Influence of Menthol Cigarette Smoking on Lung Cancer Screening Eligibility in a National Prospective Study

PROJECT SUMMARY/ABSTRACT
Lung cancer is the leading cause of cancer death among US men and women and accounted for more than
125,000 deaths in 2023—more than 20% of all cancer deaths. An important strategy to reduce mortality is lung
cancer screening by low-dose computed tomography (LDCT), which has been estimated to reduce lung cancer
mortality by up to 20%. In 2013, the US Preventive Services Task Force (USPSTF) began recommending LDCT
lung cancer screening for people aged 55–80 years with a 30 pack-year history of smoking who currently smoke
or had quit within 15 years; in 2021, these criteria were revised to include adults aged 50–80 with a 20 pack-
year smoking history. Although uptake has been slow, there have been favorable shifts in diagnoses towards
earlier stages. Still, nearly half of lung cancers today are diagnosed at distant stages, and inequities in lung
cancer screening and mortality persist for several groups such as African Americans, women, and people with
lower income, many of whom smoke menthol vs non-menthol cigarettes and at increasing rates. Menthol in
cigarettes is associated with increased smoking initiation, propensity to progress to regular smoking, increased
nicotine dependence, and decreased cessation success. Paradoxically, people who smoke menthol cigarettes
have comparable levels of nicotine and carcinogen exposure biomarkers yet consume fewer cigarettes per day
than people who smoke non-menthol cigarettes. Prior studies have concluded that menthol cigarette type need
not be considered when estimating risk for lung cancer. However, these studies predated growth in the menthol
cigarette market and the introduction of LDCT lung cancer screening, for which eligibility is determined largely
by cigarettes smoked per day. This raises new questions about the potential indirect impact of menthol cigarette
smoking on lung cancer screening and outcomes: if people who smoke menthol consume fewer cigarettes per
day, are they less likely to meet screening eligibility criteria, despite having the same exposure to carcinogens?
If true, people who smoke menthol face greater risk for later-stage diagnosis, and subsequently, mortality. This
application will utilize the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) and the
Tobacco Longitudinal Mortality Study (TLMS) to evaluate the influence of menthol in cigarettes on lung cancer
screening eligibility and outcomes. Under Aim 1, we will compare lung cancer screening eligibility for people who
smoke menthol vs nonmenthol cigarettes, hypothesizing that menthol smoking will be associated with decreased
probability of meeting screening eligibility criteria. We will also examine changes over time and differences by
race/ethnicity, sex, and income through stratified analyses. Under Aim 2 we will evaluate lung cancer screening
eligibility and menthol smoking exposure among individuals who have died of lung cancer using a case-case
approach. We hypothesize that adjusted odds of menthol smoking will be higher for ineligible vs eligible cases
and will evaluate heterogeneity by time (< 2013 vs after), race/ethnicity, sex, and income. We will also investigate
the reasons for ineligibility among those not eligible (e.g., pack-years vs age) and if this differs by menthol status.

Grant Number: 1R21CA301405-01
NIH Institute/Center: NIH
Principal Investigator: Michelle Bover Manderski