Banning Menthol Cigarettes: The Time Has Come

The systematic exploitation of the African American community by the targeted marketing of menthol-flavored tobacco products is a sorry chapter in the squalid history of the tobacco industry. A long-standing pattern of misinformation concerning the supposed health benefits of menthol cigarettes, an appropriation of the Civil Rights movement’s values and messaging, and self-serving “philanthropy” were hallmarks of the decades of calculated deception that characterized industry activities as it sought to ingratiate itself with Black culture and communities (1-3). African Americans pay dearly, and disproportionately, for that exploitation. The cost has been staggering: 1.5 million smoking initiators, 157 000 premature deaths, and 1.5 million life-years lost in recent decades attributed to menthol smoking in the African American community (4). The damage inflicted on the overall US population is no less clinically significant: 10.1 million initiators, 378 000 premature deaths, and 3 million life-years lost (5). The addition of menthol to tobacco products began decades ago; it serves to reduce the harshness of smoking (leading to deeper inhalation, greater nicotine intake, and greater addiction) (6), upregulates nicotinic receptors, facilitates trans-buccal drug absorption, and dilates bronchial airways (7). Of prime importance to the tobacco industry, menthol serves to ease the initiation of smoking (8), and allows for the false suggestion of harm reduction, represents a “cultural trademark” for smokers within the African American community—85% of whom now use menthol products (4)—and decreases the likelihood of cessation within that population (6,9,10). Lung cancer is the leading cause of cancer death among Black men in the United States and the second leading form of cancer death among African American women (11). Any attempt to address these stark epidemiological realities must involve strategies to minimize smoking initiation and accelerate rates of smoking cessation. It follows that the addition of a product known to ease smoking initiation and forestall smoking cessation when added to cigarettes should be the focus of thoughtful product regulation. The benefits of a menthol ban would seem incontrovertible and such a step viewed as an integral part of enlightened public health policy. Multiple authors posit that important reductions in smoking initiation and increases in cessation would follow the introduction of such a ban (8,10,12). What has been the experience elsewhere? Menthol bans have already been introduced in jurisdictions including Canada, Brazil, and the European Union. Within the Canadian context, the ban on the sale of menthol cigarettes has been shown to significantly increase overall rates of cessation attempts and cessation success among menthol smokers compared with nonmenthol smokers (13,14). The Canadian experience, it has been suggested, might usefully be emulated elsewhere with a “tremendous public health impact at the population level … especially for jurisdictions with higher prevalence of menthol smokers” (14). In this issue of the Journal, Munro and colleagues (15), in a thoughtful and thorough comparison of smoking cessation rates of menthol vs nonmenthol smokers, raise questions regarding the perhaps unanticipated consequences of a ban on the sale of menthol cigarettes. Their analysis based on a long-term examination of a distinct, disadvantaged population of low-income Americans leads them to suggest that, within this population, there are similar rates of cessation among both menthol and nonmenthol smokers but a slightly higher rate of smoking resumption among those who were menthol users. They point out that a ban on the sale of menthol cigarettes might cause migration of smokers to nonmenthol products and an enhanced risk of lung cancer. This, they suggest, warrants concern as the possibility of a menthol ban seems more likely. They acknowledge that their analysis is based on self-reported smoking behavior—a not unimportant limitation—and that there are questions regarding the generalizability of their findings to the broader population. More than 9000 African Americans were included in their analysis, but, importantly, they note the numbers for robust analysis of menthol vs nonmenthol differences in the reuptake of smoking were not large (15). Their study assesses cessation and does not, understandably, examine the impact of a menthol ban on the initiation of smoking within the study communities; the impact of menthol in facilitating the adoption of smoking behaviors is well understood and an important consideration in any discussion of the implications of such a ban. Others who have examined the need for a menthol ban have been almost universal in noting the benefits that will follow, particularly to the African American community. They note that such a ban would reduce initiation of youth smoking, improve rates of cessation among adult smokers, benefit public health, and contribute to health equity and social justice (9,16,17). African Americans, with the removal of menthol from cigarettes, are expected to experience greater reductions in smoking than the general population (12). Smokers of menthol products have indicated in the past that they would try to stop smoking if menthol was prohibited (18), and support for such a ban is highest within populations with the greatest prevalence of menthol use (19). Overall, notwithstanding the concerns identified by Munro and colleagues (15) about a segment of the menthol-smoking population who do not quit and migrate to conventional cigarette use, it is difficult to imagine that the introduction of a menthol ban would be anything other than positive from a public-health perspective. Those concerns merit examination but, more importantly, underscore the need for an enhanced approach to cessation assistance coincident with the introduction of a menthol ban—particularly in communities where the use of menthol cigarettes is common. That would serve to forestall the likelihood of migration to other tobacco products while enhancing the likelihood of cessation success and would be particularly relevant in assisting those in minority or disadvantaged groups where rates of smoking and burdens of tobacco disease are much higher (20). Clinicians, understandably, are frustrated by the inertia, bordering on indifference, which often seems to characterize governments’ approaches to the regulation of the tobacco industry. The menthol “story” is a case in point. It would seem clear that an enlightened approach to tobacco control would eliminate this “minty poison,” which, with singular impact, has added to the burden imposed by tobacco products on the African American community. A menthol ban is long overdue. No funding was provided in support of the preparation of this manuscript. Role of the funder: Not applicable. Disclosures: The author (ALP) has previously served as a consultant to Johnson & Johnson and Pfizer and as an expert witness for the Government of Canada, Department of Justice. Author contributions: ALP: conceptualization, writing—original draft, writing—review and editing. No data was generated in the preparation of this editorial.

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