Menthol is a common additive in tobacco products. The tobacco industry maintains that menthol is added as a flavour.1 However, there are many concerning effects of added menthol, beyond changing the flavour of the tobacco product. Menthol masks the harshness of smoke, increases addiction and facilitates uptake of smoking in young people. Menthol cigarettes are also marketed to and used disproportionately by specific groups of people such as African Americans.2
12.7.1 Use of menthol in tobacco products
Menthol is a carbon-based compound that can be produced synthetically or isolated from mints such as peppermint and corn mint. Menthol is added to the tobacco filler of cigarettes or to the cigarette filter. It is present in amounts of up to 1.6% of the total weight of cigarettes sold in Australia (Table 12.5.2 in Section 12.5).3 When these cigarettes are smoked, menthol is vapourised and is detected in the smoke.4 Menthol can be found in cigarettes that are not branded as menthol cigarettes (described herein as non-mentholated), but at lower concentrations.5 ,6 Menthol is also added to the tobacco used in some cigars, pipes, roll-your-owns, waterpipes and smokeless tobacco.2 ,7 Some bidis and kreteks may also contain menthol.8 ,9
Menthol was first added to tobacco products in the 1920s and 1930s but became popular and widespread from the 1950s. Its rising popularity coincided with increased use of cigarette filters as well as aggressive marketing of menthol products.6 ,10 ,11 Prior to 1956, menthol cigarettes were often sold as ‘’throat’’ cigarettes, to be used when a cough or a cold prevented the use of other brands.10 In more recent years, advertising for menthol cigarettes has focused on their 'smoother'/ 'fresher' smoke, although there have been secondary marketing points concerning implied ‘healthiness’ or reduced harm.12
From having a low percent of the market until the 1950s, menthol cigarettes eventually rose in popularity to having 28% of the market share by 1978 and remain popular in the contemporary market.10 Data from the US in 2015 show that mentholated products made up 32.5% of cigarettes, 0.2% of cigarillos, 19.4% of little cigars, 0.7% of chewing tobacco, 57% of moist snuff and 88.5% of snus.13
12.7.2 The effects of added menthol in tobacco products
Studies of cigarette smoking indicate that menthol is a problematic additive in tobacco products.14 People who smoke menthol cigarettes are more likely to show signs of nicotine dependence than non-menthol smokers.15-17 Menthol smokers have lower rates of quitting, especially so for African American smokers.16 Some studies have shown that menthol smokers have their first cigarette each day sooner after waking up, compared to smokers of non-mentholated cigarettes, which can indicate increased withdrawal symptoms. Menthol cigarettes are preferred over non-mentholated by younger people, perhaps due to the smoother taste during smoking initiation. Menthol smokers may smoke fewer cigarettes per day but they have similar mortality rates to smokers of non-mentholated cigarettes.14
This section examines the potential biological mechanisms that underpin these effects of menthol on smokers.
12.7.2.1 Increasing the addictiveness of tobacco products
Menthol modifies the effects of nicotine on the brain
Nicotine binds to nicotinic acetylcholine receptors on the cell surface of neurons (nerve cells) in the brain. Under normal conditions, nicotinic acetylcholine receptors respond to a brain signalling molecule called acetylcholine, but nicotine hijacks these receptors, producing an aberrant effect on the brain. Binding of these receptors to nicotine leads to neuron activation, causing a release of dopamine in the brain and a subsequent feeling of euphoria.14
Nicotine acetylcholine receptors are referred to as a ‘family of receptors’, meaning that a number of similar proteins make up a multi-protein complex that binds to its targets. Functional nicotine acetylcholine receptors in the brain contain five subunits, consisting of alpha and beta subunits. There are numerous types of alpha and beta subunits that are used in a ‘mix and match’ way. Which subunits are forming the receptor complex can modify the response of the receptor to nicotine.
