Minnesota Physician Perceptions and Knowledge of Menthol Cigarettes

Minnesota Physician Perceptions and Knowledge of Menthol Cigarettes Physician Advocacy Network A project of the Twin Cities Medical Society Funded by BlueCross BlueShield Center for Prevention June, 2016 For further information, contact: Physician Advocacy Network 1300 Godward Street NE, #2000 Minneapolis, MN 55413 612.362.3706 eparker@metrodoctors.com

About the Physician Advocacy Network The Physician Advocacy Network (PAN) is a statewide project of the Twin Cities Medical Society. The PAN is committed to educating physicians about e-cigarettes and other tobacco products, engaging physicians in discussions around tobacco policy and cessation, and empowering physicians to become leaders in reducing tobacco use in Minnesota. Survey Background The Physician Advocacy Network surveyed Minnesota physicians about their knowledge, perception, and beliefs related to the harms caused by menthol cigarettes. The survey also examined physician awareness of the health inequities related to menthol cigarettes. The survey questions referred to commercial tobacco use, not traditional, sacred, medicinal, spiritual, and ceremonial use of tobacco by American Indians or other groups. The survey was funded by BlueCross BlueShield Center for Prevention. The survey results detailed in this report reveal an opportunity to better educate physicians on the harms of menthol cigarettes and their role in tobacco-related health inequities. The Physician Advocacy Networked emailed the survey link to Minnesotan physicians; 273 responded. Results are specifi c to physicians in Minnesota and may not generalize. There is a potential for non-response bias. Which of the following best describes your specialty? Family Medicine 29% Internal Medicine 14% OB/GY N 4% Pediatrics 7% Psychiatry 7% Surgery 7% Other 33% Are you involved in direct patient care? Yes 84% No 16% Page 1 of 14

About Menthol Tobacco Menthol is a chemical compound extracted from peppermint or corn mint plant or created synthetically. Menthol is used in many consumer and medicinal products for its cooling and analgesic properties. Because menthol makes cigarettes more palatable, it is used as an additive in 90% of tobacco products, even those not marketed specifi cally as menthol-fl avored cigarettes. 1 Throughout this paper, we will use the term menthol cigarettes to refer to cigarettes where menthol is used as characterizing fl avor and non-menthol cigarettes to refer to cigarettes that do not use menthol as a characterizing fl avor but may still contain menthol. Tobacco as a Health Issue in the African American Community Smoking-related illnesses are the number one cause of death in the African-American community. 2 Death from smoking-related illnesses is higher among African Americans than among whites, despite the fact that African Americans typically tend to smoke fewer cigarettes per day and begin smoking later in life than whites. 3, 4 How signifi cant of a health issue do you think tobacco use is in the African American community? Very signifi cant Somewhat signifi cant Not too signifi cant Not an issue Not Sure 67% 24% 1% 0% 8% 91% 91% of surveyed physicians believe that tobacco use is a very or somewhat significant health issue in the African American community. As detailed throughout this report, there is an opportunity to educate physicians about how disproportionately high use of menthol cigarettes among African American smokers impacts tobacco-related health disparities. Page 2 of 14

Physician-Patient Discussions About Menthol Use While most respondents ask their patients about tobacco use always or most of the time, 88% of respondents rarely or never discuss menthol use with patients that report using tobacco. Identifying menthol users may be relevant because menthol smokers are more likely to make quit attempts, but are less successful at continuing to abstain from tobacco. 5 Menthol smokers attempting to quit are also susceptible to relapse as menthol from food or toothpaste could serve as a sensory cue and prompt a craving. 6 How often do you ask patients about tobacco use? Always 49% Most of the time Sometimes 7% 35% Rarely 3% Never 6% How often do you discuss menthol use with your patients that report using tobacco? Always Most of the time 1% 4% Sometimes 7% Rarely 26% Never 62% Page 3 of 14

