How Smokers of Menthol Cigarettes and Flavored Cigars Might Respond to FDA’s Proposed Bans

Abstract

Introduction

A ban on menthol cigarettes and flavored cigars may reduce smoking and tobacco-related disparities.

Aims and Methods

We aimed to examine the response of current smokers to a hypothetical ban on menthol cigarettes and flavored cigars. Current smokers were recruited online and reported the alternative products that they may switch to under a hypothetical ban, if they would try to obtain the banned products from illicit channels, and their support to the ban.

Results

51% of current smokers would use nonflavored cigarettes and cigars as alternatives, 45% would switch to flavored heated tobacco products or e-cigarettes or quit smoking. 17% would try to obtain the banned flavored products from illicit markets. A majority of menthol only smokers opposed the ban. Daily smokers would be more likely to switch to nonflavored smoking, to try illicit market products, and were less supportive of the ban. Black smokers would be less likely to switch to nonflavored smoking and were more supportive of the ban. Smokers who used menthol cigarettes only would be more likely to switch to nonflavored smoking, less likely to try illicit market sellers, and were the least supportive of the ban.

Conclusions

In response to a ban of all added flavors for cigarettes or cigars, nearly half of the current smokers would quit smoking, largely by switching to nonsmoking products. However, smokers with more chronic use and those who used only menthol cigarettes would be more likely to switch to nonflavored smoking, diminishing the harm reduction potential. The ban may decrease the relatively higher prevalence of menthol cigarette smoking among Blacks compared with other groups.

Implications

A ban on the sale of menthol cigarettes and flavored cigars may decrease the prevalence of smoking because some current smokers may quit smoking and switch to nonsmoking products. However, smokers with more chronic use and those who used menthol cigarettes only were more likely to switch to nonflavored cigarettes or cigars, diminishing the harm reduction potential of the ban. Black smokers would be more likely to switch to products other than cigarettes and cigars thus decreasing their relatively higher prevalence of smoking compared with other groups.

Introduction

The use of flavors, including menthol, is a public health concern. Menthol is added as a flavoring to tobacco because it makes smoking feel less harsh by creating a cooling sensation in the throat and airways of smokers¹ Menthol, as a flavor, promotes smoking initiation among youth and young adults, and increases nicotine dependence, and reduces cessation among current smokers.^2–5 Added flavors, including menthol, also have continued to increase the initiation and use of cigars and other tobacco products.^6–8 The prevalence of smoking flavored cigars was higher than or similar to smoking menthol cigarettes among youth⁹ and youth have reported more favorable perceptions of cigars compared with cigarettes.¹⁰ The recent decline in overall smoking prevalence primarily reflects a decreasing prevalence of nonmenthol tobacco smoking while the prevalence of menthol smoking remained relatively stable.^11,12 At the same time, African Americans and individuals with low income are disproportionately more likely to use menthol cigarettes and flavored cigars.^13,14 Thus, a ban of menthol and other flavors could not only reduce youth initiation and increase smoking cessation but also reduce certain tobacco-related disparities.¹⁵

In 2009, the US Tobacco Control Act banned all characterizing flavors except menthol in cigarettes. Afterwards, some countries (eg, Canada, Brazil, European Union countries, and the United Kingdom), and some US states (eg, Massachusetts) and cities (e.g., Minneapolis and San Francisco) have banned the sale of menthol cigarettes, typically as part of a broader ban on flavors for cigarettes or other tobacco products.^16,17 Over the past 2 years, there have been more sale restrictions in the United States on all or some flavored tobacco products including menthol cigarettes, flavored cigars, and flavored e-cigarettes.¹⁶ Recently, the US Food and Drug Administration (FDA) announced a plan to ban menthol in cigarettes and all characterizing flavors in cigars, including menthol.¹⁸ As indicated by FDA and other sources, a comprehensive ban on flavored cigarettes and cigars would directly impact not only smoking initiation and cessation but also substitution among various tobacco products, particularly between cigarettes and cigars and between smoked tobacco products and e-cigarettes, if e-cigarettes are still available in menthol or other nontobacco flavors.^18–21

