the truth about menthol

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1 the truth about menthol WHAT IS MENTHOL? Menthol is a chemical compound extracted from the peppermint or corn mint plant or created synthetically. It reduces the harshness of cigarette smoke due to its characteristic cooling effects on the mouth and throat. 1,2 Menthol suppresses the coughing reflex 3 which makes inhaling smoke from cigarettes more tolerable. Menthol was first added to cigarettes in the 1920s and 1930s, and became widespread in the 1950s and 1960s. 1,4,5 Although most cigarettes contain some menthol, certain brands use menthol in greater quantities making it detectible as a characterizing flavor. 6 Tobacco manufacturers market and advertise those brands as menthol cigarettes. *Photo credit: Keith Homan / Shutterstock.com PATTERNS OF USE In 2010, 8.2% (20.7 million) of those ages 12 or older in the U.S. used menthol cigarettes. 7 Decline In Cigarette Use: NON-MENTHOL CIGARETTES MENTHOL CIGARETTES 0-5% -10% -15% -20% -25% -30% -35% Menthol cigarette smoking is more prevalent among youth, 9 female smokers, 9-13 racial/ethnic minorities, 9-14 sexual minorities, 15 and those with mental illness. 12,16 Menthol cigarettes are slowing the reductions in overall cigarette smoking prevalence. From 2000 to 2011, the decline in cigarette consumption was greater among non-menthol cigarettes (37% decline) than for menthol cigarettes (20% decline). Eighty-nine percent of the total decline in cigarette consumption is attributed to nonmenthol cigarettes. 8 9 in 10 African American smokers use menthol cigarettes. African American smokers predominantly use menthol cigarettes. 9 Nearly 9 in 10 African American smokers (88.5%) aged 12 years and older use menthol cigarettes. 9 pg 1

2 Youth Menthol cigarettes are disproportionally used by young smokers and may facilitate addiction. Menthol reduces the harshness of cigarette smoke, which may appeal to young, inexperienced smokers. 1,17,18 Longitudinal studies show that initiation with menthol cigarettes facilitates progression to established cigarette use in young smokers. 19,20 Data from nationally representative samples show that from the youngest age groups among cigarette smokers use menthol at the highest rates (Figure 1). 9,10 In 2014, the prevalence of menthol cigarette use among past 30-day cigarette users was 54.5% among all high school students and 48.4% among all middle school students. 21 Most African American youth smokers smoke menthol cigarettes. From , 94.9% of African American past 30-day smokers used menthol cigarettes. This is compared to 51.3% of White and 60.7% of Asian American past 30-day smokers who smoke menthol cigarettes (Figure 2). 9 Figure 1. Prevalence of Use of Menthol Cigarettes among Past 30-Day Smokers by Age in the United States, % 60% 40% 20% 56.7% 45% 34.7% 30.5% 30.7% Figure 2. Prevalence of Youth (12-17) Use of Menthol Cigarettes among Past 30-Day Smokers by Race/Ethnicity in the United States, ASIAN WHITE 51.3% 60.7% BLACK 94.9% 0% % 20% 40% 60% 80% 100% A nationally representative study found that among youth and young adults, non-menthol cigarette prevalence declined from 2004 to By contrast, menthol cigarette prevalence remained constant among youth and increased among young adults over this period. 9 Smoking Rates Among Young Adult and Youth Smokers From 2004 To 2010 YOUNG ADULT NON-MENTHOL SMOKERS 25.7% YOUNG ADULT MENTHOL SMOKERS 14.0% 17.3% 16.3% ADOLESCENT NON-MENTHOL SMOKERS ADOLESCENT MENTHOL SMOKERS 6.0% 5.3% 4.5% 3.4% pg 2

