Virginia Tech researchers find menthol restrictions may drive smokers to healthier alternatives
Fralin Biomedical Research Institute at VTC scientists find smokers may shift to nicotine replacement options with the right mix of products and pricing.
News Release
Virginia Tech
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Roberta Freitas-Lemos, assistant professor at the Fralin Biomedical Research Institute at VTC, was part of a team that analyzed preferences for menthol-flavored cigarettes and e-cigarettes and the effect of filter ventilation options on purchase decisions. The research was published in the October issue of Drug and Alcohol Dependence.
view moreCredit: Clayton Metz/Virginia Tech
Nationwide, fewer people smoke than did a decade ago, but the proportion who smoke menthol-flavored cigarettes is on the rise.
More than 9 million adults, or about 32 percent of all smokers, use menthol cigarettes, according to the Centers for Disease Control and Prevention. In Virginia, the proportion stands higher, at 38 percent.
A team of researchers including Roberta Freitas-Lemos, assistant professor at Virginia Tech’s Fralin Biomedical Research Institute at VTC, found that if menthol products were unavailable, smokers found replacement therapies such as nicotine gum and lozenges were practical alternatives, potentially improving health outcomes for people who use menthol cigarettes.
The findings come from a study that examined what products adult smokers purchased in an experimental marketplace that adjusted prices and availability of tobacco and nicotine products.
“We were trying to understand how different flavor policies interact, the role of cigarette filter ventilation, and how different types of smokers would respond to those policies,” said Freitas-Lemos, who is with both the institute’s Center for Health Behaviors Research and Cancer Research Center in Roanoke. “We wanted to understand the effect of restrictions on purchases.”
The study, which published in the October issue of Drug and Alcohol Dependence, analyzed preferences for menthol-flavored cigarettes and e-cigarettes and the effect of filter ventilation options on purchase decisions.
What they did
Researchers analyzed data from 172 people who exclusively smoke cigarettes — 76 of whom smoke menthol and 96 non-menthol cigarettes — and 91 people who use multiple tobacco products. Participants were older than 21, smoked at least 10 cigarettes daily, and had smoked a minimum of 100 cigarettes in their lifetime.
The volunteers were asked to complete trial purchases in the Experimental Tobacco Marketplace, a tool addiction recovery research expert Warren Bickel created to study the effects of tax and regulatory policies on health behaviors. Bickel, who died in September, was a professor at the Fralin Biomedical Research Institute, director of its Addiction Recovery Research Center and Center for Health Behaviors Research, and one of the study’s principal investigators.
In the marketplace, participants used an account in an online platform to purchase tobacco and nicotine products, including replacement therapies. Options were tailored to each participant’s preferred flavors and nicotine concentrations, and they were given an account balance designed to reflect their personal budget constraints.
Research participants shopped for products under different market conditions — with varying prices and restricted or unrestricted cigarette or e-cigarette flavors.
What they found
When menthol cigarettes were not available, smokers who preferred menthol cigarettes were less willing to purchase any type of cigarettes and more willing to purchase products such as nicotine gum and other replacement therapies.
In addition, cigarette smokers who prefer menthol products were less likely to substitute e-cigarettes when menthol flavored e-cigarettes were also restricted.
For individuals in the study who use multiple tobacco products, restricting flavors had no impact on their purchases.
The study also found higher demand for cigarettes among smokers who preferred high-ventilation cigarettes — cigarettes with filter holes for airflow.
Why it matters
Menthol, a compound found in plants such as peppermint, is added to tobacco products to make them more appealing. In addition, menthol enhances nicotine’s effects and can make them more addictive.
Tobacco product design features, including flavors and cigarette filter ventilation, are subject to regulation by the Food and Drug Administration, which is why the study examined the effects of cigarette and e-cigarette flavors on demand and substitution by preferred cigarette flavor and ventilation.
An area that requires more investigation, Freitas-Lemos said, is the relationship between cigarette filter ventilation and smoking behavior, which could be connected to smokers’ perception of their cigarettes.
“Cigarettes with ventilation are milder and people think they are less harmful, but it is a false perception,” said Freitas-Lemos, who also holds an appointment as an assistant professor of psychology in the College of Science. One study showed higher rates of lung adenocarcinoma among people who smoke ventilated cigarettes.
“It could be that people who smoke ventilated cigarettes are more responsive to one ban than another,” said Freitas-Lemos, who noted that more research is needed to better understand how perception and ventilation influence behavior.
“I think the most important conclusion from this study is that we can improve health outcomes by emphasizing policies that reduce sales of flavored products and increase accessibility of nicotine replacement therapies,” Freitas-Lemos said.
Journal
Drug and Alcohol Dependence
Method of Research
Experimental study
Subject of Research
People
Article Title
Restrictions of cigarette and e-cigarette flavor and filter ventilation on demand and substitution in the Experimental Tobacco Marketplace
COI Statement
Although the following activities/relationships do not create a conflict of interest pertaining to this manuscript, in the interest of full disclosure, Dr. Bickel would like to report the following: W. K. Bickel is a principal of HealthSim, LLC; BEAM Diagnostics, Inc.; and Red 5 Group, LLC. In addition, he serves on the scientific advisory board for Ria Health; and serves as a consultant for Lumanity and AlphaSights. Dr. Tegge works on a project supported by Indivior, Inc. The other authors report no conflict of interest.
