Motivation to Quit Smoking Among Black Adults Residing in Los Angeles County Communities With Menthol Cigarette Sales Restrictions

Abstract Background: Research is needed to identify the determinants of motivation to quit smoking among non-Hispanic Black (NHB) adults who smoke menthol cigarettes and reside in communities covered by menthol cigarette bans. Objectives: This study examined the associations between motivation to quit smoking and a range of individual-level predictors, including measures of demographics, harm/risk perception of menthol cigarettes, and awareness of a ban on menthol cigarettes in Los Angeles County unincorporated communities. Self-identified NHB adults who currently smoke menthol cigarettes (N=50; M=47.2 years; SD=13.7; 46% female) were recruited in Los Angeles County unincorporated communities. Participants completed an interviewer-administered cross-sectional survey between January to September 2021. Results: Participants (74%) reported an annual household income of less than $25,000. Participants’ mean age at cigarette initiation was 15.7 years old (SD=5.68). Most (88%) were aware of the ordinance banning menthol cigarette sales. Employing multivariable linear regression analysis, harm/risk perception of menthol cigarettes (B=14.69, p<0.01) and awareness of the local menthol ban (B=26.18, p<0.05) were found to be independently associated with motivation to quit smoking. Conclusions: Findings from this community-based sample suggest that among NHB adults who smoke menthol cigarettes, motivation to quit smoking is influenced by their perception of menthol cigarettes as harmful and awareness of local policy banning the sale of menthol cigarettes. Findings underscore the need for community-centered and culturally grounded interventions to facilitate quitting among NHB adults who smoke in order for communities covered by menthol bans to achieve health equity in reducing preventable racial inequities due to menthol cigarettes.


Introduction
The burden of combustible tobacco-related disease and death in the United States falls disproportionately on vulnerable populations (e.g., non-Hispanic Black (NHB) people, lower socioeconomic status groups), due in significant part to menthol cigarettes (Drope et al., 2018;Villanti et al., 2016).By design, when menthol is added, cigarettes are made even more harmful and palatable by reducing throat irritability, blocking respiratory symptoms, leading to nicotine dependence, and making it harder to quit smoking (Willis et al., 2011).Research suggests that people who smoke menthol cigarettes may be less motivated to quit smoking compared to people who smoke non-menthol cigarettes because menthol cigarettes are more palatable than non-menthol cigarettes (Anderson, 2011).
Although NHB people account for 12% of the total U.S. population (Jones et al., 2021), a recent simulation study found that among them, menthol cigarettes contributed to 1.5 million (15%) new smokers, 157,000 (41%) smokingrelated premature deaths, and 1.5 million (50%) life-years lost during the period 1980-2018 (Mendez & Le, 2021).In 2019, approximately 85% of NHB people who smoke preferred menthol cigarettes, compared to 30% of their non-Hispanic White (NHW) counterparts (Substance Abuse & Mental Health Services Administration [SAMHSA], 2020).Indeed, the lived experience of NHB people in the U.S. has and continues to be characterized by entrenched inequities in policies and practices more often than their NHW counterparts (Bailey et al., 2021;Braveman et al., 2022), including less access to evidence-based smoking cessation treatments (U.S. Food & Drug Administration [USFDA], 2022), as well as predatory marketing, advertising, and pricing strategies for menthol cigarettes in Black communities (Anderson, 2011;Gardiner, 2004;Smiley et al., 2021).
Policies restricting the sale of menthol cigarettes have the potential to advance racial and health equity and save between 324,000 and 654,000 lives over time-nearly a third (between 92,000 and 238,000) among NHB people (USFDA, 2021).On April 28, 2022, following more than a decade of exemption from the 2009 federal ban on flavored cigarettes (U.S.Department of Health and Human Services, 2018b), the U.S. Food and Drug Administration announced a proposed product standard to ban menthol cigarettes and all flavored cigars, stating that it will "improve quitting and address health disparities" (USFDA, 2021).Although a federal menthol ban has not yet been enacted, a growing number of local jurisdictions across the U.S. have enacted policies restricting the sale of menthol cigarettes (Rogers et al., 2022).The commercial tobacco industry and allies have also been lobbying against menthol cigarette bans saying these bans harm Black communities (Baumgaertner et al., 2022).
In a unanimous vote on September 24, 2019, the Los Angeles County Board of Supervisors passed a comprehensive ordinance banning the sale of menthol cigarettes and other flavored nicotine and commercial tobacco products (i.e., flavored vapes, flavored little cigars, flavored hookah) in the unincorporated communities of the County (unincorporated communities are governed by the Los Angeles County Board of Supervisors) (Tobacco Control & Prevention Program, 2020).The ordinance became enforceable on May 1, 2020 (Tobacco Control & Prevention Program, 2020).Understanding what influences quitting among NHB adults who smoke menthol cigarettes is critical for advancing racial and health equity in policies restricting the sale of menthol cigarettes and can help to inform interventions to facilitate smoking cessation.In the current study, we recruited NHB adults who smoke menthol cigarettes to examine the associations between motivation to quit smoking and a range of individual-level predictors, including measures of demographics and awareness of the Los Angeles County ordinance.