Menthol Usage Rates Menthol usage rates vary signifi cantly among different communities. Across communities, menthol cigarette use was more common among smokers who are female, have a lower education, are younger and LGBT. 5, 7 Menthol Usage Among African American Smokers 88.5% of African American smokers in the U.S. use menthol cigarettes. 8 African Americans smokers use menthols at a very high rate as compared to white smokers. Though we don t know where the African American community s preference for menthol cigarettes began, tobacco industry s targeted marketing campaigns grew and cemented the preference. 9 About what percent of African American smokers in the United States use menthol cigarettes? 0-20% 21-40% 41-60% 61-80% 81-100% Don t Know 2% 9% 11% 11% 3% 64% When we asked physicians about menthol usage rates among African American smokers a majority of respondents did not know what percent of African American smokers use menthol cigarettes, and of the remaining respondents, 92% underestimated the percent of African American smokers who use menthol cigarettes. Smoking rates among African Americans in Minnesota remain disproportionately high. 10 Our data suggests there is an opportunity to better educate physicians about the link between menthol cigarettes, disproportionately high tobacco use and health inequities within the African American community. Menthol Usage Among Teen Smokers 44.3% of high school smokers in Minnesota use menthol cigarettes. 11 Internal tobacco company documents show that the companies carefully researched the menthol segment of the market in order to recruit younger smokers to their brands. 12 One Lorillard executive famously wrote the base of our business is the high-school student when referencing Newport, a top-selling menthol brand. 13 90% of addicted adult smokers began smoking in their teens. 14 By targeting and attracting teen smokers, the tobacco industry hopes to create lifelong customers. Page 4 of 14

About what percent of teen smokers in Minnesota use menthol cigarettes? 0-20% 21-40% 41-60% 61-80% 81-100% Don t Know 3% 8% 12% 11% 3% 62% A majority of respondents answered don t know when asked about menthol usage rates among teen smokers. Understanding the role menthol and other fl avored tobacco products play in teen smoking can deepen the conversation about tobacco between physicians and their teen patients and caregivers. Menthol Usage Among White Smokers 23.8% of white adult smokers in the U.S. use menthol cigarettes. 15 Menthol usage rates are signifi cantly lower among adult white smokers than among teen and African American smokers. About what percent of white smokers in the United States use menthol cigarettes? 0-20% 21-40% 41-60% 61-80% 81-100% Don t Know 15% 15% 4% 1% 1% 65% More respondents correctly identifi ed the percent of white smokers who use menthol cigarettes than the percent of menthol users among African Americans or teens; though a majority of respondents again answered they did not know what percent of white smokers use menthol cigarettes. Page 5 of 14

Menthol Cigarettes: Easier To Start and Harder to Quit A 2013 report by the Food and Drug Administration (FDA) found that menthol cigarettes lead to increased smoking initiation, greater dependence, and decreased success in smoking cessation. The report states that these factors along with menthol s anesthetic effect make it likely that menthol cigarettes pose a public health risk above that seen with non-menthol cigarettes. 15 Easier to start Menthol cigarettes make it easier to begin smoking. 16 Internal tobacco company documents show that menthol is added to cigarettes in part because it is known to be an attractive feature to inexperienced smokers who perceive menthol cigarettes as less harsh and easier to smoke. 12 Menthol s anesthetic effect makes it easier to inhale and take in more nicotine while smoking. 17 Because of these effects, menthol is included in 90% of tobacco products. 1 To what extent do you agree or disagree with the following statement? Menthol s cooling sensation makes it easier for young people to start smoking. Strongly agree 23% Agree 43% Neutral 31% Disagree 2% Strongly disagree 2% While two thirds of the surveyed physicians agreed that menthol s cooling sensation makes it easier for young people to start smoking, an opportunity remains to education physicians on the role menthol cigarettes play in smoking initiation. Dependence The FDA found consistent evidence that menthol smokers are more likely to smoke their fi rst cigarette within 5 minutes of waking than non-menthol smokers, indicating more severe dependence. Studies examining measures of craving and waking at night to smoke also fi nd consistent evidence that menthol smokers are more dependent when compared to non-menthol smokers. 16 Page 6 of 14

