Menthol Cigarettes Double Stroke Risk

Yael Waknine

April 18, 2012

April 18, 2012 — Menthol cigarettes more than double the risk for stroke compared with regular cigarettes, a new study shows. In women and nonblack smokers, the risk for stroke was more than tripled.

No significant associations were observed between the tobacco additive and other forms of cardiovascular disease, such as hypertension, myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease (COPD).

The mechanism by which menthol may increase stroke risk remains unclear.

One potential mechanism is that menthol stimulates upper-airway cold receptors, which can increase breath-holding time, which may in turn facilitate the entrance of cigarette particulate matter into the lungs, notes Nicholas Vozoris, MD, from St. Michael's Hospital, in Toronto, Ontario, Canada.

Another possibility is that menthol cigarettes exert some selective effects on the cerebrovascular system.

"[S]moking mentholated cigarettes has been found to result in increased carotid artery stiffness compared with smoking nonmentholated cigarettes, whereas equal decreases in coronary artery reserve flow were observed between the 2 cigarette types," Dr. Vosoris explains.

The study is published in the April 9 issue of Archives of Internal Medicine.

Menthol Cigarettes Linked to Increased Stroke Risk

For the study, Dr. Vosoris obtained data for 5028 current smokers aged 20 years and older by using the 2001-2008 US National Health and Nutrition Examination Survey (NHANES); 1286 individuals (25.6%) usually smoked menthol cigarettes and 3742 (74.4%) smoked other types. Given previously reported differences in effect by age, sex, and age group, fully stratified analyses looking specifically at these subgroups were performed.

After adjustment for sex, age, race, education level, total household income, body mass index, and smoking quantity/duration, menthol cigarettes were linked to a 2.25-fold increase in stroke risk compared with their nonmentholated counterparts. The increase was particularly high in women and nonblack smokers.

After further adjustment for clinician-diagnosed, self-reported hypertension, diabetes, and dyslipidemia, the risk remained significantly increased among all, female, and nonblack smokers of menthol cigarettes.

Table 1. Risk for Stroke With Menthol vs Nonmenthol Cigarettes

Group Odds Ratio (95% Confidence Interval)
Adjusted risk  
Menthol vs nonmenthol 2.25 (1.33 - 3.78)
Women vs men 3.28 (1.74 - 6.19)
Nonblack vs black 3.48 (1.70 - 7.13)
With additional adjustment for hypertension, diabetes, and dyslipidemia  
Menthol vs nonmenthol 2.19 (1.05 - 4.58)
Women vs nen 3.54 (1.60 - 7.84)
Nonblack vs black 3.02 (1.24 - 7.34)


No significant increases were detected in the risks for other diseases, such as hypertension, myocardial infarction, congestive heart failure, or COPD, with menthol over regular cigarettes.

Table 2. Other Risks Associated With Menthol Cigarettes

Cardiovascular Risk Odds Ratio (95% Confidence Interval)
Hypertension 1.17 (0.84 - 1.62)
Myocardial infarction 0.89 (0.40 - 1.99)
Heart failure 1.32 (0.56 - 3.15)
COPD 1.06 (0.50 - 2.22)


"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," Dr. Vozoris concludes.

Dr. Vozoris has disclosed no relevant financial relationships.

Arch Intern Med. 2012;172:590-591. Abstract


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