3 Young Adults and Adults Menthol cigarette use is higher in younger adults than older adults. Among adults surveyed in , past 30-day smokers ages had the highest prevalence of menthol cigarette use (45%), compared to adults aged (34.7%), adults (30.5%), and adults 50+ (30.7%) (Figure 1). 9 Prevalence of Menthol Cigarette Use Among Adult Smokers HETEROSEXUAL SMOKERS LGBT SMOKERS 0 10% 20% 30% 40% Prevalence of Menthol Cigarette Use Among Female Smokers HETEROSEXUAL FEMALE SMOKERS LGBT FEMALE SMOKERS 0 10% 20% 30% 40% From , the prevalence of menthol cigarette use among young adult past 30-day smokers (ages 18-25) was 93.9% among African Americans, compared to 36.3% among Whites and 49.7% among Asian Americans. 9 In 2010, the prevalence of menthol cigarette use among adult past 30-day smokers was 36.3% among LGBT smokers, compared to 29.3% among heterosexual smokers. This difference was even more pronounced among LGBT female smokers (42.9%) compared to heterosexual female smokers (32.4%). 15 HEALTH AND SAFETY Menthol cigarettes offer no health benefit to smokers, and in fact, are more likely to addict youth and are more difficult to quit than regular cigarettes. We agree with the Tobacco Products Scientific Advisory Committee (TPSAC) that menthol cigarettes pose a threat to public health above and beyond that posed by regular cigarettes. Menthol flavoring contributes to addiction in youth smokers. 1,22-24 There are no health benefits associated with using menthol cigarettes compared to non-menthol cigarettes. 25 Menthol cigarettes are at least as dangerous to an individual s health as non-menthol cigarettes, 9 and menthol cigarette smokers are as likely to experience premature morbidity and mortality as smokers of non-menthol cigarettes. 26 Adult menthol smokers report shorter time to first cigarette after waking than non-menthol smokers. Time to first cigarette is an important measure of nicotine addiction The weight of the scientific evidence indicates that adult menthol smokers are less likely than non-menthol smokers to successfully quit smoking 24,30-38 despite increased quit intentions 35 and quit attempts. 32,35,36 Studies show significantly reduced cessation among African American 24,30,31 and Hispanic menthol smokers compared to non-menthol smokers. 31 Successful Quitting Rates Among Adult Smokers in 2003 MENTHOL SMOKERS NON-MENTHOL SMOKERS 16% 17% 18% 19% 20% 21% Successful Quitting Rates Among Adult Smokers in 2007 MENTHOL SMOKERS NON-MENTHOL SMOKERS 16% 17% 18% 19% 20% 21% pg 3

4 MARKETING IN THE U.S. Menthol makes up a large portion of the cigarette market in the United States (31% in 2013). 39 The tobacco industry has a well-documented history of developing and marketing mentholated brands to racial and ethnic minorities and youth Evidence from tobacco industry documents shows that the industry studied smokers menthol preferences and manipulated menthol levels to appeal to a variety of smokers, including adolescents and young adults. 17,18,41,45 Evidence from tobacco industry documents also shows that tobacco companies specifically targeted African Americans with menthol cigarette advertising. 44,46-48 A recent review found that menthol marketing is higher in publications and venues that appeal to African American audiences. 43 * actual promotion found online Numerous studies show targeted marketing of menthol cigarettes at the point-of-sale in African American communities throughout the U.S In 2016, it was reported by the Wall Street Journal that Reynolds American Inc. was distributing packs of Newport cigarettes for $1 per pack at concerts and festivals popular with youth as part of a push to target young adult smokers. pg 4

5 POLICY IN THE U.S. The 2009 Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) gave the U.S. Food and Drug Administration (FDA) the authority to regulate tobacco products. The law prohibits the use of characterizing flavorings in cigarettes, except for menthol. 54 Instead, it gives FDA the regulatory authority to ban menthol. FDA has indicated that it will extend the cigarette flavor ban, excluding menthol, to small cigars, but to date, has not done so. The removal of menthol cigarettes from the market would improve the public health. Thus far, FDA s activities on menthol include: FDA s Tobacco Products Scientific Advisory Committee (TPSAC) was required by the Tobacco Control Act to conduct a review of menthol cigarettes effect on youth and other vulnerable populations. TPSAC published its report in March 2011, concluding that the removal of menthol cigarettes from the marketplaces would benefit public health in the United States. Lorillard (now Reynolds) challenged the integrity of TPSAC in a lawsuit against FDA, alleging that several experts the agency appointed to the committee were biased and therefore must be removed. The judge in the case sided with Lorillard and prohibited FDA from using the TPSAC menthol report. FDA appealed and in January 2016, the D.C. Circuit reversed the district court s decision, and now the FDA may rely on the TPSAC menthol report to take action to regulate menthol tobacco products. In July 2013, FDA published its own report which also concludes that the removal of menthol cigarettes from the market would improve the public health. In July 2013, FDA issued an Advance Notice of Proposed Rulemaking seeking additional information to help the agency make informed decisions about menthol in cigarettes. Since that time, FDA has taken no further action on menthol. pg 5