How addictive are menthol cigarettes compared to non-menthol cigarettes? 48% 32% 19% 1% Less addictive Equally addictive More addictive Not sure Less than 20% of participants responded that menthol cigarettes are more addictive than nonmenthol cigarettes. While nicotine is highly addictive in and of itself, it is important for physicians to be aware of the increased dependence in menthol smokers. Harder to Quit Menthol cigarettes are harder to quit than non-menthol cigarettes. The FDA reported evidence that supports the conclusion that menthol in cigarettes is likely associated with reduced success in smoking cessation, especially among African American menthol smokers. 16 Menthol smokers make more quit attempts than non-menthol smokers and are less successful at continuing to abstain from tobacco. 18 To what extent do you agree or disagree with the following statement? Menthol makes it harder for smokers to quit. Strongly agree 11% Agree 30% Neutral 52% Disagree 5% Strongly disagree 2% 41% of respondents agreed or strongly agreed that smoking menthol makes it harder to quit. Understanding the increased diffi culty menthol smokers face when making quit attempts may help physicians better support their patients throughout the cessation process. Page 7 of 14

Harm While some advocates suggest that menthol cigarettes may be more harmful that non-mentholated cigarettes, the FDA s review of current evidence suggests that menthol in cigarettes is not associated with an increase in disease risk. 16 Historically, tobacco companies marketed menthol cigarettes as being healthier than non-menthol cigarettes, using terms like refreshing and natural. How harmful to one s health are menthol cigarettes compared to non-menthol cigarettes? 38% 46% 15% 1% Less harmful Equally harmful More harmful Not sure Only 1% of participants responded that menthol cigarettes are less harmful than non-menthol cigarettes, suggesting that physicians have not been infl uenced by historical marketing implying that menthol cigarettes are healthier than non-menthol cigarettes. Page 8 of 14

Targeted Marketing Tobacco companies target menthol products to youth, African Americans, the LGBT community and other minority populations. The tobacco industry has a long history of marketing menthol cigarettes to African American communities. Many of the tactics that tobacco companies used in the 1960s and 1970s are still used today. In the 1960s, tobacco companies started to develop special promotions for inner city tobacco retailers. This practice continues today. Evidence shows that menthol cigarettes are cheaper in poor, intercity areas with high concentrations of people of color than in upscale white neighborhoods. 19 A 2011 study showed that tobacco companies increased advertising and lowered the sale price of menthol cigarettes in stores near California high schools with larger populations of African American students. 20 In a particularly egregious act of targeted marketing, tobacco companies have sent mobile marketing vans into black neighborhoods to distribute complimentary menthol cigarettes to residents. Vans stopped at locations such as check cashing stations, public aid offi ces, rapid transit locations and busy street corners. Tobacco industry documents identify the target market of this programs as 21-25 year old, Black, lower income, urban, menthol smoker. 21 Menthol advertisements are prominent in African American magazines and feature African American models. 1970 1976 2013 Tobacco companies have a long history of giving money to Black community organizations, including civil rights groups, churches and other nonprofi t organizations. Today, the tobacco industry is estimated to spend about $25 million a year in the African American community. 22 Creating ties with African American leadership organizations helps the tobacco industry use African Americans as a frontline force to defend industry policy positions and to defuse tobacco control efforts including efforts to regulate menthol cigarettes. 23 Page 9 of 14

The bottom line is that African Americans prefer menthol cigarettes because the tobacco industry pushed these products on and created the demand among this population. Did the industry do this on purpose? The answer to this question is an unequivocal yes. 24 To what extent do you agree or disagree with the following statement? Menthol cigarettes are targeted to African Americans more than other racial groups. Strongly agree 10% Agree 22% Neutral 63% Disagree 4% Strongly disagree 1% Less than one third of survey respondents agreed or strongly agreed that menthol cigarettes are targeted to African Americans more than other racial groups. Creating an understanding of how targeted marketing for menthol cigarettes impacts tobacco usage among African Americans, the LGBT community, youth and other minority communities is an important step in engaging physicians in advocacy efforts surrounding menthol cigarettes and tobacco related health inequities. Page 10 of 14

