On Jan. 2, the Trump administration announced a ban on most flavored e-cigarette cartridges, except for menthol and tobacco flavors. The ban is aimed at reducing the uptake of vaping among young people.
Whether it will prove effective remains to be seen. History, however, may provide some insight.
The new policy banning most flavored e-cigarette cartridges echoes prior regulation of the tobacco industry. The Family Smoking Prevention and Tobacco Control Act, passed by Congress in 2009, banned the sale of flavored cigarette products — except for menthol.
The menthol exemption has garnered heavy criticism from public health advocates. They argue that any flavored product may encourage smoking and vaping among youth. Research shows that menthol cigarette use is disproportionately high among young smokers.
“Menthol – which is an ingredient in both mint and menthol flavored products – provides a cooling sensation that masks the harsh taste of nicotine, making it easier for children to get hooked,” said American Academy of Pediatrics President Sally Goza, in a statement following last week’s partial flavored vape ban. “The idea that menthol is an adult flavor is just plain wrong.”
In fact, compared with all other age groups, youth between the ages of 12 and 17 are the most likely to use menthol cigarettes, according to a 2016 study in Tobacco Control, which tracked the prevalence of the product in the U.S. over the course of a decade. While overall smoking rates among youth declined from 2004 through 2014, the proportion of youth smokers who use menthol cigarettes increased. Nearly 40% of surveyed youth smokers reported using menthol cigarettes from 2012 to 2014, compared with 35% from 2008 to 2010.
A 2006 study in Nicotine and Tobacco Research finds that menthol cigarettes are a “starter product” for youth smokers; data from the National Youth Tobacco Survey indicate that menthol cigarette use “was significantly more common among newer, younger smokers.”
“There’s been a lot of research done on correlates and consequences of menthol cigarette smoking, particularly among younger individuals,” says Amy Cohn, associate professor in the department of pediatrics at the University of Oklahoma College of Medicine, who studies tobacco use and regulation. “It’s been linked to progression to regular smoking among younger individuals. It’s been linked to greater nicotine dependence compared to non-menthol cigarette smoking, and greater difficulty quitting smoking among adult smokers.”
A 2019 study published in the American Journal of Preventive Medicine provides further detail on these trends. The study looks at data collected in 2013 and 2014 through the Population Assessment of Tobacco and Health Study, a nationally representative study of smoking habits that includes a sample of 13,651 U.S. kids between the ages of 12 and 17.
Of the respondents who had ever smoked a cigarette, more than 2 out of 5 — 43.2% — said the first cigarette they smoked was menthol. And 42% of respondents named a menthol brand as their regular brand. Youth who smoked menthol cigarettes in the past month were more likely to report that those cigarettes were easier to smoke than youth who smoked non-menthol cigarettes in the past month.
“It’s not as if only five or 10 percent of young people who started smoking start with a menthol cigarette, it’s almost half of them,” says Cohn, who was lead author of the study. “One of the reasons hypothesized for why menthol is so appealing to young people is that it’s been proposed to, quote-unquote, ‘help the medicine go down.’ The minty cooling sensation is supposed to mask the harshness of inhaled cigarette smoke.”
Additionally, kids who reported smoking menthols in the past month were more likely to have smoked six to ten cigarettes per day and less likely to have smoked between one and five cigarettes per day than kids who reported smoking non-menthol cigarettes in the past month.
Breaking the findings down further, the researchers found that youth respondents who began smoking with a menthol cigarette and who stated a preference for a menthol cigarette brand were more likely to be black, to have started smoking at a relatively older age and to have smoked menthol cigarettes in the past month.
Research shows that menthol cigarettes in particular have been marketed toward black youth.
“A lot of research suggests that this marketing has something to do with the uptake of menthol [cigarettes], specifically in this group of individuals,” Cohn says.
For example, a 2012 study published in Nicotine and Tobacco Research examined cigarette advertising in 407 stores within walking distance of 91 California schools, located in neighborhoods of varying racial demographics. Among the findings: “For each 10 percentage point increase in the proportion of black students, the proportion of menthol advertising increased by 5.9 percentage points.”
A 2011 study in Tobacco Control examined 953 tobacco industry documents from the 1930s through 2000s to examine various research questions, including whether menthol cigarettes were marketed to specific populations. The study finds that menthol cigarettes “were marketed as, and are perceived by consumers to be, healthier than non-menthol cigarettes. Menthol cigarettes are also marketed toward specific social and demographic groups, including African Americans, young people and women, and are perceived by consumers to signal social group belonging.”
About 80% of African American smokers smoke menthol cigarettes, Cohn notes, suggesting that peer use may also influence on why menthol cigarette smoking is higher among African Americans.
The patterns, she says, raise concerns about health equity. For this reason, and others, Cohn says it’s important to keep combustible tobacco products in the public eye even as e-cigarettes draw increasing media attention.
“I think that there’s a lot of focus on e-cigarettes and vaporized products. And what I think that does for the tobacco industry is that it takes the focus off of cigarettes and things like menthol cigarettes that have been around for a long time. And I think it’s important that we keep the focus on menthol cigarettes,” Cohn says. “The FDA has been saying we need more information, we need more data on the impact of menthol cigarettes on smoking and indicators of abuse liability…. I think there’s a lot of research to make the decision.”
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