In the United States, menthol cigarettes rose to popularity during the 1950s. At about the same time, manufacturers began focusing their marketing efforts on Black Americans. The effects of these campaigns can be felt today, with Black smokers making up more than one quarter of all menthol users in the United States. Sadly, the country has been slow to adopt policies that might curb the rate of menthol cigarette consumption, and Black Americans have paid the price.
As the country grapples with various manifestations of systemic racism, failures in tobacco control must be part of the conversation. Tobacco use is now the leading cause of preventable death among Black Americans, claiming 45,000 lives each year. Of Black Americans who smoke, more than 85 percent use menthol cigarettes — a rate that is far higher than menthol use prevalence in other racial and ethnic groups.
Smoking any kind of combustible cigarette greatly increases a person’s risk of death and disease but menthol use poses unique risks. Compared to nonmenthol cigarettes, they are associated with increased smoking initiation among youth, greater addiction potential and reduced success in cessation, particularly among Black smokers. Menthol users also suffer an increased risk of dying from tobacco-related diseases like cancer, heart disease and stroke. This is troubling, given that Black Americans are already predisposed to these illnesses. In light of all this, Deidre Sully of Business Insider aptly predicted that the tobacco industry will soon face a Black Lives Matter reckoning.
In this same spirit, we propose a firm ban on menthol cigarettes in the United States — not just as matter of public health, but of civil rights. There exists precedent for such legislation: Last year, the European Union implemented a ban on the manufacture and sale of menthol cigarettes for its member countries. To further explore the implications of such a ban in the United States, the Foundation for a Smoke-Free World commissioned a survey of menthol cigarette smokers in eight EU countries before and after the ban. Promisingly, the results suggest that some menthol users did quit or switch to less harmful products as a result of the ban.
Considering that the United States remains the world’s largest menthol market in the world, a menthol ban in the country could have profound effects, particularly in the Black community.
Toward a Solution
People who use menthol cigarettes are much less likely to quit than those who use other cigarettes. And while nonmenthol cigarette consumption has been on the decline for the past decade, menthol cigarette use has remained relatively steady. These trends indicate that existing tobacco control initiatives have failed to successfully reach menthol users — and as such, they have also failed Black Americans. Encouragingly, new harm-reduction products, including snus and e-cigarettes, may offer a path to cessation.
Many menthol smokers, like all smokers, understand the risks of their habit but struggle to quit. For such individuals, HRPs offer a strategy by which to avoid some of the health consequences of smoking, without quitting nicotine cold turkey. Indeed, the Food and Drug Administration recently authorized the marketing of two HRPs — snus and heat-not-burn products — as “modified risk tobacco products.”
Mounting research indicates that e-cigarettes can help smokers quit. And, for menthol users, the efficacy of this strategy may be enhanced by flavors that satisfy users’ menthol cravings without all the risk that comes with combustible cigarettes. Indeed, even among nonmenthol smokers, flavored e-cigarettes have been shown to be particularly effective in promoting a transition away from combustible products.
Given the established success of e-cigarettes as a cessation strategy, proposed bans on flavored products would be counterproductive to public health goals. This topic has been closely studied by various organizations, including the National Bureau of Economic Research, which concluded that a ban on flavored e-cigarettes may result in “increased choice of combustible cigarettes, which is the most harmful alternative.”
There is great irony in the fact that some states and countries are pushing to ban flavored e-cigarettes while leaving deadly menthol combustibles on the market. This genre of legislation derives not from science, but from widespread misperceptions about the relative risk of HRPs. Unfortunately, misleading messaging on this topic has led many tobacco users — and some legislators — to believe that e-cigarettes are equally or more harmful than combustibles. Now, New York, New Jersey and Rhode Island have enacted policies that ban the sale of flavored e-cigarettes, while leaving menthol combustibles untouched.
The EU has a more sensible approach to tobacco control — and it’s helping smokers quit. Their 2020 ban did not affect the availability of flavored HRPs, granting menthol smokers the option to switch to reduced risk menthol products. And, indeed, the foundation’s study reveals that nearly 20 percent of the menthol smokers surveyed switched to menthol products not affected by the ban, with a majority (57 percent) switching to e-cigarettes.
These outcomes hold important lessons for the United States as the country navigates its own menthol policy. Namely, that flavored e-cigarettes can be used as a relatively safe offramp from deadly menthol products, and banning these HRPs will stifle efforts to reduce smoking rates. As the United States considers implementing a menthol ban, it must carve out a role for HRPs. Without this option, menthol users may continue to use combustible products, nullifying the stated goals of this legislation.
A Call to Action
The foundation is calling on the FDA to end the sale of menthol cigarettes and to do so in a manner that supports addicted individuals. This should include the continued availability of menthol e-cigarettes, which will help to ensure that users do not switch to nonmenthol combustibles or turn to the black market for menthol products. This recommendation is backed by scientific evidence and coheres with the views of multiple public health organizations. The FDA has the authority to implement the right policies and to correct misperceptions about HRPs. It’s time that the United States holds the tobacco industry responsible for exploiting Black Americans.
Dr. Derek Yach is the president of the Foundation for a Smoke-Free World and previously served as cabinet director and executive director for noncommunicable diseases and mental health, World Health Organization.
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