Evidence on the changes in tobacco use in response to a ban on menthol cigarettes and flavored cigars has been limited and inconsistent. Initial experimental evidence indicated that such flavor bans could prompt some smokers to quit and that smokers switching from menthol to nonmenthol cigarettes could lead to lower nicotine dependence, increase motivation to quit, and result in additional smoking declines.²² In Canada, a federal ban on menthol cigarettes went into effect in 2017. One study found that 2 years following the menthol ban, the majority of menthol cigarette smokers (59.1%) switched to nonmenthol cigarettes, 19.5% still smoked menthol cigarettes, and 21.5% quit smoking.²³ Another Canadian study found that 2 years after the ban, 10%–12% of menthol cigarette smokers had quit smoking.²⁴ Recently, a US study synthesizing opinions from experts estimated that if a menthol ban were implemented, 20%–30% of 18–54-year-old current smokers might either quit all tobacco use or switch to products other than cigarettes and cigars.²⁵

Despite existing state and local flavor bans, some smokers have still been able to obtain banned products, either by traveling to nearby jurisdictions where the flavored products are still legally sold or by purchasing illicit flavored tobacco products over the Internet or from nearby illicit market sellers. For example, following a ban on flavored cigarettes, some Canadian smokers continued to purchase menthol cigarettes legally from Indian reserves,²³ and following a flavor ban in San Francisco, smokers obtained flavored tobacco products from retailers in nearby towns and cities where the flavor ban was not implemented, as well as from local retailers illicitly selling the banned products.²⁶ In addition, manufacturers and retailers have circumvented bans through online sales, packaging changes, and by designing new products such as menthol accessories and flavor cards or capsules that can introduce flavors into nonflavored tobacco products.^27–30 Retailer compliance largely depends on the local context and enforcement efforts. For example, retailer compliance ranged from 80% to 100% in several cities in Minnesota³¹ but was moderate in San Francisco as indicated by the majority of respondents (65%) who perceived that the flavor ban had not been enforced completely.^26,32 Another concern is that a ban may trigger an illicit market for the banned product undermining regulatory efforts.³³

In general, the support for a ban on flavored tobacco products is higher among the US general public compared with current smokers.^26,34–38 Yet one study found that 35% of current tobacco users reported favorable attitudes toward prohibiting flavors in all tobacco products.³⁴ A recent study specific to banning menthol cigarettes found that 28% of current menthol cigarette smokers and 30% of current nonmenthol cigarette smokers supported the ban.³⁵ In addition, most previous studies indicate that racial and ethnic minorities were even more likely to support a menthol ban.^36–38

As a first step toward better understanding the impacts of a new, comprehensive, nationwide ban on all cigarettes and cigars with menthol or other added flavors, we need knowledge of how current smokers of menthol cigarettes and flavored cigars, those who would be most directly impacted, would respond. In this study, we examined the response of current smokers to a hypothetical ban on menthol cigarettes and flavored cigars: (1) if the banned products were not available by any channel, would smokers switch to nonflavored smoking or quit smoking and switch to products other than cigarettes and cigars? (2) if the banned products were not available through local retailers or legal channels, would smokers try to obtain them from other illicit channels? And (3) to what extent would smokers support the ban?

Methods

Survey

Data were collected between May and August 2021 on Amazon Mechanical Turk (MTurk),³⁹ an online crowdsourcing platform that has been used widely in tobacco control research.^40,41 MTurk is considered a reliable and cost-effective way to recruit samples that is largely comparable to conventional ways.⁴² Eligible respondents were adults who smoked either menthol cigarettes or flavored cigars (or cigarillos and little cigars) regularly (ie, at least once a week in the past 30 days). Eligible participants were given access to the survey, hosted by Qualtrics (Provo, UT). The “Prevent Ballot Box Stuffing” option provided by Qualtrics was used to keep participants from taking the survey multiple times. To further increase the quality of the survey and prevent fake information, we used a zipcode double-checking mechanism.²⁶ Among 3847 participants, 599 did not pass the zipcode double-checking, and 3248 participants were included in the analyses. The Institutional Review Board at the University of Memphis approved this study. In the following sections, we use “cigars” to refer to the product category inclusive of cigars, cigarillos, and little cigars.⁴³

Respondents were asked to check tobacco and nicotine products that they currently used including cigarettes, cigars, heated tobacco products, and e-cigarettes, which were further categorized as having tobacco, menthol, or some other flavor, or, for e-cigarettes, being unflavored (ie, no added flavor). Depending on the responses, respondents were stratified into three groups: (1) those who smoked both menthol cigarettes and flavored cigars regularly; (2) those who smoked menthol cigarettes regularly but not flavored cigars, and (3) those who smoked flavored cigars regularly but not menthol cigarettes.