Midwakh pipe smoking posing ‘significant’ health problems in UAE, scientists find
University of Sharjah
A traditional type of tobacco smoking locally known as midwakh is causing severe health problems and nicotine dependency among users in the United Arab Emirates (UAE), scientists from the University of Sharjah reported in a recent study.
The research’s findings are based on a quasi-experimental before-and-after study of 103 young male midwakh smokers in the UAE.
Midawkh is a traditional smoking practice involving a smoking pipe of Arabian origin and a mixture of tobacco from Iran. It is prevalent in Arabian Peninsula which includes the UAE, Oman, Qatar, Bahrain, Kuwait, and Saudi Arabia.
The Iranian element is represented in an imported sifted loose tobacco mixture locally known as dokha or dizziness that contains bark herbs and aromatic leaves.
“Midwakh smoking is deeply ingrained in UAE tradition but poses significant adverse health outcomes and nicotine dependency,” the scientists write.
Compared to shisha pipe smoking, another Middle Eastern traditional smoking practice, which has migrated to many western countries, the midwakh is more intense and even stronger.
Prof. Basema Saddik, the study’s lead author, said while global smoking rates were declining, the Middle East faced unique challenges. “Population growth and a younger demographic in the Middle East are leading to sustained high numbers of smokers despite global declines in smoking prevalence.
“This is particularly critical for the UAE, where vaping, shisha, midwakh and other alternative tobacco products are becoming increasingly popular among youth, potentially leading to significant health issues later.”
Although the results of the study are confined to data collected in the UAE, Prof. Saddik said the findings were bound to reverberate in countries where midwakh is common among smoking populations.
“While the scope of this study is regional, its implications are significant and timely, especially as we continue to address nicotine dependence trends in this population.”
The research’s data collection included surveys featuring the Hooked-on Nicotine checklist (HONC), clinical measurements, and pre/post-smoking saliva samples. The scientists note, “Midwakh smoking adversely affects clinical measurements, with early start correlating with higher nicotine dependency, worsened by using multiple tobacco products.”
Prof. Saddik, who is director of Sharjah University’s Center of Excellence for Public Health, said the study’s findings showed that midwakh users “often develop early signs of nicotine dependence and reported various clinical issues, including elevated carbon monoxide and cotinine levels, which are indicators of harmful tobacco exposure.”
The authors’ preliminary findings pointed to severe health risks related to midwakh smoking particularly the young generation in the UAE. The study reported that “33% of midwakh smokers were under 21 years, 68% had below undergrad education, and household incomes over 15,000 AED (approx. $4000) monthly. Smoking initiation was as early as 10 years.
“Smoking habits revealed 37% exclusive midwakh, 54% midwakh with e-cigarettes, 21% with shisha, and 34% with cigarettes. Post-smoking clinical measurements showed significant increases in blood pressure, heart, pulse and respiratory rates, and carbon monoxide levels.”
Prof. Saddik attributed the widespread use of midwakh in Arabia and specifically in the UAE to smokers mistakenly believing that the herbs and aromatic leaves in the tobacco – which lure many users – make it safer or less harmful than other cigarettes, leading to higher rates of initiation and dependence.
Research shows that a midwakh session, in terms of nicotine intake, can be the equivalent of smoking up to ten cigarettes, and in fact with much higher nicotine and tar levels. The diseases associated with midwakh smoking are no different from those caused by cigarette smoking including coronary artery disease, lung cancer and chronic obstructive pulmonary disease.
Prof. Saddik went on, “Clinical assessments also revealed negative health indicators, including elevated carbon monoxide levels which suggest that without intervention, a large portion of the UAE’s youth could face severe long-term health consequences.”
“Addressing these issues now with targeted prevention programs and regulations on alternative tobacco products is essential to change these projected outcomes.”
Prof. Saddik describes the findings of the study as “a wake-up call” for policy makers in the UAE and other countries with midwakh smokers to implement “strong smoking cessation policies and public education initiatives, particularly aimed at youth.
“The significance of our midwakh study lies in the immediate clinical impacts observed among users, with findings showing high nicotine dependency and harmful respiratory indicators.”
Prof. Saddik said the research had practical implications for health policy makers. The findings, she said, served as “a warning and a guide to protect future generations” in countries like the UAE “where alternative tobacco products are gaining popularity among youth.
“While alternative products like midwakh are often perceived as less addictive, our research reveals high nicotine levels and significant dependency among young users, ultimately impacting their health and future quality of life.”
Journal
European Journal of Public Health
Method of Research
Survey
Subject of Research
People
Article Title
Tradition to Concern: Health Risks and Nicotine Dependence of Midwakh Use in Young Males in the UAE
Article Publication Date
3-Nov-2024
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