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The FDA Is Moving Forward with a Menthol Cigarette Ban. Here’s What the Science Says

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Updated: | Originally published:

The U.S. Food and Drug Administration (FDA) is moving forward with plans to ban menthol cigarettes and all flavored cigars—policies that agency officials say could help prevent some of the roughly 500,000 U.S. deaths linked to tobacco each year.

“The actions we are proposing can help significantly reduce youth initiation and increase the chances that current smokers quit,” FDA Commissioner Dr. Robert Califf said in a statement. “It is clear that these efforts will help save lives.”

But whether the proposed menthol ban will work as intended is a matter of active debate.

Many influential public-health groups support the policy. Menthol adds a minty flavor and cooling feeling to cigarettes, masking their harshness. As a result, menthol cigarettes are thought to be both more appealing to new smokers and harder for current smokers to quit, which justifies their prohibition, according to many public health experts. (A new study, however, calls into question whether menthols are actually harder to quit than regular cigarettes.)

Black Americans are disproportionately likely to smoke menthols, in large part due to decades of targeted marketing from tobacco companies. Supporters of a menthol ban, including the NAACP, argue that the move would improve the health of Black Americans, while critics argue it is a racial justice issue and could result in discriminatory policing by criminalizing a product disproportionately used by people of color. In a joint letter sent to the U.S. Department of Health and Human Services secretary last year, the ACLU and other signatories wrote that a menthol ban would “prioritize criminalization over public health and harm reduction” and could create an illicit market for menthol products. (The FDA has said it would enforce penalties against retailers and manufacturers that violate the ban, not individuals.)

Others who don’t support the ban argue that it will simply push menthol smokers to use unflavored tobacco products.

After San Francisco in 2018 banned all flavored tobacco products, including menthols and e-cigarettes, fewer young adults used vaping products but more smoked cigarettes, one small 2020 study found. While other societal factors may explain that shift—including an outbreak of vaping-related lung disease beginning months after San Francisco’s policy went into full effect—the authors concluded that flavor bans could lead to more traditional cigarette smoking.

Still, a number of recent real-world studies suggest that menthol bans do have positive effects on public health.

In 2020, menthol cigarettes were banned in the U.K. A paper published in JAMA Network Open on May 3 examined how the regulation affected teenage menthol smoking, using national surveys conducted before and after it took effect. Before the policy went into place, roughly 12% of teenage smokers in the U.K. said they used menthol-flavored products. After it took effect, that number dropped to 3%—a clear sign that the ban led to a drop in youth menthol use, the authors write. (The 3% who said they continued to smoke menthols may have purchased them illegally or used products like sprays and filter tips that add a minty flavor.)

That finding, though intuitive, could strengthen support for menthol bans, since public-health authorities including the U.S. Centers for Disease Control and Prevention argue that use of flavored tobacco products can lure young people into a lifetime of addiction. However, the JAMA Network Open study didn’t look into whether former teen menthol users quit smoking altogether or simply switched to another type of tobacco product.

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“The ban in England seems to have worked in reducing [teenage] menthol smoking, so by extension we would hope it would work in the U.S., although there are obviously big market differences,” says co-author Katherine East, an academic fellow at King’s College London’s Institute of Psychiatry, Psychology, and Neuroscience. Cigarette smoking is rare among U.S. teenagers, with only about 2% of high school students using them regularly, according to the latest federal data. But among that small group, menthols are common: about 38% of teenage smokers in the U.S. use them, compared to about 12% in the U.K. before the ban.

Geoffrey Fong, chief principal investigator of the International Tobacco Control Policy Evaluation Project at the University of Waterloo, has studied menthol bans in Canada, where provinces began outlawing menthol cigarettes in 2015 and a national ban followed in 2017. In a paper published in April, Fong and his colleagues found that Canada’s regulations did, indeed, prompt many menthol users to quit smoking altogether.

By comparing national tobacco-use surveys from pre- and post-ban, they found that 22% of Canadian adults who used menthols went on to quit, compared to about 15% of non-menthol smokers. Of course, that means almost 80% of menthol users hadn’t quit, and had instead either switched to another tobacco product or found a way to keep smoking menthols, such as by purchasing them through a First Nations reserve. Reserves are subject to Canada’s ban, Fong says, but some continue to sell menthols anyway. (In the U.S., tribal lands are subject to the FDA’s proposed menthol ban.)

But Fong calls the seven-percentage-point difference in quit rates between menthol and non-menthol smokers “huge,” especially considering how difficult it is to kick a nicotine addiction of any kind.

Relatively few Canadians smoked menthols even before the ban. But Fong and his co-authors wanted to know how similar policies might affect population health in the U.S., where more people use these products. Using their Canadian findings, they estimated that more than 1.3 million U.S. smokers would quit in the wake of a menthol ban, including more than 380,000 Black smokers.

“There’s extremely strong public-health benefits from this,” Fong says. “From our research, we can expect significant positive effects, and greater proportional benefits for the public health of the Black community.”

Another research review, published in 2020, found that up to 30% of U.S. menthol smokers would consider switching to e-cigarettes if menthols were banned. While e-cigarettes aren’t harmless, experts widely consider them to be less dangerous than traditional cigarettes—so even without total nicotine cessation, most experts would consider that a net positive for public health.

Ultimately, though, researchers won’t know what effect a menthol ban could have on U.S. smokers until years after one is implemented. Since the rule faces a long bureaucratic road and likely won’t take effect until at least 2024, that means solid conclusions are a ways off.

Correction, May 6

The original version of this story misstated how Canada’s menthol ban applies to First Nations reserves. They are not exempt from the menthol-cigarette ban.

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Write to Jamie Ducharme at jamie.ducharme@time.com