Three Primary Outcomes

We first asked respondents to assume that a comprehensive FDA flavors ban for smoked tobacco products was completely implemented and there was no way to obtain any banned products; and then asked whether they would, in response to the flavors ban, initiate or increase their use of other tobacco and nicotine products. Those who responded affirmatively were further asked to select all possible alternatives they would use (in a “check all that apply” format), such as nonmenthol conventional cigarettes, nonflavored cigars, e-cigarettes with different flavor options, or heated tobacco products. We assumed that those who said they would not initiate or increase their use of other products in response to the ban would maintain their use of other tobacco products except menthol cigarettes and flavored cigars. To simplify the complexity of dual and poly use of multiple products, we categorized respondents’ postban use based on whether they expected to still be smokers, be heated cigarette users, be e-cigarette users, or not use any of those products.

To gain insights into possible illicit flavored use postban, we then asked respondents to assume that menthol and other flavored cigarettes and cigars were no longer available from local retailers or other legal channels and then asked them if they would try to obtain these products from any illicit channels. Those who responded affirmatively were asked to identify the illicit channels they would try, including local retailers who were also illicitly selling banned products, online sellers who violated the ban, illicit market sellers, friends and acquaintances, or any other illicit channels.

To gauge flavored smokers’ support for FDAs proposed flavor bans, we asked two 5-point Likert scale questions: “Do you support the FDA’s ban on the sale of menthol cigarettes?” and “Do you support the FDA’s ban on the sale of flavored cigars (including little cigars and cigarillos)”. Respondents were asked to choose among the following options: strongly support, support, neutral, oppose, and strongly oppose.

Related Variables

In addition to demographics, we collected several variables that potentially impacted respondents’ reaction to the ban including the history of smoking cigarettes or cigars (“how many years have you smoked either cigarettes or cigars regularly”). For both menthol cigarettes and flavored cigars, respondents were asked if they currently smoked daily, their dependence level, and their current channels for obtaining the product. The Heaviness of Smoking Index (HSI)^44,45 was used to assess dependence. To adapt the HSI to measure dependence on cigars, we computed the equivalent number of cigarettes from respondents’ daily use of cigars, with a simplification that a cigarillo or a little cigar is equal to a cigarette while one traditional cigar is equal to four cigarettes.⁴⁶

Analyses

First, we depicted the characteristics of respondents, their smoking status, and the three primary outcomes. Second, we used logistic regression models (PROC LOGISTIC in SAS, version 9.4) to estimate the odds of nonflavored smoking compared with all other options (ie, either quitting smoking by using only products other than cigarettes and cigars or quitting all tobacco-nicotine products). Third, we used logistic regression models to estimate the odds respondents would try to obtain banned products from illicit market sellers. Fourth, we used linear regression models (PROC GENMOD in SAS, version 9.4) to estimate the adjusted mean difference in the support for bans on menthol cigarettes and flavored cigars, respectively. All regression models included demographics and several related variables, as described above.

Results

As shown in Supplementary Table A1 (see Supplementary Material), for the three groups including (1) those who used both menthol cigarettes and flavored cigars (n = 1119); (2) those who used menthol cigarettes only (n = 1030), and (3) those who used flavored cigars only (n = 1099), the majority were White and obtained cigarettes or cigars solely from local retailers. Across the three groups, the chi-squared tests showed that respondents differed significantly by most demographic and smoking status variables (results not reported). Those who used menthol cigarettes tended to have a lower educational attainment, have a longer smoking history, were more likely to smoke daily, more likely to solely obtain their product from local retailers but less likely to use nonmenthol cigarettes or nonflavored cigars than the other two groups.