Participants and data collection
Participants were self-identified NHB adults (≥21 years) who currently smoke (defined as those who indicate that they have ever smoked 100 cigarettes and now smoke every day or some days) and who indicate that the brand they usually smoke is mentholated.Participants were recruited in Los Angeles County unincorporated communities (i.e., View-Park Windsor Hills, Westmont) from January to September 2021 via partnerships (e.g., California Black Women's Health Project, faith-based organizations), community health fairs, physical flyers, online postings (i.e., Facebook, Craigslist), and email listservs.Following informed consent, eligible participants completed a one-time, 20-minute interviewer-administered survey over the telephone and were sent an electronic $50 gift card.The University of Southern California Institutional Review Board approved this study (UP-20-00975).

Dependent variable
Motivation to quit smoking was measured using the question: "On a scale of 1 to 10, how much do you want to quit smoking, where 1 is "not at all" and 10 is "very much?"

Independent variables
Sociodemographic variables were age at survey, sex, annual household income, and highest education level attained (i.e., high school or general educational development (GED) certificate or less, some college or more).
Age at first cigarette was measured using the question: "How old were you when you had your first puff of a cigarette?" Nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND), a standard instrument for assessing the intensity of physical addiction to nicotine (de Leon et al., 2002Leon et al., , 2003;;Diaz et al., 2005;Fagerström, 2012;Fagerström et al., 1990Fagerström et al., , 1996;;Gallus & La Vecchia, 2004;John et al., 2004;Kozlowski et al., 1994;Moolchan et al., 2002).The FTND is a six-item scale, and the scale score ranges between 0 and 10 with higher scores indicative of high nicotine dependence (Heatherton et al., 1991).Questions included: (1) "How soon after you wake up in the morning do you smoke your first cigarette?"Response options were 1 = Within 5 min (3 points), 2 = 5 to 30 min (2 points), 3 = 31 to 60 min (1 point), and 4 = After more than 60 min/1 h (0 points); (2) "Do you find it difficult to refrain from smoking in places where it is forbidden such as a church, on an airplane, or at the movies?"Response options were 1 = Yes (1 point), and 2 = No (0 points); (3) "Which cigarette would you hate most to give up?" Response options were 1 = The first one in the morning (1 point), and 2 = Any of the others (0 points); (4) "How many cigarettes do you smoke each day?" Response options were 1 = 10 or fewer (0 points), 2 = 11 to 20 (1 point), 3 = 21 to 30 (2 points), and 4 = 31 or more (3 points); (5) "Do you smoke more during the first few hours after waking than during the rest of the day?" Response options were 1 = Yes (1 point), and 2 = No (0 points); and (6) "Do you smoke when you are so ill that you are in bed most of the day?" Response options were 1 = Yes (1 point), and 2 = No (0 points).
Harm/Risk perception of menthol cigarettes was measured using the question: "In your opinion, is your smoking menthol cigarettes very risky, somewhat risky, a little risky, or not at all risky for your health?"Response options were "very risky," "somewhat risky," "a little risky," "not risky at all," and "not sure."A sum score was created from responses to the question (range 1-4), with "very risky" coded as 4, and "not risky at all" coded as 1.The response option "not sure" was coded as missing.
Awareness of the local law restricting retail sales of menthol cigarettes was measured by asking: "A recent change in local smoking laws has to do with restrictions on the sale of menthol cigarettes and other flavored commercial tobacco products in unincorporated communities in Los Angeles County.This includes menthol cigarettes sold in your neighborhood convenience store.Have you heard of this law?"Response options included "yes," "no," and "I don't know."Response options were coded to "yes"=1, "no"=0, and "I don't know" as missing.

Statistical analyses
Analyses were conducted using SAS Version 9.4 (Cary, NC: SAS Institute, Incorporated).Preliminary analyses included descriptive statistics (means, standard deviations, proportions) for the overall sample.Multivariable linear regression analyses were employed where the association between each independent variable and the dependent variable was adjusted for all other variables in the model.An α level of p < 0.05 was used to determine the level of statistical significance.

Results
Of the 50 participants interviewed (Table 1), 27 (54%) were men and 23 (46%) women, with an average age of 47.2 (SD = 13.7).More than half (58%) had some college or higher and had an annual household income of less than $25,000 (74%).Fagerström Test for Nicotine Dependence scores ranged from 1 to 8, with an average score of 4.42 (SD = 2.08).Participants' mean score for harm/risk perception of menthol cigarettes was 3.45 (SD = 0.92), more than a "little risky".Most (88%) were aware of the local menthol ban.
Table 2 shows the results of multivariable analyses.Controlling for individual factors (i.e., sex, annual household income, highest education level attainment, age at cigarette initiation, and nicotine dependence), participants' perception of menthol cigarettes as harmful/risky (B = 14.69, p < 0.01), and awareness of the local menthol ban (B = 26.18,p < 0.05) were found to be significantly associated with motivation to quit in the multivariate analyses.

