Mainstream tobacco control advocates are celebrating the recent announcement that the Food and Drug Administration is poised to restrict the manufacture and sale of mentholated cigarettes and cigars.
Making national and international headlines, the messaging related to the long-awaited decision is that the FDA is “taking urgent action to reduce tobacco addiction and curb deaths.” Clearly, urgency is in the eye of the beholder.
For more than a decade, the leadership of the National Association for African American Tobacco Network and other tobacco control experts have been pushing for the FDA to act on menthol cigarettes.
Indeed, the urgent efforts being taken now by the FDA are the direct result of a lawsuit filed in 2020 by the African American Tobacco Control Leadership Council, Action on Smoking and Health, the American Medical Association, and the National Medical Association, to name just a few of the plaintiffs.
The basis of the lawsuit was the failure of the agency to act on the large body of research on the negative consequences associated with menthol cigarettes, especially in the Black community.
In our eyes, urgent action to reduce addiction and curb deaths would have been to ban menthol in 2009 when Congress passed the Family Smoking Prevention and Tobacco Control Act. The two legislative changes brought about by that act of Congress were to ban the inclusion of all characterizing flavors in cigarettes with the exemption of menthol flavoring and to give the FDA regulatory authority over the tobacco industry.
Urgency would also have also been demonstrated by banning menthol when the FDA concluded after a four-year period of scientific review that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.”
That report from the FDA was issued in 2013. Now, in 2021, the FDA announces that it is working toward product standards that could include a ban on menthol. If enacted, the ban would not take effect until 2024. Urgent action, indeed.
Why has it taken so long for the enactment of equitable and common sense public policy related to menthol flavoring?
Especially, given the experience of the menthol ban across Canada that did not lead to increased illicit menthol cigarette buying. The ban also appears to have resulted in people smoking less overall.
From a public health standpoint, no reasonable explanation exists for the FDA to allow menthol flavored tobacco products to remain on the market twelve years after banning all other characterizing flavors in cigarettes.
Nicotine addiction is an addiction of adolescence with the majority of smokers starting in their teens. Central to the rationale of the passage of the 2009 Family Smoking Prevention and Tobacco Control Act was the prevention of smoking initiation among adolescents and teens.
As argued, fruity flavored tobacco products such as cherry and bubble gum were specifically targeted to youth to increase interest and attractiveness in this demographic. To take liberties with the words of Sojourner Truth, “Ain’t menthol a flavor?”
A simple review of the data would have shown that the majority of adolescents who use nicotine containing products—both combustible cigarettes and vaping liquids—prefer a menthol flavoring.
Currently, mentholated brands of cigarettes enjoy the largest market share of all flavored tobacco products. Indeed, the most recent data suggest that more than half (54%) of youth aged 12-17 who smoke report use a mentholated brand of cigarette.
A health equity framing of the failure to ban menthol points to the enormous differences in preferences for menthol among youth of color. For example, 83% of African American youth who smoke use a mentholated brand. This same preference for mentholated cigarettes is observed among Black adults who smoke.
The disproportionate use of menthol products among Black smokers is by no means an accident. African American communities have been targeted by the tobacco industry for nearly 50 years with advertisements, free products, and discounted coupons.
In 2002, the family of Marie Evans successfully sued the Lorillard Tobacco Company, the maker of Newport cigarettes (also known by many as “the Black cigarette”), for giving free cigarettes to Black children in Boston.
Marie Evans started receiving free cigarettes at age 9 and died of lung cancer at age 54. The pernicious targeting of Black children by the tobacco industry continues. One study found that the cost of Newport cigarettes was significantly lower in convenient stores located near minority-serving high schools compared to other neighborhoods.
Further, while the majority of White youth have migrated away from combustible tobacco products to now highly regulated electronic nicotine delivery devices (i.e., e-cigarettes), Black youth prefer menthol flavored cigarillos which can be purchased in packs of three for 99 cents in low-income African American neighborhoods.
The most damning research associated with menthol are the findings linking mentholated tobacco products with higher levels of addiction and difficulty in quitting smoking. The negative consequences of being targeted with a highly addictive tobacco product are evident from the epidemiological data on Black smokers.
Smoking cessation rates among Black smokers has lagged significantly behind those of other racial/ethnic groups.
Black smokers have among the highest levels of smoking-related morbidity and mortality of any racial/ethnic group in the United States. For example, each year, approximately 17,000 Black Americans die of lung cancer. The annual loss of life associated with all tobacco-related disorders is 18% higher for Blacks than for whites.
Referred to as the Black smoking paradox, Black adults are more likely to develop and die from lung cancer than members of other racial/ethnic groups, despite smoking fewer cigarettes per day than members of other racial/ethnic groups.
As such, the lack of urgency in regulating menthol products is in effect, a lack of urgency in reducing Black tobacco addiction and curbing Black deaths.
From a public health standpoint, no reasonable explanation exists for the FDA to allow menthol flavored tobacco products to remain on the market twelve years after banning all other characterizing flavors in cigarettes.
Menthol regulation is not only a tobacco prevention and control issue, but a social justice imperative. Where are our urgent efforts needed? Increasing education in the Black community of the social justice issues associated with menthol cigarettes is imperative. Increasing access to evidence-based and culturally appropriate smoking cessation interventions is essential.
Increasing provider knowledge about the increased risk for lung cancer for Black smokers at younger ages and with lower frequency smoking must be a priority. Establishing innovative approaches to engaging Black smokers in shared decision-making regarding lung cancer early detection screening must take place.
And lastly, recognizing the inadequacies of the current lung cancer screening guidelines for saving Black lives and calling for funding a new national lung cancer screening trial for low frequency menthol smokers must be a priority. (And if the FDA is indeed serious about the ban, that study should begin pronto.)
As the FDA continues urgent deliberations regarding the future of menthol products in the United States, the work by activities and scholars to prevent Black addiction and death will continue … as if our very lives depended on it.