As shown in Table 1A, half of (51.0%) of respondents reported they would switch to nonmenthol menthol cigarettes or nonflavored cigars as alternatives, 12% would switch to heated tobacco products, and about one-third (32.4%) would switch to e-cigarettes. Continued smoking through nonflavored cigarettes or cigars was relatively higher among those who smoked only menthol cigarettes (53.6%), with lower and similar rates (49%) among the other two groups. At the same time, those who only smoked menthol cigarettes were also much more likely to quit all tobacco and nicotine products (7.0%) compared with 0.3% and 0.9% among the other two groups. As shown in Table 2, being Black, Hispanic, or having a higher education were associated with a lower likelihood of switching to nonflavored smoking compared with Whites and those with lower educational attainment. Compared with their counterparts, respondents who had a long history of smoking and used nonmenthol cigarettes or nonflavored cigars regularly were more likely to indicate that they would switch to nonflavored smoking. Respondents who used menthol cigarettes only were associated with a higher likelihood (OR = 1.75) of switching to nonflavored smoking compared to the other two groups.

Table 1.

Descriptive Results of (a) Alternative Tobacco and Nicotine Products, (b) Channels of Obtainments Among Current Adult Smokers, and (c) Support to a Hypothetical Ban on Menthol Cigarettes and Flavored Cigars, Stratified by the Use of Menthol Cigarettes and Flavored Cigars (N = 3248)

		Both menthol cigarettes and flavored cigars (n = 1119)	Use menthol cigarettes (n = 1030)	Use flavored cigars (n = 1099)	All respondents (N = 3248)
(A) Alternative tobacco/nicotine products
1Major products	Nonmenthol cigarettes or nonflavored cigars	49.2	53.6	49.9	50.8
	Heated tobacco products	15.0	11.6	10.7	12.4
	E-cigarettes	34.6	25.6	36.6	32.4
	Any other products	1.0	2.2	2.0	1.7
	Quit all tobacco/nicotine products	0.3	7.0	0.9	2.6
(B) Channels of obtainment
Would NOT try to any illicit channels		22.2	45.5	25.1	30.6
Local retailers who are also illicitly selling banned products		42.4	22.4	38.9	34.9
Online sellers who violating the ban		38.7	27.8	36.8	34.6
Illicit market sellers		20.3	11.7	17.8	16.7
Friends and acquaintances		25.7	21.0	20.8	22.6
Other illicit channels		3.7	7.7	2.3	4.5
(C) Support to the ban
To the ban of menthol cigarettes	Strongly support	18.6	9.2	16.3	14.8
	Support	28.4	11.1	30.9	23.8
	Neutral	26.0	20.2	32.8	26.5
	Oppose	15.0	20.7	9.9	15.1
	Strongly oppose	12.0	38.8	10.2	19.9
*Mean support of menthol cigarettes ban		3.3 (1.3)	2.3 (1.3)	3.3 (1.2)	3.0 (1.3)
To the ban of flavored cigars	Strongly support	15.2	8.3	11.5	11.8
	Support	29.4	13.1	29.9	24.4
	Neutral	26.5	23.7	28.8	26.4
	Oppose	15.8	21.5	15.2	17.4
	Strongly oppose	13.1	33.5	14.7	20.1
*Mean support of flavored cigars ban		3.2(1.2)	2.4 (1.3)	3.1(1.2)	2.9 (1.3)

The major products here are five categories that are mutually exclusive. The first category of nonmenthol cigarettes or nonflavored cigars included all respondents who used these products and they may also use other products; the second category of heated tobacco products includes all respondents who did not smoke nonmenthol cigarettes or nonflavored cigars, but used heated tobacco products and may also use other products; the third category of e-cigarettes includes all respondents who did not use either nonmenthol cigarettes or nonflavored cigars or heated tobacco products, but they used e-cigarettes and may also use other products.

*Support the ban was coded into values of 1–5 from the strongly oppose to strongly support, thus the mean value ranges from 1 to 5, with higher values indicating higher support and a value of 3 indicating neutral attitude.

Table 2.

