While the overall rate of cigarette smoking has decreased in the United States, the use of menthol cigarettes has risen among young adult smokers. A University of Oklahoma researcher published a study today showing that the addition of menthol flavoring to cigarettes makes them more appealing than non-menthol cigarettes, particularly among racial and ethnic minorities and the LGBTQ population, who have high rates of menthol cigarette use.

The findings point to the heightened addiction risk of smoking menthol cigarettes and the role of flavorings in enhancing the appeal of cigarettes. Amy Cohn, Ph.D., a professor of pediatrics at the OU College of Medicine and a member of the TSET Health Promotion Research Center on the OU Health Sciences campus, is the lead author of the study, published in the journal Nicotine & Tobacco Research.

“Our purpose for conducting the study is to provide empirical evidence to the Food and Drug Administration, which has proposed banning menthol in cigarettes,” Cohn said. “The study proved our hypothesis to be true – that menthol cigarettes are more appealing than non-menthol cigarettes for young people who smoke. That’s not good news because menthol is associated with greater nicotine dependence and more difficulty quitting as compared with non-menthol cigarette smoking.”

Much of Cohn’s research career has focused on the risks and appeal of cigarettes containing menthol, the flavor additive with a minty taste and smell. The FDA previously cited her studies in its proposal to ban menthol, published in the Federal Register, the official journal of the federal government. Cohn hopes the organization will draw upon her latest findings as it works toward new regulations to ban or limit menthol flavor in tobacco products.

The study was conducted in a behavioral economic framework, a common approach for understanding drug reinforcement, which is the reward of a substance that drives greater use. The central tenet of behavioral economics is that a person is willing to work harder to obtain their substance of choice if they find it highly appealing, even in the face of obstacles like higher prices.

Young adult smokers ages 18 to 26 were recruited in Oklahoma City to participate in the study. About half smoked menthol cigarettes and the other half non-menthol cigarettes. Participants sat at a computer screen, clicking on images of a menthol or non-menthol cigarette to “earn” puffs of those cigarettes. The task was repeated for 10 trials, and each round earned the participant one puff of their preferred cigarette.

However, the study came with a twist. The number of times a participant had to click on a menthol cigarette image to earn a puff increased with each round: 25 times for the first round, 50 for the second, 75 for the third, and so forth until 1,375 clicks in the 10^th round. But the clicks required for a non-menthol cigarette puff remained constant at 25. At the conclusion of the study, menthol cigarette smokers had clicked on their target an average of 1,235 times.

“Participants who smoked menthol cigarettes persisted in their clicking for nearly an hour to earn puffs of a menthol cigarette,” Cohn said. “They were willing to work very hard to get their preferred cigarette. They could have given up or clicked less for the non-menthol cigarette. But we hypothesize that they find menthol so reinforcing that they were willing to work harder to earn puffs.”

In addition, the study showed that Hispanic individuals clicked on the menthol cigarette image more times than their white counterparts, while lesbian, gay and bisexual individuals clicked the non-menthol target fewer times compared to their heterosexual peers. Tobacco companies are known to market menthol cigarettes to these populations.

“The tactics of tobacco companies have been working for decades. They target menthol to these minoritized populations to get them to begin and continue using these deadly products,” Cohn said. “And that’s what our studies show – that menthol cigarettes are extremely appealing, and people are willing to expend a lot of energy and effort to obtain them.”

Because menthol masks the harshness of inhaled smoke and creates a cooling sensation in the mouth, people who smoke often mistakenly think menthol cigarettes are less harmful and addictive, Cohn said. Her previous studies have shown that if a person’s first time smoking is with a menthol cigarette, they’re more likely to report it as a positive experience than those who have a non-menthol cigarette. Menthol, combined with nicotine, which is a stimulant, increases the reinforcing aspects of smoking and thus the likelihood that a person will continue smoking.

“A cigarette is a cigarette. Menthol doesn’t change the properties of the cigarette; it just makes it more pleasant for a person to smoke,” Cohn said. “It’s harmful anytime you’re lighting up a cigarette and combusting chemicals in your lungs.”

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About the project

Cohn’s publication, “The Relative Reinforcing Value of Menthol Among Young Adult Cigarette Smokers: Results From a Behavioral Choice Task,” is at https://doi.org/10.1093/ntr/ntae186. The study was funded by the National Institute on Drug Abuse, a component of the National Institutes of Health (grant number R01DA046359), and the FDA’s Center for Tobacco Products. The research was also supported by an Oklahoma Tobacco Settlement Endowment Trust (TSET) grant (R22-03) and an NIH core grant awarded to OU Health Stephenson Cancer Center (grant number P30CA2255520). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.