Even anti-tobacco studies must be held to basic scientific standards. A response to: Smoking intensity and intent to continue smoking among menthol and non-menthol adolescent smokers in Canada.

Abstract

I read with interest the paper recently published in your journal which sought to ‘‘examine whether menthol cigarette smoking is associated with higher smoking intensity and intention to continue smoking among adolescents.’’ In my view, the findings of the study are scientifically flawed and run the risk of misleading regulators looking at means to reduce smoking prevalence, especially among youth. The findings of the study will also incorrectly lead smokers, especially youth, to believe that non-mentholated cigarettes are less addictive than other cigarettes, something not supported by the evidence. The authors of the paper analyzed cross-sectional data from the Canadian Youth Smoking Survey (YSS), in an effort to find a link between mentholation of cigarettes and the addictiveness of cigarette smoking among Canadian youth. They conclude that their analyses ‘‘suggest the need for banning mentholated tobacco products in Canada, in part because of its significant effect on adolescent smoking.’’ Scientifically, it is well known that ‘‘association’’ does not equal ‘‘effect’’ or ‘‘cause.’’ Yet by the authors’ own admission, ‘‘this study has some limitations that are worth noting. First, causation cannot be determined from crosssectional data.’’ The authors state the limitations of the study and then go on to completely ignore those limitations when stating their conclusions. This limitation is compounded by the authors’ classification of what constitutes being a menthol cigarette user. In their analysis, they count any youth who smoked even just one menthol cigarette in the last 30 days, as a menthol smoker. This classification ignores the reality that youth smokers who get their cigarettes mainly from social sources (Youth Smoking Survey, 2013) are willing to smoke whatever they can get their hands on, mentholated or not. If a non-menthol smoker can occasionally get his or her hands on a mentholated cigarette, they will take it. This applies especially to those who are most addicted to nicotine, the known addictive component in cigarettes. It is unreasonable and unscientific to suggest that it is the menthol in the cigarettes that causes youth to smoke, even if they only smoke one mentholated cigarette a month. There is nothing wrong per se with analyzing crosssectional data, or even using a novel definition for ‘‘menthol smoker.’’ But the authors plug in this information and then make conclusions that their inputs could not possibly support. The evidence points to a much more plausible explanation for the association between youth who smoked at least one menthol cigarette during the last month, and smoking intensity as well as intention to quit. That is, menthol does not make cigarettes more addictive, but rather those who are most addicted to smoking are likely to smoke a range of whatever cigarettes they can gain access to, including a menthol cigarette. Therefore, the findings of this study tell us nothing about whether prohibitive regulation of any mentholated or flavored tobacco product would alter youth smoking rates and reduce the population-level risk of smoking. Reducing the harms associated with tobacco use is a legitimate aim for health agencies, policymakers, regulators, and the tobacco industry alike. What is needed to & Jeff Stier jeffstier@gmail.com