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Commentary: The FDA Can and Should Act Now to Address Health Disparities by Banning Menthol Flavorings in Cigarettes

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In an important step forward for victims of the past predatory marketing practices of Big Tobacco, the Massachusetts Supreme Judicial Court issued last week its decision in Evans v. Lorillard, upholding $35 million in compensatory damages against Lorillard, the makers of mentholated Newport cigarettes. Marie Evans, an African American and lifelong Newport smoker died in 2002 from cancer caused by her smoking. She began smoking when she was only a young girl, lured by free menthol-flavored Newport samples given away to children near where she lived in the Orchard Park Housing Project in Roxbury, MA. While this case underscores the devastating illness and death of one person as a result of smoking menthol cigarettes, it also illustrates a larger public health issue that demands long overdue action.

Why? Research confirms not only that menthol cigarettes are a starter product for youth, but also that the tobacco industry has a long history of targeting menthols to youth and communities of color. In fact, the overwhelming majority of African-American smokers, smoke menthols. This includes nearly 85 percent of African-American high school students who smoke and nearly 85 percent of adult African-American smokers.

Marie Evans tragically died as a result of her childhood addiction to mentholated cigarettes. Many more will continue to follow suit until the U.S. Food and Drug Administration (FDA) acts to ban menthol-flavored cigarettes, bringing menthol into line with the U.S. Family Smoking and Tobacco Control Act of 2009’s ban on all other candy flavorings in cigarettes. The public health community and policy makers must continue to raise awareness about the burden of tobacco, very much including mentholated products, on low socio-economic (SES) and minority communities. We must also continue to fund education programs that prevent young people from starting to smoke and that help smokers quit. We need to collectively push for health care policies that make lifesaving resources available to those who need it the most.

The nation’s leading public health organizations recently submitted a citizen petition urging the FDA to ban cigarettes that use menthol as a “characterizing flavor.” This petition sets in motion a process that requires the FDA to accept public comments on the topic and ultimately respond to the petition. An FDA announcement on this topic has been expected for some time and the agency has the authority and evidence to take immediate action.

The health hazard posed by menthol in cigarettes may seem obscure to some, but it has monumental implications for communities of color. After decades of minority-focused marketing pushing menthol-flavored cigarettes, in 2009, an astounding 83 percent of African-American smokers, 31 percent of Asian-American smokers and 32 percent of Hispanics smokers use menthol-flavored cigarettes, compared to just 24 percent of white smokers. According to a leading economic model, fully one-third of the lives saved by eliminating menthol cigarettes and causing menthol smokers to quit will be African American.

Beyond addressing racial and ethnic health disparities, preventing kids from getting addicted is another good reason to ban menthol-flavored cigarettes. As the tobacco industry knows, the taste and cooling sensation of menthol is especially appealing to new smokers. As a result, about half (48 percent) of 12- to 17-year old smokers smoke menthol cigarettes, compared to 31 percent of American smokers over 26 years old. Menthol-flavored cigarettes are even more popular among middle school-aged children than they are with high school-aged smokers. Each day, 3,500 youth aged 12-17 try smoking for the first time, and 1,000 youth aged 12-17 will become daily smokers. Despite declines in non-menthol cigarette use among youth in recent years, menthol use has remained stable in this age group. Given the fact that initiating smoking with menthol cigarettes has been shown to be associated with progression to established smoking and that millions of young people smoke menthol cigarettes, there is great concern about menthol’s role in youth initiation.

This decision should not be difficult for the FDA. Congress has provided the FDA with the authority to prohibit menthol if “appropriate for public health” and directed the agency to prioritize the review of menthol in cigarettes. The FDA’s own scientific advisory committee studied menthol and in 2011 concluded: “Removal of menthol cigarettes from the marketplace would benefit public health in the United States.” Incredibly, after four years with the authority to act, menthol cigarettes are still addicting and poisoning millions of Americans and banning them would be one way to chip away at tobacco-related health disparities.

So, why not eliminate menthol-flavored cigarettes? Logically speaking, a flavor is a flavor, right? The only meaningful difference between the already-banned flavors and menthol is that menthol has proven to be far more deadly than other flavors because it makes it easier to start smoking and harder to quit. Moreover, we know from internal tobacco industry documents that menthol levels in cigarettes have been intentionally manipulated specifically to make it easier for new smokers to inhale and thereby take up smoking.
The public – along with the public health community – is solidly behind removing menthol cigarettes from the market. A 2011 survey conducted by the American Academy of Pediatrics, among others, found that a strong majority (56 percent) of Americans support prohibiting menthol. The African-American community is especially supportive, with an overwhelming 68 percent of African Americans supporting such a ban.

Banning menthol-flavored cigarettes is not a symbolic issue; it is a life-and-death issue. It was for Marie Evans and it still is for the millions of Americans who smoke menthol cigarettes. One model estimates that if menthol was prohibited as a characterizing flavor in cigarettes between 2010 and 2020, more than 2.2 million people would not start smoking and about 17,000 premature deaths could be prevented. By 2050, the cumulative number of people who would not start smoking would be nine million, and more than 300,000 deaths could be prevented.

Cigarette smoking remains the leading cause of preventable death and disease in the United States. In 2011, 19 percent of U.S. adults – 43.8 million people – were current cigarette smokers. Cigarette smoking kills more than 440,000 Americans each year and leaves millions more to suffer from tobacco-related chronic disease. The death and disease caused by smoking costs the U.S. $193 billion annually, including $97 billion per year in lost productivity and $96 billion per year in health care costs. Minority populations are especially affected by tobacco use. Tobacco use is a well-known cause of various cancers, heart disease and stroke, diseases that result in disproportionately higher rates of death in African Americans than Whites.

The agency’s website promises that “FDA is dedicated to addressing these disparities and achieving the highest standard of health for all.” Beyond mere words, the actions of the FDA on this issue will show just how serious it is about addressing health disparities in America. Marie Evans’ life might have been saved if she’d never smoked menthols, and by acting now, the FDA can save millions more from her same fate.

Georges Benjamin, M.D., FACP, FACEP(E), is the Executive Director of the American Public Health Association and Cheryl Healton, DrPH, is the Chief Executive Officer of the American Legacy Foundation.

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