Background:
Research in high-income countries (HICs) has raised awareness of the harms of menthol cigarettes, providing the foundation for a growing movement in HICs to ban menthol. Menthol masks the harshness of smoke, making it easier for youth to start smoking, and encouraging health-concerned smokers to switch to menthols, incorrectly believing that menthols are less harmful. There are few studies of menthols in LMICs, and almost none in Africa. We conducted the first population study in Africa to assess the prevalence of menthol cigarettes, beliefs about harmfulness of menthols, and predictors of menthol use.

Methods:
Data were from the International Tobacco Control (ITC) Kenya Wave 1 (2012) and Zambia Wave 2 Survey (2014). These are longitudinal surveys of nationally representative samples of adults in each country. This study focuses on 1,449 smokers who answered questions on use, choice, and perceptions of menthol cigarettes (Zambia only).

Results:
Prevalence of menthols was high in Zambia (43%, highest of 24 ITC countries) and Kenya (21%, third-highest). In Zambia, the erroneous belief that menthols are less harmful was high (36%—second-highest), and most common among younger (69%), medium-income (36%), and non-daily smokers (42%). In Zambia, menthol use was associated with: belief that menthol is less harmful (OR=3.68,p=0.01), choosing brand because of taste (OR=2.46,p=0.01), health concerns (OR=3.32,p=0.0001), and price (OR=0.31,p=0.04). In Kenya, menthol use was associated with: choosing brand because of taste (OR=3.49,p=0.0002), price (OR=1.73,p=0.05); health concerns (OR=1.57,p=0.04); and perceiving that quitting is beneficial (OR=1.78,p=0.04).

Conclusions:
Menthol use was high in Zambia and Kenya, and predicted by health concerns. This is alarming because many smokers (in Zambia) incorrectly believe that menthols are less harmful. These findings support the need for African countries to raise awareness of the myth of menthols and to ban menthol and other flavorings to reduce initiation among youth and to encourage smokers to quit.