How New Tobacco Control Laws Could Help Close the Racial Gap on U.S. CancerACTA
This interactive examines how nationwide bans on menthol cigarettes and flavored cigars, as proposed by the Biden administration on April 28, 2022, could help shrink the racial gap on U.S. lung cancer death rates.
During the 2020 presidential campaign, Joe Biden promised that his administration would make a “historic effort” to reduce long-running racial inequities in health. Tobacco use—the leading cause of preventable death in America—could be the issue on which the Biden administration comes closest to fulfilling that promise. This interactive examines how nationwide bans on menthol cigarettes and flavored cigars, as proposed by the Biden administration on April 28, 2022, could help shrink the racial gap on U.S. lung cancer death rates.
The past fifty years have seen remarkable successes in tobacco control in the United States and in reducing the premature burden of associated cancers, but those gains have not been shared by all Americans equally. Both incidence and mortality from lung cancer is higher among Black Americans than their white counterparts (see figure 1). This divide is driven by the racial disparity in lung cancer among men, the gender most likely to smoke tobacco products in the United States.
One major reason for the racial disparities in U.S. tobacco use is that, beginning in the 1970s and 1980s, the tobacco industry targeted marketing for menthol-flavored products toward Black communities; popular strategies included handing out free loose cigarettes as promotions and providing discounts on menthol products in majority Black neighborhoods. Menthol in cigarettes makes it even harder to quit and to quit successfully, particularly among Black smokers. Today, almost 85 percent of Black smokers use menthol cigarettes, compared to just 30 percent of white smokers. Despite constituting only 12 percent of the U.S. population, Black Americans account for 41 percent of smoking-related premature deaths and 50 percent of the life-years lost associated with mentholated tobacco product use between 1980 and 2018.
Menthol was excluded from the U.S. national ban on flavored cigarettes in 2009, due in part to tobacco industry lobbying. Yet progress continued at the state and local level. In 2019, Massachusetts became the first state to issue a comprehensive ban on menthol cigarettes, and roughly twenty localities in California, Illinois, and Minnesota have as well. The Biden administration proposal builds on those state and local actions, adding menthol cigarettes to the list of prohibited tobacco products nationwide. In its justification of the federal regulatory action, the Food and Drug Administration (FDA) estimates this ban and the subsequent decrease in cigarette use could prevent as many as two hundred thousand deaths among Black Americans.
In this interactive, we assess and illustrate how the proposed FDA ban on menthol cigarettes could affect U.S. cancer inequities. We adjust for differences in the age structure between U.S. population groups and consider the effect of the bans had they gone into effect in 2021. We find that the ban, if implemented effectively, would indeed close the disparity in U.S. lung cancer death rates due to smoking between non-Hispanic Black Americans and other U.S. racial and ethnic groups. Without that ban, the gap between lung cancer death rates for non-Hispanic Black Americans and other U.S. racial and ethnic groups are not projected to close until 2050. With the FDA ban, the gap closes in 2025— twenty-five years sooner—and continues to fall from there, cutting smoking attributable lung cancer death rates in half for non-Hispanic Black Americans (see figure 2). For the purposes of analysis, we assume that 2019 age-standardized death rates stayed constant, but given recent historical trends, we believe our findings are underestimates and the forecasted decline in death rates from a ban are likely to be even greater. A full description of our methodology, data sources, and a few necessary simplifying assumptions can be found here.
Beyond reducing adult lung cancer deaths from smoking, nationwide bans on menthol cigarettes and flavored cigars would help prevent youth smoking. Menthol renders smoking more palatable, making the flavor less bitter and the smoke less irritating to inhale. Mentholated cigarettes are the product of choice for 56 percent of smokers aged twelve to seventeen (see figure 3). Youth who begin smoking menthol products are more likely to become nicotine dependent, and progress to regular tobacco use later in life. Banning menthol would not only reduce smoking among regular adult users but would also make smoking initiation less appealing to minors—both necessary steps forward in tackling tobacco use in the United States. It could also help pave the road for the FDA to complete its long-awaited review of marketing applications for flavored e-cigarettes, which could help lead to bans on products including mint.
The United States would not be the first nation to remove mentholated cigarettes from its market, but it would be the largest country to do so. In 2012, Brazil introduced bans on all flavor additives, including menthol, in cigarettes, followed by Ethiopia in 2015. Canada issued a national ban in 2017 after several provinces successfully implemented their own menthol cigarette bans in the years prior. Between 2017 and 2019, Moldova, Nigeria, Senegal, Turkey, and Uganda all passed national menthol cigarette bans. The European Union did so in 2020. If the United States—the country where the top three menthol cigarette brands are based—were to ban the flavor, it would be keeping pace with its peers in global tobacco control.
The FDA Center for Tobacco Products has come under criticism in recent months for its struggles to fulfill its broad policy mandate and keep pace e-cigarette industry, which is deluging regulators of new tobacco product applications. Successfully passing and implementing a menthol ban would demonstrate the potential benefits of a more streamlined approach to product approval and enforcement. The need for proactive action against the tobacco industry is likely to be ongoing. When California banned all odors or tastes in tobacco products last November, tobacco company R.J. Reynolds responding by marketing “fresh-tasting” or “cool” tobacco—products with additives that offer the same cooling sensation as menthol without the minty taste that would run afoul of the new state rules. The large health gains from a nationwide menthol cigarette ban could show what is possible with a stronger FDA that is able to evaluate products in a timely manner, enforce its decisions, and communicate risks to the public.
The menthol cigarette ban has the potential to be one of the most important public health policies of the Biden administration, delivering a significant blow to existing racial inequity in health. Between tackling long-standing racial disparities in tobacco use and preventing thousands from beginning to smoke, the FDA’s proposed ban is a necessary next step in the long fight against U.S. tobacco use.