6 State and Local Policies While several localities have prohibited flavored tobacco products in some way, most of these exclude menthol, mint or wintergreen. However, thus far, two localities have included menthol in their flavor bans. Chicago, Illinois prohibits the sale of flavored tobacco products, including menthol, within 500 feet of schools. 55 Beginning January 2017, Berkeley, California prohibits the sale of flavored tobacco products, including menthol, within 600 feet of schools. 56 BERKELEY, CA CHICAGO, IL Effects of Possible Menthol Ban A 2012 nationally representative online survey found that one in five Americans agree menthol flavoring in cigarettes should be banned. 57 If menthol cigarettes were banned, 38.9% of all menthol smokers and 44.5% of African American menthol smokers reported that they would try to quit. 58 Among young adult menthol smokers (ages 18-24) 64.6% reported they would quit smoking and not use any other products if menthol cigarettes were banned. 59 Rates of Smokers Reporting They Would Quit If Menthol Cigarettes Were Banned 38.9% 44.5% 64.6% of all menthol smokers of African American menthol smokers of young (18-24) menthol smokers If a menthol ban had gone into effect in 2011, researchers estimate conservatively that over 320,000 smoking-attributable deaths would be averted by 2050, almost a third of them among African Americans. 60 If menthol cigarettes had been banned in African Americans make up almost one third of 320,000+ smoking-attributable deaths that could have been avoided by pg 6

7 Truth Initiative s Position on Menthol Truth Initiative s mission is to achieve a culture where all youth and young adults reject tobacco. Consistent with Truth Initiative s vision of a future where tobacco is a thing of the past, we support the following policies with regard to menthol in tobacco products: FDA must issue product standards eliminating menthol as a characterizing flavor from all tobacco products particularly cigarettes, cigars, little cigars and cigarillos and other combustible tobacco. The only exception to this would be for proven harm-minimized products that can show that menthol flavor does help smokers completely switch from combustible tobacco to the harm-minimized product AND that it does not appeal to or attract youth. State and local entities should enact policies prohibiting flavors that include menthol, mint and wintergreen flavors.

