Smoking Menthol Cigarettes Tied to Stroke

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People who smoke menthol cigarettes were more likely to have a history of stroke than smokers who prefer regular cigarettes, an analysis of federal health survey data indicated.

Among 5,167 current smokers participating in the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2008, those who reported that they usually smoke menthol cigarettes were more than twice as likely to have had a stroke as those smoking nonmenthol cigarettes, according to Nicholas Vozoris, MD, MHSc, of St. Michael's Hospital and Queen's University in Toronto.

Vozoris calculated an odds ratio of 2.25 for a history of stroke among the menthol versus nonmenthol cigarette smokers (95% CI 1.33 to 3.78), according to his research letter published in the April 9 issue of Archives of Internal Medicine.

"These results highlight the need for further review of the last legally allowed tobacco additive in North America, given that mentholated cigarettes may be placing individuals at even greater risk of potentially devastating cerebrovascular disease than regular cigarettes," Vozoris wrote.

Much of the difference was seen among women and whites, he found.

The odds ratio for stroke history among female menthol cigarette smokers was 3.28 (95% CI 1.74 to 6.19) and among non-African-Americans -- who were predominantly white -- it was 3.48 (95% CI 1.70 to 7.13).

The calculations reflected adjustments for age, sex, race, education, household income, body mass index, recent smoking behavior, and age at which the respondent started smoking regularly.

Vozoris indicated that histories of other cardiopulmonary conditions -- hypertension, MI, heart failure, and chronic obstructive pulmonary disease -- were not significantly related to menthol cigarettes.

Odds ratios for these conditions in menthol versus nonmenthol cigarette smokers ranged from 0.89 to 1.32 among all smokers in the analysis, none of which came close to statistical significance.

With additional adjustments for reported histories of multiple cardiopulmonary conditions, menthol cigarette smoking was still significantly associated specifically with stroke and at odds ratios very similar to those in Vozoris's primary analysis.

In NHANES during the period covered by the analysis, participants were asked about their smoking habits, including their preference for menthol versus nonmenthol cigarettes, at what age they started smoking, how often they had smoked in the preceding month, and how many cigarettes they smoked on average.

Health history information was also supplied by respondents, who were read a list of conditions and asked whether they had been told they had them by a health professional.

Vozoris noted the oddity that menthol cigarettes were apparently associated with stroke but not other cardiovascular problems.

"A possible explanation is that mentholated cigarettes exert some selective effects on the cerebrovascular system," he wrote, citing previous studies indicating that menthol cigarette smokers had increased carotid artery stiffness whereas menthol and nonmenthol cigarette smoking had the same effects on coronary artery reserve flow.

However, he also conceded that the association of menthol cigarettes and stroke could have non-causal explanations, such as that smokers choosing menthol cigarettes may have higher baseline risk for stroke or decreased likelihood of having medical therapy to prevent stroke.

Shortly after the FDA's authority to regulate tobacco was expanded in 2009, the agency banned most flavorings in cigarettes but exempted menthol while it studied whether it poses special risks.

Last March, an FDA advisory panel determined that mentholation does indeed make cigarettes more harmful, largely by making them more addictive and therefore harder for smokers to quit.

On the other hand, it also found that there wasn't enough evidence to say whether menthol cigarette smokers were at higher risk of disease than other smokers.

The FDA has not yet taken any action against menthol in cigarettes.