DOI: 10.1093/jnci/djr102 JNCI Journal

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ARTICLE

Lung Cancer Risk Among Smokers of Menthol Cigarettes William J. Blot, Sarah S. Cohen, Melinda Aldrich, Joseph K. McLaughlin, Margaret K. Hargreaves, Lisa B. Signorello Manuscript received December 30, 2010; revised February 22, 2011; accepted February 23, 2011. Correspondence to: William J. Blot, PhD, International Epidemiology Institute, 1455 Research Blvd, Ste 550, Rockville, MD 20850 (e-mail: [email protected]).

Menthol cigarettes, preferred by African American smokers, have been conjectured to be harder to quit and to contribute to the excess lung cancer burden among black men in the Unites States. However, data showing an association between smoking menthol cigarettes and increased lung cancer risk compared with smoking nonmenthol cigarettes are limited. The Food and Drug Administration is currently considering whether to ban the sale of menthol cigarettes in the United States.



Methods

We conducted a prospective study among 85 806 racially diverse adults enrolled in the Southern Community Cohort Study during March 2002 to September 2009 according to cigarette smoking status, with smokers classified by preference for menthol vs nonmenthol cigarettes. Among 12 373 smokers who responded to a follow-up questionnaire, we compared rates of quitting between menthol and nonmenthol smokers. In a nested case–control analysis of 440 incident lung cancer case patients and 2213 matched control subjects, using logistic regression modeling we computed odds ratios (ORs) and accompanying 95% confidence intervals (CIs) of lung cancer incidence, and applied Cox proportional hazards modeling to estimate hazard ratios (HRs) of lung cancer mortality, according to menthol preference.



Results

Among both blacks and whites, menthol smokers reported smoking fewer cigarettes per day; an average of 1.6 (95% CI = 1.3 to 2.0) fewer for blacks and 1.8 (95% CI = 1.3 to 2.3) fewer for whites, compared with nonmenthol smokers. During an average of 4.3 years of follow-up, 21% of participants smoking at baseline had quit, with menthol and nonmenthol smokers having equal odds of quitting (OR = 1.02, 95% CI = 0.89 to 1.16). A lower lung cancer incidence was noted in menthol vs nonmenthol smokers (for smokers of 60

Nonmenthol

40–49

50–59

>60

No. No. No. No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean no. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y No. Mean no. of cpd ≥20 cpd, % Mean duration, y No. Mean no. of cpd ≥20 cpd, % Mean duration, y No. Mean No. of cpd ≥20 cpd, % Mean duration, y

Black men (n = 22 820) 2595 1672 853 1350 14.6 36 18.2 1454 16.7 43 23.2 774 17.9 47 30.0 131 14.9 38 18.1 340 18.5 48 23.2 635 19.6 54 29.5 6821 12.3 27 27.6 3631 12.3 27 36.5 668 11.7 28 47.0 701 13.2 32 28.6 763 14.2 35 37.9 432 12.2 27 48.4

Black women (n = 31 957) 6716 5311 3288 1924 13.8 33 16.6 1,844 14.4 34 20.9 1,175 13.3 32 26.6 176 12.0 27 14.8 445 16.3 38 22.6 620 13.6 35 27.6 5818 11.6 24 26.7 2621 11.1 21 34.1 596 9.3 16 44.3 466 13.0 31 27.5 639 12.2 29 35.8 318 11.2 21 45.5

White men (n = 9678) 828 901 752 148 24.2 58 17.8 271 25.6 67 23.5 300 25.5 69 28.0 499 24.7 68 18.7 792 26.9 71 23.9 1,198 27.5 73 29.0 410 20.6 63 30.0 262 20.6 64 38.0 80 21.3 70 51.0 1,725 22.0 68 29.7 1099 22.9 68 39.1 413 21.4 65 49.6

White women (n = 15 267) 1793 2243 1906 415 19.0 49 16.5 528 20.7 52 19.3 500 19.6 49 24.5 622 20.8 56 17.7 885 22.3 58 21.2 909 21.1 57 26.0 812 18.0 54 29.0 485 17.1 49 35.1 147 17.8 54 45.5 2,091 19.1 56 29.2 1292 19.3 57 36.6 639 18.1 57 46.1

* Analysis among the 79 722 African American (black) and white SCCS participants with known smoking histories; excluded from the table are 3670 (4.4%) cohort members with baseline smoking data who are of other or unknown race. Other race participants are included in the analyses shown in Tables 2 and 3. cpd = cigarettes per day.

users were statistically significantly more likely to have quit than nonmenthol users (adjusted OR = 1.55, 95% CI = 1.41 to 1.70). Among SCCS participants who have thus far completed prospective follow-up, 7886 and 4487 reported being current smokers of menthol and nonmenthol cigarettes, respectively, at baseline 4   Article

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enabling prospective determination of quit rates. After an average 4.3 (range 1–8) years of follow-up, 21% of these smokers reported that they had quit smoking. The odds of quitting were inversely related to pack-years smoked, increased with age and income, and did not differ statistically significantly by sex, race, or type of cigarette Vol. 103, Issue 10  |  , 2011

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Nonmenthol

Characteristic(sample size, cpd,smoking duration)

smoked (data not shown). The odds of quitting smoking during follow-up were similar among menthol compared with nonmenthol smokers (adjusted OR =1.02, 95% CI = 0.89 to 1.16).

Table 2. Lung cancer incidence in relation to menthol and non menthol cigarette smoking* Baseline smoking status, type of cigarette, cpd† Never smoker Current, nonmenthol, ≥20 cpd Current, nonmenthol, 10–19 cpd Current, nonmenthol,