Regulating Menthol Cigarettes Current Menthol Regulations The 2009 Family Smoking Prevention and Tobacco Control Act banned fl avored cigarettes. This ban exempted tobacco and menthol fl avored cigarettes. Do you believe that menthol fl avoring in cigarettes is regulated differently by the FDA than other cigarette fl avorings? Yes 8% No 24% Not sure 69% Only 8% of respondents correctly identifi ed that menthol fl avoring in cigarettes is currently regulated differently by the FDA than other cigarette fl avorings. Menthol and tobacco are the only cigarette fl avorings allowed; all other characterizing fl avors are banned from cigarettes under current FDA regulations. Increasing Menthol Regulations Canadian provinces, Brazil and the European Union have all banned the sale of menthol tobacco products. Minneapolis and St. Paul both recently enacted ordinances that restrict the sale of fl avored tobacco products, except for menthol fl avored products, to adult-only tobacco stores. Fruity and candy fl avored tobacco products appeal to youth. This policy makes it more diffi cult for youth to access these products. Tobacco control organizations in the Twin Cities area are beginning to explore options to include menthol in these regulations in the future. Page 11 of 14

Physicians have an opportunity to shape public health policy using their unique role in the community as trusted thought leaders. In November 2000, an Arizona study examined city and county policymakers approach to tobacco-related policymaking concluding that policymakers trusted medical sources more than any other source on tobacco public policy issues. 25 This trust provides physicians with an opportunity to work closely with community groups and stakeholders to advance public health policies. To what extent do you agree or disagree with the following statement? The sales and marketing of menthol cigarettes should be regulated more tightly than they are now. Strongly agree 44% Agree 23% Neutral 24% Disagree 5% Strongly disagree 5% Over two thirds of respondents agree or strongly agree that the sales and marketing of menthol cigarettes should be more tightly regulated than they are now. The Physician Advocacy Network is encouraged to see such a high level of support for additional regulations, especially when it appears that physicians may not have a full understanding of some of the more harmful or predatory aspects of menthol cigarettes. The Physician Advocacy Network will be providing training on menthol cigarettes to physicians throughout Minnesota in the coming year and is confi dent that by increasing physician s knowledge of menthol cigarettes, we will increase support for additional regulations on these products and cultivate advocates to help lead efforts to reduce the harms caused by menthol cigarettes. Page 12 of 14