Results of Logistic Regression Models: Odds of Using Nonflavored Cigarettes or Cigars as Alternatives Compared with all Other Reactions Responding to a Hypothetical Ban on Menthol Cigarettes and Flavored Cigars (N = 3248)

Category	Options	Odds ratios
Gender	Male (ref)	1
	Female	0.99(0.85,1.15)
Age, in years	18–24 (ref)	1
	25–34	0.97(0.75,1.30)
	35–54	0.99(0.76,1.36)
	55 and above	1.20(0.83,1.82)
Race/ethnicity	White (ref)	1
	Black	0.69(0.55,0.86)**
	Asian	1.12(0.74,1.66)
	Hispanic	0.67(0.55,0.80)**
	Other/mixed race	0.81(0.50,1.30)
1Educational attainment		0.72(0.63,0.81)**
2Household income		1.03(0.96,1.09)
3History of smoking cigarettes or cigars		1.20(1.09,1.33)**
Use of nonmenthol cigarettes or nonflavored cigars	Not use (ref)	1
	Use, but not regularly	5.66(4.45,7.20)**
	Use regularly	6.35(5.08,8.14)**
If smoke daily	Not daily (ref)	1
	Daily	1.16(0.99,1.37)
If moderate or high addiction to smoking	No (ref)	1
	Yes	0.85(0.68,1.07)
If obtains cigarettes or cigars only from local retailers	No (ref)	1
	Yes	0.92(0.77,1.06)
The use of menthol cigarettes and flavor cigars	Use both menthol cigarettes and flavored cigars (ref)	1
	Use menthol cigarettes only	1.75(1.41,2.16)**
	Use flavored cigars only	1.05(0.87,1.27)

Notes: boldface indicates statistical significance, with * for p < .05, and ** for p < .01.

Educational attainment was categorized into three levels: (1) high school or less; (2) less than bachelor and more than high school; and (3) bachelor or more.

Household income was categorized into five levels: (1) Less than $24,999; (2) $25,000 to $49,999; (3) $50,000 to $74,999; (4) $75,000 to $99,999; and (5) $100,000 or more.

History of smoking cigarettes or cigars was categorized into three levels: (1) <5 years; (2) 6–10 years; (3) >10 years.

As shown in Table 1B, the majority of respondents (69.4%) would consider trying to obtain the illicit products. The most popular illicit channels were local legal retailers also selling the illicit flavored products and Internet sellers, followed by getting the illicit products from friends and acquaintances, and from illicit market sellers (eg, street sellers). More than half of those who used only menthol cigarettes indicated that they would try to obtain menthol or other flavored cigarettes and cigars after the ban (54.5%), compared to roughly three-quarters of those who smoked flavored cigars, with or without smoking menthol cigarettes as well. Those who used menthol cigarettes only were also less likely to try most channels of obtaining illicit flavored products. For example, only 11.7% of those smoking only menthol cigarettes would try to obtain illicit products from illicit market sellers compared with 20.3% of those smoking both flavored cigars and menthol cigarettes and 17.8% of those smoking only flavored cigars. Compared with Whites, Asians and those who identified as members of other or mixed races were less likely to report they would seek illicit flavored cigarettes and cigars (Table 3). Compared with their counterparts, respondents who smoked daily, were more smoking dependent, or did not obtain cigarettes or cigars solely from local retailers were more likely to indicate that they would seek illicit menthol cigarettes or flavored cigars. Compared with respondents who used flavored cigars, either alone or along with menthol cigarettes, those who only used menthol cigarettes were less likely to indicate that they would seek illicit flavored cigarettes or cigars. At the same time, 7% of smokers of only menthol cigarettes stated that they would try to obtain menthol cigarettes from other channels, with 2% stating they would switch to “roll your own” cigarettes and cigars and add menthol flavor themselves.

Table 3.

Result of a Logistic Regression Model: the Odds of Trying to Obtain Banned Products from Illicit Market Sellers Compared with all Other Reactions Responding to a Hypothetical Ban on Menthol Cigarettes and Flavored Cigars (N = 3248).