8 TRUTH INITIATIVE S AFFILIATED PUBLICATIONS Rath JM, Villanti AC, Williams VF, Richardson A, Pearson JL, Vallone DM. Correlates of current menthol cigarette and flavored other tobacco product use among U.S. young adults. Addict Behav. 2016;62: PMCID: PMC Cohn, A. M., Johnson, A. L., Hair, E., Rath, J. M., & Villanti, A. C. (2016). Menthol tobacco use is correlated with mental health symptoms in a national sample of young adults: implications for future health risks and policy recommendations. Tob Induc Dis, 14, 1. Ambrose BK, Day HR, Rostron B, Conway KP, Borek N, Hyland A, Villanti AC. Flavored Tobacco Product Use Among US Youth Aged Years, JAMA. 2015;314(17): Wackowski OA, Delnevo CD, Pearson JL. Switching to e-cigarettes in the event of a menthol cigarette ban. Nicotine & Tobacco Research Oct;17(10): Rose SW, Emery SL, Ennett S, McNaughton Reyes HL, Scott JC, Ribisl KM. Public Support for Family Smoking Prevention and Tobacco Control Act Point-of-Sale Provisions: Results of a National Study. Am J Public Health. 2015;105(10):e PMCID: PMC Rose SW, Emery SL, Ennett S, Reyes HL, Scott JC, Ribisl KM. Retailer opinions about and compliance with family smoking prevention and tobacco control act point of sale provisions: a survey of tobacco retailers. BMC Public Health. 2015;15:884. PMCID: PMC Delnevo CD, Villanti AC, Wackowski OA, Gundersen DA, Giovenco DP. The influence of menthol, e-cigarettes and other tobacco products on young adults self-reported changes in past year smoking. Tob Control Rath, J., Villanti, A. C., Williams, V., Richardson, A., Pearson, J., & Vallone, D. Patterns of longitudinal transitions in menthol use among U.S. young adult smokers. Nicotine & Tobacco Research Jul;17(7): Fagan P, Pohkrel P, Herzog T, Pagano I, Vallone D, Trinidad DR, Sakuma KL, Sterling K, Fryer CS, Moolchan E.Comparisons of three nicotine dependence scales in a multiethnic sample of young adult menthol and non-menthol smokers. Drug Alcohol Depend Apr 1;149: doi: /j. drugalcdep Epub 2015 Feb 14. Cantrell J, Ganz O, Anesetti-Rothermel A, Harrell P, Kreslake JM, Xiao H, Pearson JL, Vallone D, Kirchner TR. Cigarette price variation around high schools: evidence from Washington DC. Health Place. 2015;31: Giovino G, Villanti A, Mowery P, Sevilimedu V, Niaura R, Vallone D, Abrams D. Differential trends in cigarette smoking in the USA: is menthol slowing progress? Tobacco Control Jan;24(1): Delnevo CD, Villanti AC, Giovino GA. Trends in menthol and non-menthol cigarette consumption in the USA: Tobacco Control Nov;23(e2):e Richardson A, Ganz O, Pearson J, Celcis N, Vallone D, Villanti A. How the industry is marketing menthol cigarettes: the audience, the message and the medium. Tobacco Control Nov;24(6): pg 8

9 Villanti AC, Richardson A, Vallone DM, Rath JM. Flavored tobacco product use among U.S. young adults. Am J Prev Med. 2013;44(4): Villanti AC, Giovino GA, Burns DM, Abrams DB. Menthol cigarettes and mortality: keeping focus on the public health standard. Nicotine & Tobacco Research. Feb 2013;15(2): Nonnemaker J, Hersey J, Homsi G, Busey A, Allen J, Vallone D. Initiation with menthol cigarettes and youth smoking uptake. Addiction Jan; 108(1): Pearson, J, Richardson, A, Niaura, R, Vallone, D, Abrams, DB. A ban on menthol cigarettes: impacts on public opinion and smokers intention to quit. American Journal of Public Health Nov, 102(11):e Villanti AC, Giovino GA, Barker DC, Mowery PD, Sevilimedu V, Abrams DB. Menthol brand switching among adolescents and young adults in the National Youth Smoking Cessation Survey. American Journal of Public Health Jul; 102 (7): Levy D, Pearson J, Villanti A, Blackman K, Vallone D, Niaura R, Abrams D. Modeling the Future Effects of a Menthol Ban on Smoking Prevalence and Smoking-Attributable Deaths in the United States. American Journal of Public Health Jul;101(7): Levy DT, Blackman K, Tauras J, Chaloupka FJ, Villanti AC, Niaura RS, Vallone DM, Abrams DB. Quit attempts and quit rates among menthol and nonmenthol smokers in the United States. Am J Public Health. 2011;101(7): PMCID: PMC Winickoff JP, McMillen RC, Vallone DM, Pearson JL, Tanski SE, Dempsey JH, Cheryl H, Klein JD, David A. US attitudes about banning menthol in cigarettes: results from a nationally representative survey. Am J Public Health. 2011;101(7): PMCID: PMC Tauras JA, Levy D, Chaloupka FJ, Villanti A, Niaura RS, Vallone D, Abrams DB. Menthol and nonmenthol smoking: the impact of prices and smoke-free air laws. Addiction Dec;105 Suppl 1: pg 9