Menthol changes the effects of nicotine on the brain via several mechanisms:
1) Menthol increases the number of some nicotine acetylcholine receptor subunits in the brain, which may change the sensitivity of the brain to nicotine.18 ,19
2) Menthol changes the stoichiometry of the nicotine acetylcholine receptors; i.e. it changes the range of subunits making up the receptors. Different subtypes of the receptor have different sensitivities to nicotine and different desensitisation rates. Nicotine can bind to different forms of its receptor in the brains of people who smoke menthol compared to non-menthol cigarettes, thereby modifying nicotine reinforcement mechanisms.14
3) Menthol can enhance the euphoric effects of nicotine by causing dopamine release after exposure to smaller amounts of nicotine.14
4) Menthol can alter nicotine metabolism, essentially increasing its bioavailability (making it stay around in the body for longer, see Section 12.6.2.1). This increases the length of time that nicotine can affect the brain.20 ,21 However, the effect of menthol on nicotine metabolism seems counterintuitive, since faster metabolism of nicotine predicts greater dependence and poorer cessation.14 ,22 ,23 More research is required to understand the effects of the increase in bioavailability of nicotine caused by menthol.
Menthol may enhance nicotine absorption through the lungs
‘Cold’ receptors (sensory nerve endings) in the upper airways detect cold air, leading to a depressive effect on breathing. The menthol in tobacco smoke can stimulate the activity of the same cold receptors in the upper airways and may also increase cool sensations in the lungs. This can lead to breath-holding, and subsequently a greater opportunity for exposure and transfer of the contents of the lungs into the blood. These changes may lead to a greater exposure of nicotine, potentially increasing addictiveness.24
12.7.2.2 Increasing the attractiveness of tobacco products
Flavouring
Cigarettes and other tobacco products with sufficient menthol added during their manufacture often have a recognisable menthol taste. Menthol is designated as a characterising flavour of cigarettes.24 Characterising flavours are defined as a ‘clearly noticeable smell or taste other than one of tobacco, resulting from an additive or a combination of additives, including, but not limited to, fruit, spice, herbs, alcohol, candy, menthol or vanilla, which is noticeable before or during the consumption of the tobacco product.’25 Characterising flavours are important strategic concepts in tobacco product regulation; they are banned in cigarettes and roll-your-owns in the European Union by the European Tobacco Products Directive 2014/40/EU.25 Characterising flavours, with the exception of menthol, are also banned in the US26 and Canada.27
Masking the harshness of smoke
Menthol in smoke stimulates a ‘cooling’ sensation in the mouth and throat, which reduces the harsh feeling of smoke , as described in Section 12.7.2.1 above.24 ,28 Menthol also has analgesic properties and may reduce feelings of pain in the upper airways that occurs due to the harshness of smoke.14 Menthol can therefore mask harshness of smoke, facilitating smoking in people who would otherwise be irritated by it.
Analysis of tobacco industry documents uncovered industry research showing that menthol reduces negative sensory characteristics associated with smoking in those that cannot tolerate the harshness of smoke.29
12.7.2.3 Health effects of menthol tobacco products
Menthol is not a carcinogen and has no known toxicity at the concentration used in cigarettes.30 There are no known pyrolysis or combustion products of menthol with toxicity. At higher concentrations, menthol may have toxic and irritant effect, especially to the eyes.
Menthol affects the addictiveness of cigarettes, leading to increased uptake of smoking and decreased quitting (see Section 12.7.4). Therefore, at a population level the use of menthol by tobacco companies has caused considerable harm to health. The harm caused by menthol cigarettes in the US from 1980 to 2018 was estimated using a prevalence simulation model. This study predicted that the use of menthol cigarettes was responsible for slowing down the decline in smoking prevalence by 2.6 percentage points (13.7% vs 11.1% in 2018) and was responsible for 10.1 million extra smokers, three million life years lost and 378,000 premature deaths in the US from 1980 to 2018.31
Nicotine and nicotine biomarker (cotinine, see Section 12.5.6) levels do not differ in the saliva of menthol and non-menthol cigarette smokers. However, young adult daily menthol smokers have slower rates of nicotine metabolism, indicating that nicotine stays in the body for a longer period of time in smokers of menthols, as described above.21
A number of studies have examined the overall profile of people who smoke menthol compared to non-menthol cigarettes. On average, menthol smokers smoke a slightly lower number of cigarettes per day.32 ,33 This has been shown by studies that controlled for sex, age and race.32 Former menthol smokers have slightly higher weight as measured by body mass index, and are over twice as likely to have visited the emergency room due to asthma, compared to former smokers of non-mentholated cigarettes.32 Despite smoking fewer cigarettes on average, there was no difference in health care utilisation33 or mortality rates of menthol smokers compared to smokers of non-mentholated cigarettes.14 ,34 (See also Section 18.3).
