Cigarette smoking annually claims the lives of 480,000 Americans, accounting for a sixth of all deaths (a seventh in the extraordinary pandemic year of 2020). That is more — a lot more — than the combined total of deaths caused by all licit and illicit drugs, alcohol, homicide, suicide, motor vehicle collisions, HIV/AIDS, and fires.
Cigarettes are not an equal opportunity killer, however. Notably, African Americans’ death rate from smoking exceeds that of white Americans, despite the fact that African Americans smoke fewer cigarettes and start smoking at a later age. One potential factor is a far larger percentage of African American smokers use menthol cigarettes than do the smokers in any other racial/ethnic group. More than 80% of African American adult smokers smoke menthol cigarettes; less than a third of whites do. Why does this matter? Because menthol makes it easier to start smoking, more likely to progress to established smoking, and harder to quit. As a consequence, menthol cigarettes were responsible for 10.1 million extra smokers and an additional 378,000 premature deaths from 1980 to 2018. A disproportionate number of those additional premature deaths were experienced by African Americans.
Menthol cigarettes are especially popular among new initiates to smoking of all racial/ethnicity groups. Creating a cooling sensation, menthol reduces the harshness of inhaled smoke, making it easier to start smoking. More than half of all youth smokers, ages 12 to 17, use menthol cigarettes, including 95% of African American youth and 51% of whites.
Now, after a multi-year fight over these products, FDA announced last week a proposal to ban menthol in cigarettes and cigars. But even after the long and bumpy road to get to where we are today, there’s much more work to be done.
The Recent History of Menthol in the U.S.
In 2009, Congress passed the Family Smoking Prevention and Tobacco Control Act, giving FDA the responsibility to regulate tobacco products. Among its provisions, the Act prohibited the use of flavors in cigarettes — except for menthol. It did, however, require the newly-established Tobacco Products Scientific Advisory Committee (TPSAC) to review the effects of the use of menthol in cigarettes on public health, including use by children, African Americans, and other racial and ethnic minorities.
TPSAC issued its report in 2011. The committee concluded that “removal of menthol cigarettes from the marketplace would benefit public health.” In 2013, FDA produced a report on its own internal scientific investigation. Similarly to TPSAC, FDA found “it likely that menthol cigarettes pose a public health risk above that seen with nonmenthol cigarettes.” In particular, the agency noted the problem menthol posed for African Americans regarding smoking cessation. However, the report emphasized that “This document does not constitute a decision about what regulatory action, if any, FDA might take with respect to menthol in cigarettes.”
That was 8 years ago. At the time, 20 medical and health organizations, including two African American tobacco control organizations, petitioned FDA to remove menthol cigarettes from the market. In 2018, FDA Commissioner Scott Gottlieb, MD, proposed a ban, but the Trump administration rejected the idea following substantial tobacco state political opposition. Last year, two organizations sued to force FDA to respond to the petition. The court required FDA to respond by April 29, 2021. On that day last week, FDA announced that it would issue “proposed product standards within the next year: one to ban menthol as a characterizing flavor in cigarettes and another to ban all characterizing flavors (including menthol) in cigars.” The latter is important because many young people smoke flavored small cigars, a behavior as dangerous as smoking cigarettes.
Matthew Myers, president of the Campaign for Tobacco Free Kids, responded to the announcement by saying, “The Administration’s new policy has the potential to be the strongest action our nation has ever taken to drive down the number of kids who start smoking and the number of Americans who are sickened and killed by tobacco.” The statement reflects the enthusiasm with which the public health community greeted the announcement.
The Fight Isn’t Over Yet
The move is definitely encouraging — but before we fall head-over-heels in a rapturous response, we need to recognize that the actual implementation of the regulations, should it ever occur, is years into the future. There are two major time-consuming impediments. One is the complex and lengthy bureaucratic maze that FDA must traverse. The second is the protracted tobacco industry legal challenges that invariably follow any proposed regulation that might actually decrease cigarette sales.
Responding to the announcement, industry analysts uniformly concluded that, for these reasons, any outcome will take many years. Tellingly, the cigarette companies’ stock prices hardly budged in response to the news.
Throughout the process, the political battle over the proposal will be intense. The move has had consistent support from African American medical and public health organizations. It has garnered increasing political support, including recently, from prominent African Americans in Congress. But other prominent African Americans have expressed their opposition. Notably, the Reverend Al Sharpton has labeled the policy discriminatory and said it could exacerbate tensions between police and African Americans who were smoking smuggled menthol cigarettes. Arguments like these contributed to the defeat of a menthol ban in New York City in 2019. But FDA considers the concern about police interactions unwarranted as the regulations would have legal ramifications only for the manufacturers and distributors of cigarettes, not individual consumers.
A ban on menthol cigarettes would serve the interests of social justice. The burden of disease and death wrought by smoking clearly falls disproportionately on African Americans, as well as other minority groups. Ultimately, a ban would reduce the significant disparity in life expectancy between Blacks and whites in our society. As well, it almost certainly would reduce smoking among adolescents.
With 37 other countries having banned menthol in cigarettes, the U.S. is a laggard. People have died as a consequence. Massachusetts and California have banned menthol, as have over 100 U.S. cities and towns. That FDA may one day extend this protection to the entire country is welcome news, if long overdue.
Kenneth E. Warner, PhD, is the Avedis Donabedian Distinguished University Professor Emeritus and Dean Emeritus at the University of Michigan School of Public Health.