedretrospectivedataandadultrecollectionsofsmokinginitiationmaynotprovideanaccuraterepre-sentationoftheproductused.
Onlythreestudiesfol-lowedindividualsprospectively,andtwoofthesestudiesbeganfollowingindividualsaftersmokinghadbeeninitiated.
Thethirdofthesestudies[9]hadasmallsam-plesize.
However,Herseyetal[5]specificallyaddressedtheissueofpotentialincompleteknowledgeofmentholsta-tusofcigarettesusedbyyoungersmokers.
Theseresearchersexaminedthedatabasedonseveraldifferentdefinitionsof"mentholcigarettesmoker"andfoundthattheresultsweresimilarregardlessofthedefinition,indicatingthattherateofmisclassificationofmentholstatusofcigarettesbynewuserswaslow[5].
Evenwiththeabovelimitations,however,theexistingliteraturedoessupportthefollowingconclusions:Thevastmajorityofindividualswhobecomeregularsmokersbeginsmokingasyouthoryoungadults.
Mentholcigarettesarewidelyusedamongyouthwhohavesmokedforlessthanoneyearandareusedlessfrequentlybyyouthwhohavesmokedformorethanoneyear.
Althoughlimiteddataareavailable,thereappearstobenodifferencesinageofinitiationbetweenthosewhostartsmokingwithmentholcigarettesandthosewhostartsmokingwithnon-mentholcigarettes;however,becausethedataareretrospective,theyreflectinitiationrates16-30yearsago,notcurrentpatterns.
Resultsareinconsistentregardingthefrequencyanddirectionofswitchingbetweenmentholandnon-mentholcigarettes.
Nodataexistonwhethermentholcigaretteusealtersthetrajectoryfrominitiatingcigaretteusetoregu-larsmoking.
Reviewsofpubliclyavailableinternaltobaccoindus-trydocumentssuggestanindustryawarenessoftheappealofmentholcigarettestonewersmokers.
AcknowlegdementDisclaimer:ThisarticlereflectstheviewsoftheauthorsandshouldnotbeconstruedtorepresentFDA'sviewsorpolicies.
ThisarticlehasbeenpublishedaspartofTobaccoInducedDiseasesVolume9Supplement1,2011:Mentholatedcigarettesandpublichealth.
PublicationofthissupplementhasbeensupportedbytheCenterforTobaccoProducts,FoodandDrugAdministration.
Thefullcontentsofthesupplementareavailableonlineathttp://www.
tobaccoinduceddiseases.
com/supplements/9/S1Authordetails1CenterforTobaccoProducts,U.
S.
FoodandDrugAdministration,Rockville,MD,USA.
2KWBHealthCommunications,Inc,USA.
RisingandWasson-BladerTobaccoInducedDiseases2011,9(Suppl1):S4http://www.
tobaccoinduceddiseases.
com/content/9/S1/S4Page3of4CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Published:23May2011References1.
SubstanceAbuseandMentalHealthAdministration:Resultsfromthe2008NationalSurveyonDrugUseandHealth.
DetailedTablesRockville(MD):OfficeofAppliedStudies;,[accessed2010August9]Availableathttp://oas.
samhsa.
gov/NSDUH/2K8NSDUH/tabs/Sect4peTabs1to4.
pdf.
2.
SubstanceAbuseandMentalHealthAdministration:Resultsfromthe2008NationalSurveyonDrugUseandHealth.
DetailedTablesRockville(MD):OfficeofAppliedStudies;,[accessed2010August9]Availableathttp://oas.
samhsa.
gov/NSDUH/2K8NSDUH/tabs/Sect4peTabs10to11.
pdf.
3.
OfficeoftheSurgeonGeneral:YouthandTobacco:PreventingTobaccoUseamongYoungPeople.
AReportoftheSurgeonGeneral.
Washington,D.
C:USDeptofHealthandHumanServices;1994.
4.
TrinidadDR,GilpinEA,LeeL,etal:DothemajorityofAsian-AmericanandAfrican-AmericansmokersstartasadultsAmericanJournalofPreventiveMedicine2004,26(2):156-158.
5.
HerseyJC,NgSW,NonnemakerJM,etal:ArementholcigarettesastarterproductforyouthNicotineandTobaccoResearch2006,8(3):403-413.
6.
SubstanceAbuseandMentalHealthServicesAdministration,OfficeofAppliedStudies:TheNSDUHReport:UseofMentholCigarettes.
Rockville,MD:OfficeofAppliedStudies;2009.
7.
HymowitzN,CorleD,RoyceJ,etal:Smokers'baselinecharacteristicsinthecommittrial.
PreventiveMedicine1995,24(5):503-508.
8.
PletcherMJ,HulleyBJ,HoustonT,etal:Mentholcigarettes,smokingcessation,atherosclerosis,andpulmonaryfunction:theCoronaryArteryRiskDevelopmentinYoungAdults(CARDIA)study.
ArchivesofInternalMedicine2006,166(17):1915-1922.
9.
DiFranzaJR,SavageauJA,FletcherK,etal:Recollectionsandrepercussionsofthefirstinhaledcigarette.
AddictiveBehaviors2004,29:261-272.
10.
SidneyS,TekawaI,FriedmanGD:Mentholatedcigaretteuseamongmultiphasicexaminees,1979–86.
AmericanJournalofPublicHealth1989,79(10):1415-1416.
11.
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