Ralph S. Caraballo, PhD, MPH Valerie J. Rock, MPH Epidemiology Branch Chief Office on Smoking and Health CDC TM 2nd Conference on Menthol Cigarettes October 19, 2009 Overview of Current Use of Menthol Cigarettes and Trends in Recent Years

Presentation Outline  Smoking Prevalence by Race/Ethnicity  Who is smoking menthol cigarettes?  Recent trends: smokers of menthol cigarettes  Summary  Future directions

Smoking Prevalence by Race/Ethnicity

Prevalence of Cigarette Smoking among Racial/Ethnic Groups, United States, White African American American Indian/ Alaska Native Asian Hispanic Smoking Prevalence Among Race Native Hawaiian and Other Pacific Islander 31.4 Source: Caraballo RS, Yee SL, Gfroerer J, Mirza SA. Adult Tobacco Use among Racial and Ethnic Groups Living in the United States, Preventing Chronic Disease, 2008; 5(3).

Race or Ethnicity Sex Men Women Total NON-HISPANIC White African American American Indian or Alaska Native Native Hawaiian and Other PI Asian Chinese Filipino Japanese Asian Indian Korean Vietnamese HISPANIC Mexican Puerto Rican Central or South American Cuban Percentage of Respondents Aged 18 or Older Who Smoked Cigarettes During the 30 Days Before Being Surveyed, by Race/Ethnicity and Sex, NSDUH, Source: Caraballo RS, Yee SL, Gfroerer J, Mirza SA. Adult Tobacco Use among Racial and Ethnic Groups Living in the United States, Preventing Chronic Disease, 2008; 5(3).

Who is Smoking Menthol Cigarettes?

Domestic Market Share of Menthol Cigarettes: United States, 1963 – 2006 Source: Federal Trade Commission, % 27% 29% 16%

Market Share of Menthol Cigarette Brands and Percentage of Smokers Who Use Menthol Cigarettes—United States, Sources: 2009 FTC Report , NSDUH , and NHANES Market Share NSDUH Menthol Use Prevalence NHANES Menthol Use Prevalence n=87,810n=2,135 Out of 371 billion cigarettes sold per year

Percentage of Smokers Who Use Menthol Cigarettes by Race/Ethnicity—United States, NSDUH and NHANES Sources: Self-Reports from the Population Aged 12 Years or Older from the National Surveys on Drug Use & Health, ; and UPC (Bar Code) Collected from the Population Aged 20 Years or Older from the Data National Health and Nutrition Examination Surveys, * NSDUH captures Hispanic/Latinos; NHANES captures specifically Mexican Americans. NSDUHNHANES * n=461 n=1,350 n=324 n=62,502 n=8,563 n=10,302 *

Percentage of Smokers Who Use Menthol Cigarettes by Race/Ethnicity—United States, § National Surveys on Drug Use and Health, African American Native Hawaiian and Other Pacific Islander Multi-racialAsianHispanicAmerican Indian and Alaska Native White

Multi-racial American Indian/AN Native Hawaiian PI Asian Hispanic African American Population in millions Source: National Surveys on Drug Use & Health, Number of Smokers Who Use Menthol Cigarettes by Race/Ethnicity—United States,

African American Source: National Survey on Drug Use & Health, 2006 White Hispanic Asian (2.4%) 55.1% 11.1% 28.7% Multi-race (1.6%) Native Hawaiian PI (0.5%) AIAN (0.6%) Percent Distribution of Menthol Cigarette Smokers by Race/Ethnicity—United States,

Percentage of Current Smokers Aged ≥ 12 Years Who Use Menthol Cigarettes, by Race/Ethnicity and Sex—United States, § National Surveys on Drug Use & Health, *Statistically significant African American White Hispanic American Indian/ Alaska Native Native Hawaiian and Pacific Islander Asian * * * Multi-racial *

Percentage of Current Smokers Aged ≥ 12 Years Who Use Menthol Cigarettes by Race/Ethnicity and Age Group— United States, § National Surveys on Drug Use & Health, African American White HispanicAmerican Indian/ Alaska Native Native Hawaiian and Other Pacific Islander AsianMulti-racial 50%

Percentage of Smokers Who Use Menthol Cigarettes by Education among Persons Aged ≥18 Years—United States, § National Surveys on Drug Use and Health, <HSHigh School Some College College Grad

Percentage of Smokers Who Use Menthol Cigarettes by Family Income among Persons Aged ≥25 Years—United States, § National Surveys on Drug Use and Health, <20K20-49K 50-74K 75+K

