COMMENTARY
Prohibiting menthol in tobacco products: a policy whose time has come
This special issue examines questions surrounding the properties and health effects of menthol cigarettes, and Legacy applauds the efforts of all the scientists participating in this important area of inquiry. These findings are particularly relevant as the US transitions into an unprecedented policy context as a result of the 2009 Family Smoking Prevention and Tobacco Control Act, which vested the Food and Drug Administration (FDA) with regulatory authority over tobacco. The FDA’s new Tobacco Product Scientific Advisory Committee (TPSAC) is currently reviewing the evidence related to the impact of mentholated cigarettes on the health of the American public, including use among children, African Americans, Hispanics and other racial and ethnic minorities. It is, none the less, important to acknowledge what we already know about menthol cigarettes, because what we do know provides a compelling rationale for the FDA to ban these lethal products. Menthol cigarettes continue to serve as a starter product for millions of America’s youth. This additive not only masks the harsh taste of tobacco with a minty flavor, it also provides a cooling sensation that reduces the throat irritation associated with smoking. These facts are well known to the tobacco industry. Internal company documents reveal a keen awareness that menthols are ‘good starter products’, [1] particularly attractive to new and young smokers. After all, the executive who famously wrote ‘the base of our business is the high school student’ was talking about Newport, the no. 1 selling menthol brand [2,3]. Lorillard, the manufacturer of Newport, has not been alone in targeting young people with its menthol cigarettes. A 1983 internal Brown & Williamson document laments that ‘KOOL is no longer attracting new smokers’ and states that ‘to increase KOOL’s share of starters, it will be necessary to increase KOOL’s share among young smokers’. [4] The US District Court opinion finding the major tobacco companies guilty of racketeering also found that both KOOL and Newport had been advertised in publications with substantial youth readership, including Sports Illustrated and Playboy [5]. Tobacco companies have also manipulated the level of menthol in cigarettes specifically to gain market share among youth. After discovering that long-term smokers preferred products with higher menthol levels while younger smokers preferred milder menthol products, tobacco companies introduced new menthol brands with lower menthol levels to appeal to younger smokers [6]. It is also widely accepted that sweet products appeal to youth. In fact, numerous products such as cereals and prescription medicine use flavors to increase their appeal © 2010 The Authors, Addiction © 2010 Society for the Study of Addiction
to young consumers. Congress banned strawberry, chocolate, licorice and a host of other flavors from cigarettes for precisely this reason—because such flavors ‘appeal to youth’. [7] Menthol does, too. Thus, menthol gives young smokers a ‘twofer’—a cigarette that tastes like candy and is easier to smoke; and, thus, it is not surprising that young people smoke menthol cigarettes at dramatically higher rates than older smokers, with almost half (47.7%) of smokers aged 12–17 years smoking menthol cigarettes compared to fewer than onethird (31.5%) of those over the age of 25 years [8]. There is also concern that menthol use is increasing in popularity, particularly among teenagers. Between 2004 and 2008, the overall menthol smoking rate increased by 9% and those gains were most pronounced among adolescents and young adults [8]. The fact that menthol makes a deadly product even more appealing to our nation’s young people is reason alone to ban it. Most recently, Reynolds (RJR) launched a new brand of cigarettes, Camel no. 9, which was promoted in five of the top 10 magazines read by teenage girls. During this shortlived, but chillingly effective campaign, more than 9% more female teens in a national survey named Camel as their favorite brand, while no similar increase was found among teen males during the same period [9]; not surprising, given the youthful hot pink packaging for the non-mentholated version and their teal-colored menthol version with a tagline of ‘light and luscious’ (see Fig. 1). Current data demonstrate that if a young person can identify a favorite cigarette brand or campaign, they are 50% more likely to initiate smoking [10]. This steep increase in brand awareness is likely to translate into more young female smokers, many of whom will smoke menthol. If we can prevent our young people from being recruited, the likelihood of stemming the tobacco epidemic increases significantly. The tobacco industry has also used mentholated cigarettes as part of a decades-long, deliberate and fraudulent attempt to reduce smoker’s concerns about the health effects of its products. Just as it did with light cigarettes, the industry has long tried to delude smokers into believing that menthol cigarettes provide a healthier alternative to regular cigarettes. Due to its anesthetic effects, menthol is not only an ingredient in cigarettes, but an additive in many cold medicines. The industry has used menthol’s association with cold remedies to infer that smoking menthol cigarettes has some medicinal or health benefit for more than 70 years. For example, a 1976 document discussing a possible new Reynolds menthol brand explains that it would ‘offer the smoker Addiction, 105 (Suppl. 1), 5–7
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Commentary
Figure 1 Camel No. 9 advertising. Teal packaging indicates menthol cigarettes; pink indicates non-mentholated. Image courtesy of UMDNJ, Trinkets and Trash Project, www.trinketsandtrash.org