10 MENTHOLS MENTHOL CIGARETTES ARE POPULAR WITH TEEN SMOKERS. 54% of current smokers in high school and 48.4% of current smokers in middle school smoked menthols. OF CURRENT SMOKERS IN MIDDLE 48.4% SCHOOL SMOKE MENTHOL 54% OF CURRENT SMOKERS IN HIGH SCHOOL SMOKE MENTHOL MENTHOL SMOKING RATES AMONG TEEN SMOKERS AFRICAN AMERICAN ASIAN 61% 95% NEARLY ALL AFRICAN AMERICAN TEEN SMOKERS SMOKE MENTHOLS. 95% of African American teens who are current smokers smoke menthols. HISPANIC 58% WHITE 51% BANNING MENTHOL TOBACCO PRODUCTS COULD SAVE LIVES. 38.9% of all menthol smokers and 44.5% of African American menthol smokers say they would try to quit smoking if menthols were banned. Menthol cigarettes are slowing reduction in overall cigarette smoking. NON-MENTHOL SMOKERS MENTHOL SMOKERS 20% 37% IF A BAN ON MENTHOL HAD PASSED IN 2011, IT COULD HAVE SAVED AN ESTIMATED 320,000 LIVES. MMWR Morb Mortal Wkly Rep Tobacco Control 2013, 2015 American Journal of Public Health, 2012 Nicotine & Tobacco Research, 2014

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12 41. Kreslake JM, Wayne GF, Connolly GN. The menthol smoker: tobacco industry research on consumer sensory perception of menthol cigarettes and its role in smoking behavior. Nicotine Tob Res. 2008;10(4): Cruz TB, Wright LT, Crawford G. The menthol marketing mix: targeted promotions for focus communities in the United States. Nicotine Tob Res. 2010;12 Suppl 2:S Anderson SJ. Marketing of menthol cigarettes and consumer perceptions: a review of tobacco industry documents. Tob Control. 2011;20 Suppl 2:ii U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups- African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders and Hispanics: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998.: U.S. Department of Health and Human Services; Sutton CD, Robinson RG. The marketing of menthol cigarettes in the United States: Populations, messages, and channels. Nicotine Tob Res. 2004;6(Suppl_1):S Gardiner PS. The African Americanization of menthol cigarette use in the United States. Nicotine Tob Res. 2004;6(Suppl_1):S MSA Inc. The Growth of Menthols, Brown & Williamson. Legacy Tobacco Documents Library. Bates No /3446. Available at: The Beaumont Organization Consumer Wants Study: Areas of Opportunity for R. J. Reynolds R. J. Reynolds. Legacy Tobacco Documents Library. Bates No /8054. Available at: library.ucsf.edu/tid/oqx89d Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and health disparities: tobacco industry targeting of inner cities. J Health Care Poor Underserved. 2007;18(4 Suppl): Widome R, Brock B, Noble P, Forster JL. The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing. Ethn Health. 2013;18(2): Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted advertising, promotion, and price for menthol cigarettes in California high school neighborhoods. Nicotine & Tobacco Research. 2012;14(1): Seidenberg AB, Caughey RW, Rees VW, Connolly GN. Storefront cigarette advertising differs by community demographic profile. American Journal of Health Promotion. 2010;24(6):e26-e Pearson JL, Cantrell J, Ganz O, et al. Lorillard brands availability, price and advertising: association with neighborhood. 19th Annual Society for Research on Nicotine and Tobacco Research Meeting. Boston, MA Food and Drug Administration. Tobacco Control Act Overview Business Affairs & Consumer Protection. Tobacco Regulations 2016; Clerk C. Berkley Municipal Code: A Codification of the General Ordinances of the City of Berkley, California. Berkeley/. 57. Pearson JL, Abrams DB, Niaura RS, Richardson A, Vallone DM. A ban on menthol cigarettes: impact on public opinion and smokers intention to quit. Am J Public Health. 2012;102(11):e Pearson JL, Abrams DB, Niaura RS, Richardson A, Vallone DM. A ban on menthol cigarettes: impact on public opinion and smokers intention to quit. Am J Public Health. 2012;102(11):e Wackowski OA, Manderski MT, Delnevo CD. Young Adults Behavioral Intentions Surrounding a Potential Menthol Cigarette Ban. Nicotine Tob Res Levy DT, Pearson JL, Villanti AC, Blackman K, Vallone D, Abrams D. Modeling the future effects of a menthol ban on reduced smoking prevalence and deaths averted in the United States. Am J Public Health. 2011;101(7): pg 12