An Experimental Evaluation of Menthol-Flavored Tobacco Accessories: Subjective Effects and Purchasing Behavior

Cigarette smoking remains the leading preventable cause of death and disease in the United States (US), accounting for half a million deaths per year and nearly 30% of all cancer deaths. More than 28 million US adults smoke daily, 35% of whom smoke menthol flavored cigarettes. Menthol cigarettes are linked to increased risk of smoking initiation and reduced likelihood of cessation. In addition to increased product appeal and attractiveness, menthol's cooling properties may induce misperceptions of reduced harm and mask early symptoms of respiratory disease. A cohort study (N ≈ 1 million) by the American Cancer Society found that former menthol smokers had a 12-43% higher risk of all-cause and heart disease mortality compared to former non-menthol smokers.

Efforts to reduce the appeal of cigarettes have been enacted worldwide, with several countries adopting regulatory policies on menthol flavor in tobacco products. In the US, state and local governments have been leading these tobacco control efforts, with over 140 localities implementing a menthol cigarette ban as of December 2024, including California and Massachusetts. Menthol bans have been effective in reducing smoking prevalence and increasing cessation rates. Nonetheless, at least one-third of menthol smokers continue to smoke after a menthol ban. A key contributor is the tobacco industry's promotion of mentholation accessories - including crush balls, filter tips, aroma cards - that consumers can use to flavor non-menthol cigarettes after purchase. These accessories, often nicotine-free and sold separately from tobacco products, fall outside the scope of tobacco regulations and have grown in popularity in jurisdictions with bans. Studies indicate that up to 40% of pre-ban menthol smokers may adopt these accessories after restrictions take effect, undermining public health objectives.

In this study, the investigators will experimentally examine subjective ratings of non-menthol cigarettes, flavored with various menthol-flavor accessories (e.g., crush balls, filter tips, aroma cards), compared to participants' own preferred brand of menthol cigarettes and non-menthol cigarettes equivalent.

In a within-subject design, menthol cigarette smokers will sample non-menthol cigarettes mentholated with menthol-flavor accessories (e.g., crush balls, filter tips, aroma cards), non-menthol cigarettes and their own cigarettes. Participants will provide subjective ratings of each product (e.g., liking, strength, ease of use) in comparison to their usual menthol cigarette brand. They will complete hypothetical cross-commodity purchase tasks and will complete one control trial and two ETM conditions representing different levels of restriction on menthol flavor in cigarettes. Within each condition, the investigators will manipulate availability of products and observe purchasing patterns across tobacco products and menthol-flavored accessories.

The study will consist of one in-lab visit. The study phases include: 1) Screening Phase; 2) Consent and assessments; 3) Sampling and subjective ratings assessments, and 4) ETM and hypothetical purchasing trials.