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Table.  
Expected, Short-term Actual, and Long-term Planned Reactions to the Ban on Menthol in Tobacco, Ontario, Canada
Expected, Short-term Actual, and Long-term Planned Reactions to the Ban on Menthol in Tobacco, Ontario, Canada
1.
O’Connor  RJ, Bansal-Travers  M, Carter  LP, Cummings  KM.  What would menthol smokers do if menthol in cigarettes were banned? behavioral intentions and simulated demand.  Addiction. 2012;107(7):1330-1338.PubMedGoogle ScholarCrossref
2.
Chaiton  M, Diemert  L, Cohen  JE,  et al.  Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.  BMJ Open. 2016;6(6):e011045.PubMedGoogle ScholarCrossref
3.
Bondy  SJ, Victor  JC, Diemert  LM,  et al.  Transitions in smoking status over time in a population-based panel study of smokers.  Nicotine Tob Res. 2013;15(7):1201-1210.PubMedGoogle ScholarCrossref
4.
Nugent  R, Tremblay  G. Tobacco sales in Canada 2014. Paper presented at: Tobacco Control Directorate, Health Canada, National Conference on Tobacco or Health; March 1, 2016; Ottawa, Ontario, Canada.
5.
Bird  Y, May  J, Nwankwo  C, Mahmood  R, Moraros  J.  Prevalence and characteristics of flavoured tobacco use among students in grades 10 through 12: a national cross-sectional study in Canada, 2012-2013.  Tob Induc Dis. 2017;15(1):20.PubMedGoogle ScholarCrossref
6.
Giovino  GA, Sidney  S, Gfroerer  JC, O'Malley  PM, Allen  JA, Richter  PA, Cummings  KM.  Epidemiology of menthol cigarette use.  Nicotine Tob Res. 2004;6(suppl 1):S67-S81.Google ScholarCrossref
Research Letter
Health Care Policy and Law
May 2018

Association of Ontario’s Ban on Menthol Cigarettes With Smoking Behavior 1 Month After Implementation

Author Affiliations
  • 1Ontario Tobacco Research Unit, Toronto, Ontario, Canada
  • 2Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  • 3Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Virginia Commonwealth University, Richmond
JAMA Intern Med. 2018;178(5):710-711. doi:10.1001/jamainternmed.2017.8650

The province of Ontario, Canada, implemented a full menthol cigarette ban on January 1, 2017. To date, there has been no population-wide, systematic evaluation of the association of the implementation of a menthol ban with smoker behavior. Assessments of perceived behavioral responses to hypothetical menthol flavor bans are useful1; however, there is no guarantee that individuals will follow through with their planned behaviors. This study compares respondents’ planned behavior before the ban with actual behavior 1 month after the ban.

Methods

Eligible participants were residents of Ontario 16 years or older who had smoked at least 1 menthol cigarette in the past year and were past-month smokers. A total of 325 participants were recruited using random-digit dialing of residential telephone numbers from September 12 through December 31, 2016. Participation rate for the random-digit dialing was 44.1%, with a 6.7% refusal rate among known eligible participants, consistent with an established provincial health monitoring survey. Participants were contacted for follow-up beginning 1 month (February 1, 2017) after the implementation of the ban (January 1, 2017) through an online survey (206 recontacted [63.4%]). Those who were unavailable for follow-up did not differ by level of menthol smoking, age, sex, income, educational level, or smoking characteristics. Planned reaction to the ban, actual behavior at 1 month after the ban, and planned future reaction beyond 1 month after the ban were compared. Oral consent was obtained from all participants, and the analytic data set was deidentified. This study was approved by the research ethics board of the University of Toronto, Toronto, Ontario, Canada.

Results

A total of 325 participants participated in the study (181 [55.7%] male; 143 [44.0%] female; mean [SD] age, 47.1 [0.9] years). Before the ban, most menthol smokers (123 [59.7%]) said that they would switch to or only use nonmenthol cigarettes, but only 51 (28.2%) had done so at follow-up (Table). In contrast, a larger proportion (60 [29.1%]) attempted to quit compared with only 30 (14.5%) who said they would do so. Similarly, a larger proportion (60 [29.1%]) reported using other flavored tobacco or e-cigarette products (menthol was not banned in e-cigarette products) compared with their preban plans (12 [5.8%]). After the ban, participants were less likely to anticipate using other flavored products. Of those who made a quit attempt, 16 (80.0%; 95% CI, 56.3%-92.5%) of those who primarily smoked menthol cigarettes at baseline suggested that the ban affected their decision to quit at least a little compared with 10 (25.6%; (95% CI, 14.1%-41.0%) of those who smoked menthol cigarettes only occasionally. Before the ban, 1 individual (0.3%) suggested trying to switch to marijuana and 4 (1.2%) suggested adding menthol to cigarettes separately using flavor cards, oils, or papers as substitutes for the lack of menthol, but none reported planning to use these substitutes in the future.