Trends: Menthol Cigarette Use

Trends in Menthol and Non-Menthol Cigarette Use among Current Smokers Aged ≥ 12 Years, United States, Source: National Surveys on Drug Use & Health, Significant

Trends in Menthol Cigarette Use among Current Smokers Aged ≥ 12 Years, by Family Income, United States, Source: National Surveys on Drug Use & Health, Significant

Trends in Menthol Cigarette Use among Current Smokers Aged ≥ 18 Years, by Education, United States, Source: National Surveys on Drug Use & Health, Significant

Trends in Menthol Cigarette Use among Current Smokers Aged ≥ 12 Years, by Race/Ethnicity, United States, Source: National Surveys on Drug Use & Health, Significant Significantt

Trends in Menthol Cigarette Use among African American Current Smokers Aged ≥12 Years, by Sex, United States, Source: National Surveys on Drug Use & Health, Significant increase for males and females

Trends in Menthol Cigarette Use among African American Current Smokers Aged ≥ 12 Years, by Age, United States, Source: National Surveys on Drug Use & Health, All 3 had significant increases

Trends in Menthol Cigarette Use among African American Current Smokers Aged ≥ 12 Years, by Reported Age of Smoking Initiation, United States, Source: National Surveys on Drug Use & Health, All 3 had significant increases

Trends in Menthol Cigarette Use among African American Current Smokers Aged ≥ 12 Years Number of Cigarettes Smoked Per Day, United States, Source: National Surveys on Drug Use & Health, Significant

Quantity and Frequency of Past Month Cigarette Use among Students Aged Years, National Youth Tobacco Survey, United States, 2004 Source: Caraballo RS, Novak SP, Asman K. Linking quantity and frequency profiles of cigarette smoking to the presence of nicotine dependence symptoms among adolescent smokers: findings from the 2004 NYTS. Nicotine Tob Res 2009;11(1):49-57.

Trends in Menthol Cigarette Use among White Current Smokers Aged ≥ 12 Years, by Age, United States, Source: National Surveys on Drug Use & Health, stat. sig.

Trends in Menthol Cigarette Use among Hispanic Current Smokers Aged ≥ 12 Years, by Sex, United States, Source: National Surveys on Drug Use & Health, Significant Signiificant

Menthol Brand Use by Race/Ethnicity

Top 10 Cigarette Brands Smoked by African American Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use and Health, 2006 Newport Kool Marlboro SalemDoralBasicB&H WinstonGPCVirginia Slims

Summary

 Significant overall increase of menthol cigarette use among smokers  Women seem to be more likely to smoke menthol cigarettes than men  Proportionally, African Americans more likely to smoke menthol cigarettes than other groups  Numerically, Whites are the majority of smokers of menthol cigarettes

 Significant increase of cigarette menthol use among the following African American smokers:  Men and Women  Ages 12 – 64 years  All “age of initiation” groups  Who smoke <5 cigarettes per day when they smoke  Who smoke 16 – 25 cigarettes per day when they smoke

 Significant overall increase of menthol use among smokers of all family incomes except $50,000 – $74,999 per year  Significant increase of cigarette menthol use among White smokers aged 12 – 25 years  Significant increase of cigarette menthol use among Hispanics  The leading menthol brand among African American smokers is Newport, the leading brand smoked by other Racial/Ethnic groups is Marlboro

Future Directions

 To closely monitor menthol cigarette use among:  African Americans  Hispanics  Native Hawaiians and Pacific Islanders  Youth and Young Adults  Triers and Experimenters

 Although out of the scope of this presentation, to closely monitor:  Targeted advertising and promotions to all segments of the U.S. populations, especially  African Americans  Hispanics  Native Hawaiians and Pacific Islanders  Asians  Youth and Young Adults  Triers and Experimenters  Low income  LGBT

Acknowledgment  Kat Asman  Valerie Rock  Julie Cessna  Lynn Hughley

Ralph Caraballo, PhD, MPH Valerie Rock, MPH Epidemiology Branch Chief Office on Smoking and Health TM Overview of Current Use of Menthol Cigarettes and Trends in Recent Years The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Extra Slides Not Presented

African American Source: July 1, 2006 estimates (accessed September 29, 2009) White Hispanic Asian (4.2%) Percent Population Distribution by Race/Ethnicity— United States, July 1, % 14.5% 12.2% Multi-race (1.4%) Other (0.4%) AIAN (0.8%)