The presence of menthol in cigarettes affects the tobacco microbiota (the range of microorganisms present), by changing the types of bacteria present in the tobacco.35 ,36 The health impacts, if any, of these changes are currently unknown.
12.7.3 Consumer perceptions of menthol tobacco products
Menthol tobacco products are a very popular choice among smokers, with over 32% of cigarettes sold in the US and 20% of little cigars being mentholated.13 Reasons for adults choosing menthol cigarettes include ‘tasting better’, ‘soothing the throat’, ‘easier to inhale’ and ‘easier to inhale deeply’.37 An Australian study has shown that people who smoke menthol cigarettes are more likely to experience these as favourable sensory experiences, including feeling smooth, being soothing on the throat, fresh-tasting and clean-feeling, than non-mentholated products.38
Tobacco industry documents detail industry studies showing that menthol smokers, particularly women, perceive the aroma of menthol cigarettes as more socially acceptable than that of non-menthol products.39 Tobacco industry research also indicates that menthol smokers perceived that these products signalled social group belonging.40
Many smokers are under the misperception that menthol cigarettes are less dangerous to their health than non-mentholated products.37 ,38 ,41 ,42 Advertising and branding are likely to have played a role in driving this misperception. Prior to the 1950s, menthol cigarettes have been advertised as having health benefits. Since this time, menthol cigarettes have been described by words such as ‘fresh’ and imagery such as snowfields, beaches and rainforests.37 Young people who smoke menthol cigarettes perceive them as easier to smoke and less harmful than smoking non-mentholated cigarettes.43 ,44 Studies in Australia and New Zealand also show that many smokers hold the misperception that menthol cigarettes are less harmful than non-mentholated.38 ,45 There is some evidence that misperceptions of lower harmfulness are strengthened by the experience of the sensations of smoothness created by mentholated smoke.30
12.7.4 Menthol cigarette use by specific groups of people
Menthol cigarettes are more popular among specific demographics. Compared to White and Hispanic smokers, African American people are more likely to smoke menthol cigarettes. A 2010 study of over 280,000 people (20–65 years old) from 2003 to 2007 found that 70% of African American smokers used menthol cigarettes compared to 20% of White smokers and 25% of Hispanic/Latino smokers.46 A 2015 study estimated that 84.6% of non-Hispanic black/African American smokers were menthol users.47 Menthol cigarettes were predicted to be responsible for 1.5 million new smokers, 157,000 premature deaths and 1.5 million life-years lost among African Americans over the period from 1980 to 2018.48 Similar proportions were found by numerous other studies in the US.30 American smokers were also more likely to smoke menthol cigarettes if they were female49 or younger (as described in Section 12.7.5). Furthermore, menthol smokers were more likely to have lower education levels and lower incomes compared with smokers who used non-mentholated cigarettes.30 Menthol cigarette use may also differ according to sexuality and/or gender. A study of adult LGBT smokers in the US showed a 1.31-fold higher odds of smoking menthols than their non-LGBT counterparts.50 Among LGBT smokers, 36.3% were menthol users.50
Targeted advertising campaigns since the 1960s are likely to have contributed to the disproportionate use of menthol cigarettes used by African American people.10 There is also evidence of targeted marketing to LGBTQIA+ people,51 women and young people.52
A genetic propensity to experience heightened bitter taste perception may modestly increase the preference for menthol cigarettes in people with specific variants of the TAS2R38 bitter taste receptor gene.53 ,54 A variant of a gene called MRGPRX4, found solely in people with African ancestry, was strongly associated with menthol smoking in a US cohort. This gene produces a receptor found on the cell surface of sensory nerve cells believed to be involved in pain detection. There was a 5-to 8-fold increase in the odds of menthol cigarette use in people with the gene variant. However, even in African people, this gene variant is relatively uncommon, meaning that its presence cannot account for most of the strong preference of African American smokers for menthol cigarettes.55
12.7.5 Effects of menthol on smoking initiation and cessation
