How to Get 4.5 Million Americans to Quit Smoking

How to Get 4.5 Million Americans to Quit Smoking

You wouldn’t think it would be easy to get nearly 4.5 million Americans—the equivalent of the entire state of Louisiana or Kentucky—to give up smoking. But it can be done in a single, straightforward step: prohibiting the sale of menthol cigarettes. That’s the conclusion of a new study in the journal Nicotine & Tobacco Research.

The study is one more piece of evidence in favor of a nationwide menthol ban, the authors say. The U.S. Food and Drug Administration (FDA) proposed just such a ban in 2022, but in Dec. 2023, the Biden Administration postponed implementation following intense lobbying by tobacco company lobbyists and convenience store owners, who complained that the action could cost untold jobs and billions of dollars in sales.

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“The FDA has done its work,” says Sarah Mills, the paper’s lead author and an assistant professor in the department of health behavior at the University of North Carolina’s Gillings School of Public Health. “The White House has decided to put off their decision, which simply delayed what could be an important step in promoting public health.” 

Medical experts have long argued that menthol cigarettes are a particularly pernicious form of tobacco. The flavoring cools the smoke, encouraging users to consume more, and nonsmokers—typically young people—to pick up the habit.

“When added to cigarettes, menthol sweetens the poison of nicotine, making it easier to start smoking and harder to quit,” says Mills. What’s more, the chemical stimulates the activity of so-called nicotinic receptors in the brain, increasing the addictive power of nicotine. 

Read More: What the Science Says About Menthol Cigarette Bans

Black Americans are especially likely to smoke menthols. According to the U.S. Centers for Disease Control and Prevention (CDC), 42 million U.S. adults reported using any tobacco product last year. Of those, 18.5 million consume menthol. That represents just 34% of white smokers—but 81% of Black smokers. “A menthol cigarette ban would provide the greatest benefits to Black people who smoke,” said Mills in a statement that accompanied the release of the paper.

The investigators conducted a meta-analysis of 78 previously published studies, principally of populations in the U.S., as well as in Canada and the European Union, both of which have imposed nationwide or continent-wide bans. In the U.S., only two states—Massachusetts and California—prohibit the sale of menthol cigarettes, imposing bans in 2020 and 2022 respectively. An additional 170 cities—including Chicago; Aspen, Colorado; Bangor, Maine; and Duluth, Minnesota—have banned menthols as well.

The most important part of what the authors of the new paper learned concerns the share of menthol smokers who would quit entirely if their preferred product was no longer available. Based on the collective findings of the 78 papers—and what happened in places where menthols were banned—the researchers estimated that 50% of menthol smokers would switch to a non-menthol brand and 24% would continue smoking menthol cigarettes—either buying them online or crossing state or national boundaries to purchase the products where they are still legal. A remaining 24% of menthol smokers would simply give up cigarettes.

If the FDA’s proposed ban were rolled out nationwide, the 24% quit rate would mean 4.44 million American ex-smokers.

The data also provide a granular look at the effects of menthol bans.  Up to 65% of menthol smokers, when asked, said that a ban would get them off cigarettes for good—or 2.7 times the share who actually did quit, a possible sign of how addictive mentholated tobacco is. Switching to a non-menthol brand actually had some salutary effects, with users reporting, on average, that they smoked 2.2 fewer cigarettes a day and experienced fewer nicotine cravings.

Menthol bans are not always comprehensive, and in some cities and countries, menthol e-cigarettes are still available. A study in Massachusetts found that 7% of menthol smokers had switched to menthol e-cigarettes six months after the statewide ban was imposed. In Canada, the number was much higher—29% within just one month of the ban. This could be due to the greater difficulty of traveling out of the country to buy menthol cigarettes as opposed to the ease of crossing a state line. “Compared to a national ban,” says Mills, “individuals under a state or city ban can readily visit places nearby that sell the product.”

Retailers and cigarette manufacturers are not going down without a fight, and their resistance to bans goes beyond lobbying. In the U.S., manufacturers have mounted a public relations campaign, sending mailers to homes, holding community meetings, and arguing that a ban would discriminate against Black Americans. In the European Union, tobacco makers have introduced menthol capsules that can be inserted into cigarettes and cigarillos. Brazilian cigarette makers have gone to court to litigate against bans. Canadian companies have relied more on marketing, conspicuously labeling cigarette packs with the words “smooth taste without menthol.”

American retailers have been uneven in obeying bans, with compliance ranging from as low as 17% in shops in San Francisco to 100% in some in Minnesota, according to studies the authors cite that took place in those and other cities from 2019 to 2022. Retailers acquire their forbidden menthol products the same way individual consumers do: shopping online or importing from across state or city lines. In a few localities that have partial bans—prohibiting menthol sales only to young people—some retailers have managed a workaround, establishing an enclosed, adults-only space within their stores where menthol products are sold.

The prospects for the FDA’s proposed U.S. ban remain uncertain, with some commentators speculating that President Biden will wait until after the November election before allowing the prohibition to go through, fearing a backlash from Black voters. “This is ultimately coming down to a political decision by the president and his senior advisers,” Erika Sward, assistant vice president at the American Lung Association, told The Hill.

Whatever the reason for the ban’s delay, Mills and her colleagues maintain that the time to act is now. Every year, more than 480,000 Americans die of smoking-related causes, according to the CDC. “Menthol bans,” the authors write in their paper, “promote smoking cessation.”

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