Category	Options	Odds ratios
Gender	Male (ref)	1
	Female	0.89(0.74,1.08)
Age, in years	18–24 (ref)	1
	25–34	0.82(0.58,1.16)
	35–54	0.98(0.68,1.41)
	55 and above	0.88(0.54,1.45)
Race/ethnicity	White (ref)	1
	Black	0.79(0.59,1.07)
	Asian	0.51(0.27,0.97)*
	Hispanic	1.09(0.86,1.36)
	Other/mixed races	0.31(0.12,0.78)*
1Educational attainment		0.97(0.83,1.14)
2Household income		1.03(0.95,1.11)
3History of smoking cigarettes or cigars		1.04(0.92,1.17)
Use of nonmenthol cigarettes or nonflavored cigars	Not use (ref)	1
	Use, but not regularly	1.3(0.97,1.75)
	Use regularly	1.13(0.84,1.51)
If smoke daily	Not daily (ref)	1
	Daily	1.38(1.13,1.69)**
If moderate or high addiction to smoking	No (ref)	1
	Yes	1.26(0.96,1.65)
If obtains cigarettes or cigars only from local retailers	No (ref)	1
	Yes	0.76(0.62,0.93)**
The use of menthol cigarettes and flavor cigars	Use both menthol cigarettes and flavored cigars (ref)	1
	Use menthol cigarettes only	0.59(0.45,0.78)**
	Use flavored cigars only	1.00(0.79,1.26)

Notes: boldface indicates statistical significance, with * for p < .05, and ** for p < .01.

Educational attainment was categorized into three levels: (1) high school or less; (2) less than bachelor and more than high school; and (3) bachelor or more.

Household income was categorized into five levels:(1) Less than $24,999; (2) $25,000 to $49,999; (3) $50,000 to $74,999; (4) $75,000 to $99,999; and (5) $100,000 or more.

History of smoking cigarettes or cigars was categorized into three levels: (1) <5 years; (2) 6–10 years; (3) >10 years.

As presented in Table 1C a majority of those who used menthol cigarettes opposed or strongly opposed a ban for either menthol cigarettes or flavored cigars, with opposition to a menthol cigarette especially high, while the percentages of supporters were larger than the percentages of nonsupporters among those who used flavored cigars, with or without also using menthol cigarettes. As presented in Table 4, males, older adults, Blacks and Hispanics, those with higher levels of educational attainment, those with lower levels of household income, those with a shorter history of smoking, those who used nonmenthol cigarettes or nonflavored cigars, those who smoked less than daily, those who had moderate or high levels of dependence on smoking, and those who did not obtain cigarettes or cigars solely from local retailers were all more likely to be supportive of both bans compared with their counterparts.

Table 4.

The Adjusted Mean of the Support a Hypothetical Ban on Menthol Cigarettes and Flavored Cigars, Respectively (N = 3248). Support the Ban was Coded Into Values of 1–5 from the Strongly Oppose to Strongly Support, thus the Mean Value Ranges from 1 to 5, with Higher Values Indicating Higher Support.

Category	Options	Ban of menthol cigarettes	Ban of flavored cigars
Gender	Male (ref)	0	0
	Female	−0.09(−0.17, −0.01)*	−0.13(−0.21, −0.05)**
Age, in years	18–24 (ref)	0	0
	25–34	0.08(−0.07,0.23)	0.16(0.01,0.31)*
	35–54	0.07(−0.09,0.22)	0.14(−0.01,0.3)
	55 and above	0.18(−0.04,0.39)	0.38(0.16,0.59)**
Race/ethnicity	White (ref)	0	0
	Black	0.27(0.15,0.39)**	0.25(0.13,0.38)**
	Asian	0.12(−0.1,0.33)	0.19(−0.03,0.41)
	Hispanic	0.3(0.2,0.41)**	0.33(0.23,0.43)**
	Other/mixed race	0.09(−0.17,0.35)	−0.04(−0.3,0.22)
1Educational attainment		0.31(0.24,0.38)**	0.34(0.28,0.41)**
2Household income		−0.07(−0.1, −0.03)**	−0.06(−0.1, −0.03)**
3History of smoking cigarettes or cigars		−0.21(−0.26, −0.15)**	−0.19(−0.24, −0.14)**
Use of nonmenthol cigarettes or non−flavored cigars	Not use (ref)	0	0
	Use, but not regularly	0.2(0.08,0.32)**	0.14(0.02,0.26)*
	Use regularly	0.39(0.27,0.51)**	0.27(0.15,0.38)**
If smoke daily	Not daily (ref)	0	0
	Daily	−0.11(−0.2, −0.03)*	−0.1(−0.19, −0.01)*
If moderate or high addiction to smoking	No (ref)	0	0
	Yes	0.16(0.03,0.29)*	0.16(0.03,0.29)*
If obtains cigarettes or cigars only from local retailers	No (ref)	0	0
	Yes	−0.38(−0.47, −0.3)**	−0.38(−0.47, −0.3)**
The use of menthol cigarettes and flavor cigars	Use both menthol cigarettes and flavored cigars Use menthol (ref) cigarettes only	0	0
	Use menthol cigarettesonly	−0.4(−0.52, −0.29)**	−0.24(−0.35, −0.13)**
	Use flavored cigars only	0.05(−0.05, 0.16)**	−0.10(−0.20,0.01)

Notes: boldface indicates statistical significance, with * for p < .05, and ** for p < .01.