Measurement of Menthol Use (Cigarettes) in National Surveys

First Conference on Menthol Cigarettes’ Selected Epidemiological (Surveillance) Needs (Giovino et al.)  “The best way to measure menthol use in large national surveys must be explored”  Of all smokers who self-reported they smoked a specific menthol or non-menthol only brand, 0.25% of them seem to have miss-reported the information (NSDUH)  No inaccurate reporting (0.00%) was found in NHANES among smokers for which UPC cigarette data were not available (NHANES) Sources: National Cancer Institute. The First Conference on Menthol Cigarettes: Setting the Research Agenda; Executive Summary: March 21-22, Atlanta, GA; National Surveys on Drug Use & Health,

First Conference on Menthol Cigarettes’ Selected Epidemiological (Surveillance) Needs (Giovino et al.)  However,  Of all smokers who self-reported they smoked Newport, Salem, Alpine, Belair, Coronas or Jade, 7.2% of them said they smoked a non-menthol version of those brands (NSDUH)  About 1.13% of Newport smokers reported smoking a non-menthol brand (NSDUH) Sources: National Cancer Institute. The First Conference on Menthol Cigarettes: Setting the Research Agenda; Executive Summary: March 21-22, Atlanta, GA; National Surveys on Drug Use & Health,

First Conference on Menthol Cigarettes’ Selected Epidemiological (Surveillance) Needs (Giovino et al.)  “The best way to measure menthol use in large national surveys must be explored”  Funded by CDC’s Office on Smoking and Health, since 2001 NHANES collects UPC bar code data on the side of the cigarette pack Sources: National Cancer Institute. The First Conference on Menthol Cigarettes: Setting the Research Agenda; Executive Summary: March 21-22, Atlanta, GA; National Surveys on Drug Use & Health,

 “The need to monitor the use of “cross-brands” such as Marlboro Menthol and non-menthol Newport”  Of all Marlboro smokers (n=879), 7.6% (n=65) provided a brand (UPC code) that was Marlboro Menthol  Of all Newport smokers (n=276), 0.4% (n=1) provided a brand (UPC code) that was Newport Non-Menthol Sources: National Cancer Institute. The First Conference on Menthol Cigarettes: Setting the Research Agenda; Executive Summary: March 21-22, Atlanta, GA; National Health and Nutrition Examination Surveys, First Conference on Menthol Cigarettes’ Selected Epidemiological (Surveillance) Needs (Giovino et al.)

Trends in Menthol Cigarette Use among White Current Smokers Aged ≥12 Years, by Sex, United States, Source: National Surveys on Drug Use & Health, No change

Trends in Menthol Cigarette Use among Current Smokers Aged ≥ 20 Years, by Race/Ethnicity, NHANES, Source: National Health and Nutrition Examination Survey, No Change Significant increase No change

Trends in Menthol Cigarette Use among African American Current Smokers Aged ≥ 20 Years, by Sex, NHANES, Source: National Health and Nutrition Examination Survey, Male Female Significant to increase no change

Trends in Menthol Cigarette Use among White Current Smokers Aged ≥ 20 Years, by Sex, NHANES, Source: National Health and Nutrition Examination Survey, Significant to increase no change

Top 10 Cigarette Brands Smoked by White Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use and Health, 2006 MarlboroCamelNewportBasicDoralWinstonParliamentUSA GoldPall MallKool

Top 10 Cigarette Brands Smoked by American Indian/ Alaska Native Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use & Health, 2006 MarlboroNewportCamelBasicBenson & Hedges GPCDoralMistyUSA GoldKool

Top 10 Cigarette Brands Smoked by Hispanic Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use & Health, 2006 MarlboroNewportCamelKoolBenson & Hedges DoralWinstonVirginia Slim SalemPall Mall

Top 10 Cigarette Brands Smoked by Asian Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use & Health, 2006 CamelAmerican Spirit ParliamentBenson & Hedges NewportKoolCapriUSA GoldKentMarlboro

Top 10 Cigarette Brands Smoked by Multiracial Current Smokers Aged ≥ 12 Years, United States, 2006 Source: National Survey on Drug Use & Health, 2006 MarlboroNewportBasicCamelGPCDoralMistyUSA GoldKoolMonarch

Percentage of African American Current Smokers Who Used Newport Cigarettes, by Sex and Age, United States, Source: National Survey on Drug Use and Health,

Percentage of White Current Smokers Who Used Newport Cigarettes, by Sex and Age, United States, Source: National Survey on Drug Use and Health,

Percentage of Hispanic Current Smokers Who Used Newport Cigarettes, by Sex and Age, United States, Source: National Survey on Drug Use and Health,