Consistent evidence supports a role for menthol cigarettes in promoting the initiation of smoking in young people, above the extent of non-mentholated cigarettes.16 It is likely that the cooling sensation of menthol on the upper airways aids the transition to smoking, reducing irritation in the throat in people who are new to the practice. A systematic review of studies on initiation of smoking concluded that there was a strong association between youth and smoking of menthol cigarettes compared to adult use of menthols.16 Numerous studies have demonstrated a higher prevalence of menthol than non-menthol use in younger people and an age gradient where younger smokers were more likely to smoke menthols.16 ,47 Young people who recently started smoking were more likely to use menthol cigarettes than those who have smoked for longer than one year.16 ,56 Longitudinal studies have also shown that young people who start smoking menthol cigarettes were at greater risk of progressing to regular smoking and nicotine dependence than those who start with non-mentholated cigarettes.57 ,58
The smoking of menthol cigarettes is associated with reduced smoking cessation. This is consistent with biological evidence that menthol can increase the addictiveness of tobacco products described in Section 12.7.2.1. There is evidence that smokers of menthol cigarettes are more dependent on nicotine and experience increased emotional attachment to cigarettes compared to people who smoked non-mentholated cigarettes.59
Longitudinal studies measuring smoking cessation have shown that people who smoke menthol cigarettes have a lower rate of cessation than people who smoke non-mentholated cigarettes. African American and Latino people who smoked menthols were less likely to quit compared to people of the same ethnicity who smoked non-menthol cigarettes.60 ,61 Young people who smoked menthol cigarettes had a higher chance of intending to continue smoking than nonmenthol cigarette users.62 In White people, the use of menthol cigarettes has led to significantly lower odds of maintaining continuous abstinence and maintaining postpartum smoking abstinence (in women) compared to use of non-mentholated cigarettes.63 ,64 A systematic review of randomised controlled trials for smoking cessation described five studies that found significantly reduced cessation among menthol smokers compared to non-menthol smokers.16 This review concluded that cessation is reduced in non-Hispanic White people as well as in racial and ethnic subgroups of menthol smokers compared to non-menthol smokers, despite increased quit attempts of menthol smokers.16 A later meta-analysis of 19 cessation studies in the US did not find a significant association between menthol use and cessation overall (i.e. in combined data for all groups of people); but did find that among African Americans, menthol users were significantly less likely to quit than users of non-menthol products (OR 0.88).17
12.7.6 Use and perceptions of menthol cigarettes in Australia
Menthol cigarettes were traditionally promoted as a 'feminine' cigarette within the Australian market. Unsurprisingly, more women than men in Australia have smoked menthol cigarettes in the past.65 Alpine, manufactured by Philip Morris, was strongly marketed to younger women in particular, prior to the current regime of advertising bans and was also 'stealth marketed' to young women at fashion events after the bans were in place.66-69 Alpine was also sold in packets of 15 cigarettes, which may have appealed to younger smokers with less money.65
Menthol cigarette popularity may have declined in Australia from 1980 to 2008.65 About 20% of female smokers aged 19–29 years used menthols in the 1980s, but this reduced to less than 10% by 2008. In women over 30 years (women who had been in their teens prior to 1990), this proportion fell from 25% to just less than 20%.65 More recent data from a national online panel study in 2019 found that 25.2% of the current smokers taking part in the research study were current users of menthol cigarettes. Smokers in the study who were aged 18 to 29 years were 3.50 times more likely to be current menthol smokers (34.0%) compared to those aged 50 to 69 years (12.8%; OR = 3.50, 95% CI = 2.70, 5.37, p = < 0.001). Likewise, smokers aged 30 to 49 years were 2.70 times more likely to be current menthol smokers (28.4%) than those aged 50 to 69 years (OR = 2.70, 95% CI = 1.81, 4.02, p = < 0.001).38
Australian secondary students are exposed to menthol in crushable capsules, which may provide a palatable pathway to smoking initiation. Five percent of secondary students had tried flavour capsule cigarettes in 2017, which would mostly be menthol flavour.70 Students who used flavour capsules multiple times were more likely to have greater involvement in smoking, being more likely to have smoked in the past week or month, consistent with menthol promoting a progression to regular smoking. Those who had smoked previously were more likely to agree that 'some brands of cigarettes are easier to smoke than others' if they had tried a flavour capsule cigarette.70 See Section 10.8.4.1 for more information about menthol ‘crushball’ capsules in cigarette filters.
Relevant news and research
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