References 1 Ahijevych, K. and Garrett, B.E. (2004) Menthol pharmacology and its potential impact on cigarette smoking behavior. Nicotine and Tobacco Research, 6(Suppl 1), S17-28. 2 American Cancer Society, Cancer Facts & Figures for African Americans, 2013 2014, 2013, http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036921.pdf. 3 HHS, Tobacco Use Among US Racial/Ethnic Minority Groups African Americans, American Indians and Alaskan Natives, Asian Americans and Pacifi c Islanders, and Hispanics: A Report of the Surgeon General, 1998, http://www.cdc.gov/tobacco/data_statistics/sgr/1998/complete_report/pdfs/complete_report.pdf 4 Roberts, ME, et al., Understanding tobacco use onset among African Americans, Nicotine & Tobacco Research, 18(S1): S49-S56, 2016. 5 FDA, Preliminary Scientifi c Evaluation of the Possible Public Health Effects of Menthol Versus Nonmenthol Cigarettes, http://www.fda.gov/downloads/scienceresearch/specialtopics/ PeerReviewofScientifi cinformationandassessments/ucm361598.pdf, 2013. 6 Tobacco Products Scientifi c Advisory Committee. (2011). Menthol cigarettes and public health: Review of the scientifi c evidence and recommendations. Available at http://www.fda.gov/downloads/advisorycommittees/ CommitteesMeetingMaterials/TobaccoProductsScientifi cadvisorycommittee/ucm269697.pdf 7 Fallin, Goodin, King (2015). Menthol cigarette smoking among lesbian, gay, bisexual, and transgender adults. Am J Prev Med. 8 Giovino GA, Villanti AC, Mowery PD et al. Differential Trends in Cigarette Smoking in the USA: Is Menthol Slowing Progress? Tobacco Control, doi:10.1136/tobaccocontrol-2013-051159, August 30, 2013 [cited 2015 Sep 17]. 9 Gardiner, P. (2004). The African Americanization of menthol cigarette use in the United States. Nicotine & Tobacco Research, 6(1), 55-65. doi:10.1080/14622200310001649478 10 Centers for Disease Control, Behavioral Risk Factor Surveillance System. (2014) 2014 BRFSS Data. [Data fi le]. Retrieved from http://nccd.cdc.gov/statesystem/rdpage.aspx?rdreport=osh_state.highlights. 11 Teens and tobacco in Minnesota, 2014 Update Executive Summary. (2014). Saint Paul: Minnesota Department of Health Center for Health Equity Center for Health Statistics. 12 Klausner, K. (2011). Menthol cigarettes and smoking initiation: A tobacco industry perspective. Tobacco Control, 20(Supplement 2), Ii12-Ii19. doi:10.1136/tc.2010.041954 13 August 30, 1978 Lorillard memo from Achey to CEO Curtis Judge about the fantastic success of Newport. Bates No. TINY0003062 14 US HHS. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings (Abbreviated); September 2011. 15 Tobacco Control Legal Consortium. (2015). Regulating menthol tobacco products. Page 13 of 14

16 Food and Drug Administration. (2013). Preliminary scientifi c evaluation of the possible public health effects of menthol versus nonmenthol cigarettes. 17 Ahijevych, K. and Garrett, B.E. (2004) Menthol pharmacology and its potential impact on cigarette smoking behavior. Nicotine and Tobacco Research, 6(Suppl 1), S17-28. 18 Levy, D., Blackman, K., Tauras, J., Chaloupka, F., Villanti, A., Niaura, R.,... Abrams, D. (2011). Quit Attempts and Quit Rates Among Menthol and Nonmenthol Smokers in the United States. American Journal of Public Health, 7(101), 1241-1247. doi:10.2105/ajph.2011.300178 19 Cruz, T., Wright, L., & Crawford, G. (2010). The Menthol Marketing Mix: Targeted Promotions For Focus Communities in the United States. Nicotine & Tobacco Research, 12(Supplement 2). doi:10.1093/ntr/ntq201 20 Henriksen, L., Schleicher, N., Dauphinee, A., & Fortmann, S. (2011). Targeted Advertising, Promotion, and Price For Menthol Cigarettes in California High School Neighborhoods. Nicotine & Tobacco Research, 14(1), 116-121. doi:10.1093/ntr/ntr122 21 PROMOTIONAL MARKETING. R. J. REYNOLDS TOBACCO COMPANY SALEM BLACK INITIATIVE PROGRAM REVIEW PRESENTATION. 1989 August 01. RJ Reynolds. https://www.industrydocumentslibrary. ucsf.edu/tobacco/docs/tgpw0087 22 Gardiner, P. (2001). Tobacco industry philanthropy in the Black community. Burning Issues, 4(2), 1, 3 5, 16. 23 Yerger, V. B., & Malone, R. E. (2002). African American leadership groups: Smoking with the enemy. Tobacco Control, 11, 336 345. 24 Gardiner, P. (2004). The African Americanization of menthol cigarette use in the United States. Nicotine & Tobacco Research, 6(1), 55-65. doi:10.1080/14622200310001649478 25 Eisenberg, M. R., Elliott, K., Taylor, K., & Woodard, R. (2000). Understanding tobacco policy making from local policy makers point of view: A study of elected Arizona policy makers at the city and county levels. Phoenix, AZ: Arizona Tobacco Information Network. Page 14 of 14