Educational attainment was categorized into three levels: (1) high school or less; (2) less than bachelor and more than high school; and (3) bachelor or more.

Household income was categorized into five levels:(1) Less than $24,999; (2) $25,000 to $49,999; (3) $50,000 to $74,999; (4) $75,000 to $99,999; and (5) $100,000 or more.

History of smoking cigarettes or cigars was categorized into three levels: (1) <5 years; (2) 6–10 years; (3) >10 years.

Discussion

In a survey of adult smokers that considered a hypothetical flavor ban, half of the current smokers who either smoked menthol or flavored cigarettes indicated they would switch to nonflavored smoking as alternatives, and the other half would stop smoking, either by switching to products other than cigarettes and cigars or, to a lesser extent, quitting using all tobacco and nicotine products.

These findings are consistent with an earlier scoping review that concluded 25%–64% of US smokers would attempt to quit smoking if a menthol ban were to be implemented²⁷ and an empirical study in Canada that found a majority of smokers switched to nonmenthol cigarettes after a ban on menthol cigarettes.²³ Overall, heavier smokers (ie, those who had a long history of smoking, smoked daily, and were more dependent on smoking) were more likely to switch nonflavored tobacco smoking as an alternative or to try to obtain illicit versions of the banned flavored products, and were less supportive of the ban than other smokers. One exception was that more-dependent smokers tended to be more supportive of the ban compared to less-dependent smokers, perhaps indicating that they might be more likely to perceive the harms of smoking and the benefits from the ban or to see the need for a ban to help them quit.

Among the three groups stratified by their use of menthol cigarettes and flavored cigars, smokers who used menthol cigarettes only had significantly different views from the other two groups. Although smokers who used menthol cigarettes only were less likely to state that they would try to obtain the banned products from the illicit market, they were also less supportive of the ban and more likely to state that they would use nonflavored cigarettes as alternatives. Compared with switching to products other than cigarettes and cigars such as e-cigarettes and heated tobacco products, which could reduce health harms and risks, switching from menthol cigarettes to nonflavored cigarettes and cigars is unlikely to secure any harm or risk reduction. However, at the same time, the percent of respondents who would quit all tobacco and nicotine products that will result in the most health gains was much higher among smokers who used menthol cigarettes only than the other two groups (7% compared with 0.3% and 0.9%).

One aim of the ban on menthol cigarettes and flavored cigars is to decrease the disparate burden of smoking, particularly the high prevalence of menthol cigarettes and flavored cigars use among Blacks and people with low income. Consistent with previous findings that racial and ethnic minorities were more supportive of a menthol ban than other ethnic groups,^36–38 we found that Black and Hispanic smokers of menthol cigarettes and/or flavored cigars were more supportive of a ban on menthol cigarettes and flavored cigars and less likely to use nonflavored cigarettes or cigars in response to a ban. This finding suggests that Blacks and Hispanics will be more likely to switch to products other than cigarettes and cigars, thus decreasing their relatively higher prevalence of smoking compared with members of other racial or ethnic groups. However, we also found that a lower household income was associated with lower support for the cigarette and cigar flavor bans.

One unique aspect of this study is that we considered smokers’ different responses to a ban according to where they usually obtained their flavored products (ie, from local retailers or not). Consistent with our expectations, smokers who obtained cigarettes or cigars solely from local retailers were less supportive of the ban, probably because they thought that local retail sales would be most powerfully impacted. In contrast, those smokers obtaining flavored cigarettes or cigars from sources other than local retailers might think that a flavor ban would be less likely to interfere with their purchases and use of the flavored cigarettes or cigars or, because of their experience obtaining flavored products from other sources, feel more confident in their ability to circumvent the ban. It is noteworthy that smokers who obtained cigarettes or cigars not solely from local retailers were also more likely to use nonflavored products and more likely to engage with the illicit market. For this group, restrictions on mailing tobacco and nicotine products will be an important complement to the ban.