greater appeal’ by ‘capitaliz[ing] on the “healthier” feeling of a menthol smoke’. [11] Thus, not only do menthols lure our children into smoking with their minty taste and cooling sensation, but they delude smokers of all ages into believing they are smoking a healthier or medicinal type of cigarette. Banning menthols is also a simple matter of social justice. The industry has used menthol to target not only young people, but African American youth specifically, as well as the broader African American community and other communities of color [12,13]. At a Lorillard sales seminar in 1978 regarding their flagship menthol brand, Newport, their promotional efforts included ‘a specially designed Black newspaper campaign for NEWPORT on an on-going basis’ . . . ‘If necessary, outside consultants specializing in Black promotion should be brought in’, and suggests sponsoring the ‘Miss Black Teenager’ contest. These targeted marketing efforts have been remarkably effective. The latest data reveal that the vast majority (82.6%) of African American smokers of all ages smoke menthol cigarettes [8]. Other racial and ethnic groups also smoke menthol cigarettes disproportionately, including Native Hawaiian and other Pacific Islander (53.2%), Hispanic/Latino (32.3%) and Asian American smokers (31.2%) compared with white smokers (23.8%) [8]. © 2010 The Authors, Addiction © 2010 Society for the Study of Addiction
Some research findings point to negative health effects associated with mentholated tobacco use. One study found that high school menthol smokers were more likely to report symptoms of dependence compared to nonmenthol cigarette smokers, while another study found that adult menthol smokers were more likely to have their first cigarette within a shorter time-period after waking than non-menthol smokers [14,15]. Another area of concern is the high lung cancer rate among African Americans. African American men develop lung cancer at a rate 36% higher than white men, even though they smoke about the same amount [16,17]. African American smokers are also more likely to die from lung cancer than white smokers [16]. Further research is needed to understand the underlying mechanisms that give rise to these health disparities, particularly as they relate to menthol use. As this special issue goes to press, President Obama has just signed landmark, comprehensive health care reform. While the new law contains a number of significant provisions that will improve the health of Americans for decades to come, the law mandates Medicaid coverage for cessation services only for pregnant smokers [18]. While a step forward, this is also a missed opportunity to help millions of non-pregnant smokers who could rely on Medicaid to quit smoking, an investment that would have ultimately paid for itself in saved health care costs [19]. Moreover, the failure to provide Medicaid coverage for smoking cessation for all Medicaid recipients disproportionately affects millions of African Americans, 24% of whom receive health care through Medicaid [20], and if they smoke are more likely to smoke mentholated cigarettes [8]. Even more concerning is the possibility that budget-strapped states that currently provide cessation coverage for non-pregnant smokers might reduce that benefit given the lack of a federal mandate. Such an unintended consequence of health care reform could further exacerbate existing tobacco-related health disparities. Every day in the United States, 1200 people die prematurely as a result of tobacco-related disease; and every day, particularly in underserved communities, youth are lured into taking up this deadly addiction by the minty taste and cooling sensation of menthol. While further research may yield additional reasons to outlaw this additive, we should not delay in banning menthol based on what we know today. It is time for the public health and regulatory communities to act to protect our youth. It is time to ban the use of menthol in tobacco products.
Declarations of interest None. Addiction, 105 (Suppl. 1), 5–7
Commentary
Keywords
Menthol, prohibiting, tobacco industry. CHERYL G. HEALTON, STACY E. BECK,
JULIA CARTWRIGHT & DONNA M. VALLONE
American Legacy Foundation, Washington DC, WA, USA Correspondence to: DONNA M. VALLONE, American Legacy Foundation, 1724 Massachusetts Avenue, NW Washington, DC 20036 USA. E-mail:
[email protected]
References 1. Cantrell-D B. W. Kool Isn’t Getting the Starters/236. 17 February 1987. Brown & Williamson. Bates no. 620307825/7829. Accessed 21 October 2010. URL: http://legacy.library.ucsf.edu/tid/wks03f00. Accessed: 21 October 2010. (Archived by WebCite® at http://www. webcitation.org/5teHeztdV) 2. Achey T. L. Product Information. 30 August 1978. Lorillard. Bates no. 94671153/1154. Accessed 21 October 2010. URL: http://legacy.library.ucsf.edu/tid/nlt13c00. Accessed: 21 October 2010. (Archived by WebCite® at http://www.webcitation.org/5teHlh3DH) 3. Sutton C. D., Robinson R. G. The marketing of menthol cigarettes in the United States: populations, messages, and channels. Nicotine Tob Res 2004; 6 (Suppl): S83–91. 4. Unknown Author. Marketing Dynamics. 1983. Brown & Williamson. Bates NO. 670585237/5256. Accessed 21 October 2010. URL: http://legacy.library.ucsf.edu/tid/ vzx04f00. Accessed: 21 October 2010. (Archived by WebCite® at http://www.webcitation.org/5teHr4JkR) 5. United States v. Philip Morris, 449 F. Supp. 2d 1 (D.D.C. 2006), aff’d, 566 F.3d 1095 (D.C.Cir. 2009), cert. denied, 130 S.Ct. 3501 (2010). 6. Kreslake J. M., Wayne G. F., Alpert H. R., Koh H. K., Connolly G. N. Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults. Am J Public Health 2008; 98: 1685–92. 7. U.S. House of Representatives Report 111–58, 26 March 2009 at 37. 8. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The NSDUH Report: Use of Menthol Cigarettes. Rockville, MD: Substance Abuse and Mental Health Services Administration; 19 November 2009.
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