Association of menthol-flavoured cigarette smoking with all-cause and cause-specific mortality risk

Menthol-flavoured cigarettes remain unregulated in the USA and in many low- and middle-income countries (LMICs) despite their known impacts on smoking uptake and reduced cessation. Yet, evidence about whether menthol cigarettes are associated with higher disease risks than non-menthol cigarettes is inconclusive, and the industry has used this argument to lobby against regulation.

All-cause and cause-specific mortality risk was assessed according to baseline smoking status (current, former and never) and menthol flavour status (menthol and non-menthol) of the cigarette brand smoked for the longest period among 969 349 persons from Cancer Prevention Study-II, a population-based prospective cohort study enrolled in 1982-1983 with mortality follow-up of 6 years.

73 486 and 281 680 persons reported menthol brands and non-menthol brands, respectively, among whom 4071 and 20 738 deaths occurred, respectively. Currently smoking cigarettes, whether menthol or non-menthol brands, was associated with highest mortality risks (eg, all causes: about two times higher risk vs never smoking) but quitting substantially reduced risks for both types. Among persons who formerly smoked, menthol versus non-menthol smoking was associated with an elevated mortality risk of 12% from all-causes, 16% from all cardiovascular diseases, 13% from ischaemic heart disease, and 43% from other heart diseases Among individuals currently smoking, there was no difference in mortality risks for menthol versus non-menthol cigarettes except for elevated risk among those smoking≥40 cigarettes per day. Black persons currently smoking menthol versus non-menthol brands had an 88% elevated mortality risk for other heart diseases.

Findings of a unique excess mortality risk associated with menthol cigarettes provide additional scientific evidence-apart from their known impacts on initiation and cessation-in support of menthol flavour regulation in the USA and similar policies in LMICs. Public communication efforts must reiterate that quitting all cigarette types is the only safe option to reduce disease risk.