Without a doubt, smokers’ reported intentions in response to a hypothetical ban, as in this study, could differ considerably from their actual reactions to a real ban. For example, comparing respondents’ planned reactions before the menthol cigarette ban with actual reactions one month after the ban, a Canadian study found that 60% of respondents intended to switch to nonmenthol cigarettes and 14% intended to quit smoking in response to a ban, while postban 28% switched to nonmenthol cigarettes and 29% quit smoking.⁴⁷ In addition, initial behavior changes after a flavor ban could be quite different from longer-term changes. In addition, ban-related actions by other stakeholders such as retailers, tobacco companies, and public health practitioners as well as the interactions among them will affect smokers’ reaction to the ban.

At the same time, the effect of a ban on menthol cigarettes and flavored cigars will vary depending on other policies in existence. The past several years saw several US states and local governments restrict the sales of flavored e-cigarettes. In 2020, FDA initiated a temporary ban on the sale of all capsule-based e-cigarettes with flavors other than tobacco or menthol. Currently, FDA is deliberating on the premarket tobacco product applications (PMTAs) submitted by e-cigarette manufacturers to enable their products to stay on or enter the market as legal products. Having menthol e-cigarettes available when FDA implements its planned menthol ban for cigarettes and ban of all added characterizing flavors for cigars could enable and prompt some menthol smokers to switch to using menthol e-cigarettes instead of switching to unflavored cigarettes, which could reduce their health risks compared to switching to combustible products. However, having flavored e-cigarettes available could also prompt some flavored smokers to switch to menthol or other flavored e-cigarettes instead of quitting all use, thereby increasing their health harms and risks. Further studies are needed to examine respondents’ reactions to various policy scenarios. Accordingly, further studies are needed to examine respondents’ likely reactions, depending on what other policies are in place when the FDA menthol cigarette and flavored cigar bans go into effect.

This study also has several other limitations. First, the study was based on a convenience sample. Some groups such as young adults and people with high educational attainment were overrepresented in our sample; thus some results may be biased. For example, as our analyses showed, people with higher educational attainment were less likely to use nonflavored cigarettes or cigars as alternatives and were more supportive of ban policies. Thus our findings of the percent of smokers who may use nonflavored cigarettes or cigars as alternatives may be lower, and the support for the ban may be higher, than in reality. Second, the quality of data may be an issue due to MTurk’s potentially overused respondents and fraudulent access.^48,49 However, through our zipcode double-checking and other mechanisms, we have tried to mitigate these risks. Third, we simplified the categories of dual and poly use of multiple products a respondent would use by focusing on the most harmful product. Thus, we may have missed some details such as use frequency. Considering the consensus that smoking is significantly more harmful than the exclusive use of e-cigarettes and heated tobacco products, instead, and our aim was to examine if a smoker would switch to nonflavored smoking and quit smoking, this simplification may not affect our findings.

Despite these limitations, our study provides strong evidence that a large portion of current smokers of menthol cigarettes or flavored cigars would respond to a comprehensive, nationwide ban on such flavored smoked tobacco products by quitting smoking, primarily by switching to products other than cigarettes and cigars, likely producing a net benefit for public health and reducing related smoking and health disparities relating to Blacks and lower income persons. However, the study also indicates that heavier smokers (ie, daily smokers and those with longer use histories and greater dependence) would more likely switch to nonflavored cigarettes or cigars as an alternative, compared with their counterparts, diminishing the harm reduction potential of the ban, and showing the need for additional policies to prevent and reduce smoking beyond the flavor bans.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This research was supported by the National Institute of Drug Abuse of the National Institutes of Health under Award Number R03DA048460 and also supported by the National Cancer Institute of the National Institutes of Health and FDA Center for Tobacco Products under Award Number U54CA229974. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

Declaration of Interests

ENL has served as a paid expert witness in some litigation against the Juul e-cigarette company.

Data Availability Statement

The data underlying this article will be shared at reasonable request to the corresponding author.