Discussion

This study is, to our knowledge, the first evaluation of the immediate association of a menthol cigarette ban with behavior change. Actual behaviors contrast sharply with planned behaviors. Although a substantial decrease in menthol cigarette use was observed, there was a considerable increase in use of flavored e-cigarettes and cigars. Furthermore, 29.1% of menthol smokers attempted to quit smoking shortly after ban implementation. Because previous studies2,3 have found an expected rate of 0.5 quit attempts and a 7.7% abstinence rate during a 6-month period in this population, this finding suggests that the ban substantially increased quit attempts. Few smokers used aftermarket additive flavorings, and there was no increase in the use of contraband tobacco. Limitations of this study include the unique demographics of menthol cigarette smokers in Canada, where menthol cigarettes comprise 5% of cigarette sales4,5 compared with 30% in the United States6 and use is not concentrated among black Canadians.5 The initial results suggest that removing menthol tobacco from the market is a feasible strategy that may influence cessation behavior, although differences between menthol users in Ontario, Canada, and other jurisdictions may affect the potential influence of a ban.

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Article Information

Accepted for Publication: December 21, 2017.

Corresponding Author: Michael Chaiton, PhD, Ontario Tobacco Research Unit, 155 College St, Toronto, Ontario, M5T 3M7 Canada (michael.chaiton@utoronto.ca).

Published Online: March 5, 2018. doi:10.1001/jamainternmed.2017.8650

Author Contributions: Dr Chaiton had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Chaiton, Schwartz, Cohen, Eissenberg.

Drafting of the manuscript: Chaiton.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Chaiton.

Obtained funding: Chaiton, Schwartz, Eissenberg.

Administrative, technical, or material support: Schwartz, Cohen.

Supervision: Chaiton.

Conflict of Interest Disclosures: Dr Eissenberg reported serving as a paid consultant in litigation against the tobacco industry and is named on a patent application for a device that measures the puffing behavior of electronic cigarette users. No other disclosures were reported.

Funding/Support: This research was supported by award P50DA036105 from the National Institute on Drug Abuse of the National Institutes of Health and the Center for Tobacco Products of the US Food and Drug Administration.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health or the US Food and Drug Administration.

References
1.
O’Connor  RJ, Bansal-Travers  M, Carter  LP, Cummings  KM.  What would menthol smokers do if menthol in cigarettes were banned? behavioral intentions and simulated demand.  Addiction. 2012;107(7):1330-1338.PubMedGoogle ScholarCrossref
2.
Chaiton  M, Diemert  L, Cohen  JE,  et al.  Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers.  BMJ Open. 2016;6(6):e011045.PubMedGoogle ScholarCrossref
3.
Bondy  SJ, Victor  JC, Diemert  LM,  et al.  Transitions in smoking status over time in a population-based panel study of smokers.  Nicotine Tob Res. 2013;15(7):1201-1210.PubMedGoogle ScholarCrossref
4.
Nugent  R, Tremblay  G. Tobacco sales in Canada 2014. Paper presented at: Tobacco Control Directorate, Health Canada, National Conference on Tobacco or Health; March 1, 2016; Ottawa, Ontario, Canada.
5.
Bird  Y, May  J, Nwankwo  C, Mahmood  R, Moraros  J.  Prevalence and characteristics of flavoured tobacco use among students in grades 10 through 12: a national cross-sectional study in Canada, 2012-2013.  Tob Induc Dis. 2017;15(1):20.PubMedGoogle ScholarCrossref
6.
Giovino  GA, Sidney  S, Gfroerer  JC, O'Malley  PM, Allen  JA, Richter  PA, Cummings  KM.  Epidemiology of menthol cigarette use.  Nicotine Tob Res. 2004;6(suppl 1):S67-S81.Google ScholarCrossref
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