Discussion
This cross-sectional exploratory investigation sought to identify the determinants of motivation to quit smoking among a Los Angeles County-based sample of NHB adults who smoke menthol cigarettes and were recruited in communities that have banned the sale of menthol cigarettes in the retail environment.Most participants in this study reported wanting to quit smoking menthol cigarettes.Motivation to quit smoking was significantly associated with awareness of the local menthol ban and perceptions of menthol cigarettes as harmful.These findings suggest that NHB adults who smoke menthol cigarettes want to quit, and a menthol ban may prompt them to do so.These findings underscore the need for community-centered messages about menthol cigarettes' harmful effects, and how a menthol ban benefits NHB adults who smoke by encouraging cessation.Future research is needed to understand to what extent participants' reported motivation to quit smoking correlates with their current smoking behavior (e.g., successfully quitting menthol cigarettes, switching to non-menthol cigarettes, switching to noncombustible products) in the policy context.
This study adds to the literature (Keller et al., 2020) in finding that higher menthol cigarette harm/risk perception was significantly associated with motivation to quit smoking among study participants.Policymakers may be able to leverage study findings in local, statewide, and national health communication messages about the rationale for banning menthol cigarettes and protecting public health.These data may also be valuable for designing public information campaigns on harms of menthol cigarettes and benefits of menthol bans.These factors are important as Californians on November 8, 2022, voted to uphold a 2020 state law that banned the retail sale of menthol cigarettes and most flavored nicotine and commercial tobacco products (Tobacco Control & Prevention Program, 2020).
Our findings also suggest that NHB adults who smoke menthol cigarettes are of low socioeconomic status (e.g., most participants had an annual income of $25,000) and lends support to our argument that menthol bans can advance health equity by addressing the impact of structural racism (i.e., unjust policies and practices) on cessation outcomes.NHB adults who smoke cigarettes have been shown to be more likely to attempt to quit (Davila et al., 2009;Malarcher et al., 2011;Mowls et al., 2014) but less likely to successfully quit smoking compared to NHW adults (Babb et al., 2017;Gallus & La Vecchia, 2004;King et al., 2004;Trosclair et al., 2002).Additionally, compared to their NHW counterparts, NHB adults who smoke are less likely to have health insurance coverage (Hostetter & Klein, 2018), utilize evidence-based cessation treatments (Babb et al., 2017), or to receive smoking cessation services in healthcare settings (Babb et al., 2017;Hostetter & Klein, 2018;Zhang et al., 2019), due in part to experiences of racial discrimination (Webb et al., 2020).Previous research (Cornelius et al., 2020) shows that having health insurance increases the odds of quitting smoking, due to more primary care visits, follow-up smoking assessments, and evidence-based cessation treatments.Policies banning menthol cigarettes may be sufficient for prompting cessation among NHB adults who smoke but not for achieving cessation if the policy context does not promote reparative justice for Black communities.Policies banning menthol cigarette sales should include a provision that addresses the decades-long harm done by the commercial tobacco industry (Gardiner,   Findings from this study should be interpreted in light of its limitations.We adopted a cross-sectional survey; hence, causality should not accordingly be inferred in the results.Additionally, the results were based on participants' self-report, which would be subject to social desirability and recall biases.Future studies with larger sample sizes and in other localities that have menthol bans could be conducted to confirm findings observed in this study.Despite these limitations, identifying factors associated with motivation to quit smoking in the policy context provides opportunities for moving beyond focusing on disparities, to shaping inclusive, data-driven policies and interventions for increasing quitting among NHB adults who smoke menthol cigarettes.

Conclusions
Menthol cigarettes disproportionately harm NHB people and their communities.As policies restricting menthol cigarette sales gain momentum, it is important to identify the determinants of quitting among NHB people who smoke menthol cigarettes.The current study, based in Los Angeles County unincorporated communities that have banned menthol cigarette sales, found that most NHB adults who smoke menthol cigarettes want to quit.Participants' perception of menthol cigarettes as harmful/ risky and awareness of the local menthol ban were found to be significantly associated with motivation to quit smoking.This suggests that efforts to reduce menthol cigarette smoking among NHB adults covered by menthol bans may need to leverage messages that convey the harms of menthol cigarettes and promote smoking cessation.Study findings can inform equitable enforcement of the ban in the retail environment across Los Angeles County unincorporated communities, in addition to, the recent state-wide menthol cigarettes and most flavored non-cigarette products (i.e., e-cigarettes, small cigars) (Trosclair et al., 2002) ban, and the proposed federal ban (USFDA, 2021).

Table 2 .
(Bailey et al., 2021;Braveman et al., 2022) individual-level factors associated with motivation to quit smoking (N = 50).),U.S. healthcare settings(Bailey et al., 2021;Braveman et al., 2022), and exemption of menthol cigarettes from the 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Products Scientific Advisory Committee, 2011).That could mean providing comprehensive health insurance for NHB people who smoke, including coverage for evidence-based cessation treatments, and dismantling structural racism by investing commercial tobacco tax revenue into Black communities, institutions, and organizations.