Recently, the United States (US) Food and Drug Administration (FDA) has expressed intention of banning menthol among tobacco products—a move that could have enormous impact on health in US and in particular on reducing the disparity of health faced by Black Americans.
The province of Ontario, Canada implemented a ban on menthol-flavoured tobacco products in January 2017, before a nation-wide menthol ban on October 2017. Two years following the ban, data from our study showed that the menthol ban was associated with significant level of quitting smoking among regular menthol smokers compared to non-menthol smokers. If we extrapolate the results of a menthol ban to the US, it suggests that this low-cost intervention might lead to over 1 million people quitting smoking in the US long term, including over 200,000 Black Americans. This finding is consistent with the results of other shorter-term evaluations of the Canadian menthol ban. Our experience in Ontario can inform the US policy makers to take action needed to implement this important intervention.
Menthol is a flavouring agent which is added to cigarettes that masks the taste of tobacco, provides greater discretion, induces strong sensory effects, and leads to greater nicotine dependence. Menthol is popular among younger people who initiate smoking with menthol and progress to regular cigarette use. Menthol smokers also find it hard to quit smoking compared to non-menthol smokers.
Even more so, menthol cigarettes have been actively promoted to Black Americans by the tobacco industry—currently 85.8% of Black American smokers smoke menthol cigarettes. While other flavours in tobacco that were predominantly used by White Americans have been already banned by the FDA, menthol was specifically left out of those bans, leaving Black Americans exposed to greater risks. Rectifying this injustice requires immediate action to include menthol on the list of banned additives.
Prior to our research the concern was that the impact of banning menthol was hypothetical. Despite implementation of a menthol ban in a few countries (i.e., Canada, Brazil, Ethiopia, Turkey, and European Union countries including the United Kingdom) and several states of the US, there is very little data on real-world effectiveness of menthol bans. We have now been following up an Ontario cohort of 1,821 smokers over two years to understand the long-term impact of the menthol ban on smoking behaviour. Our study found that one month after the ban, a higher proportion of menthol smokers attempted to quit smoking than had planned before the ban. At a one-year post-ban follow-up, 63% of daily menthol smokers and 62% of occasional menthol smokers made a quit attempt since the ban compared to 43% of non-menthol smokers. Similarly, two-year follow-up data revealed that regular menthol smokers were more likely to successfully quit and make more attempts to quit than non-menthol smokers. Consistent with these findings, analysis of cigarette wholesale data in Ontario revealed drops in overall cigarette sales in the post-ban period.
“At a one-year post-ban follow-up, 63% of daily menthol smokers and 62% of occasional menthol smokers made a quit attempt since the ban compared to 43% of non-menthol smokers.”
Data from evaluation of the national menthol ban in Canada is just emerging which suggests similar findings, with higher rates of quit-attempts, successful quitting, and preventing relapse among menthol smokers compared to non-menthol smokers. In addition, few people were found to still smoking menthol cigarettes after the ban in Ontario, with no significant increase in illegal menthol cigarette or “contraband” purchasing or transition to menthol “replacement” packs. It is clear that menthol ban is an effective policy in increasing smoking cessation among prior menthol smokers.
Compared to Canada, menthol sales are much more prevalent in the US, where 35% of all cigarettes sold are mentholated. However, in response to a hypothetical menthol ban, menthol smokers in the US expressed higher rates of intention to quit tobacco than Canadian population. Again, this rate was higher among vulnerable groups like African Americans, women, and those with less than a high school education. The results of our study suggest that the impact of a menthol ban would be even greater in the US in magnitude than seen in Ontario, with even larger impact among Black Americans. Other studies suggest that if a menthol ban were implemented in the US in 2011, an estimated 633,252 deaths could be averted by 2050 and our real-world evaluation highlights the validity of this estimate. Hence, in respect of available evidence and substantial public health benefits, it is now high time that the US should act to implement a nation-wide menthol flavour ban in cigarettes.
Featured image by Joshua Freake via Unsplash