Banning menthol leads to big drop in smoking in Canada: Implications for USA

As the April 29 deadline for the Biden Administration to respond to a lawsuit brought by the African American Tobacco Control Leadership Council and Action on Smoking and Health approaches, the results of a large national survey from Canada show that banning the sale of menthol cigarettes was followed by a huge increase in smoking cessation among menthol smokers there: 21.5% quit smoking even though they could still buy non-menthol cigarettes.

This quit rate was significantly higher than the 14.0% of non-menthol smokers who quit smoking during the same time.

The paper, “Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016–2018 ITC Four Country Smoking and Vaping Surveys,” by Janet Chung-Hall and colleagues published in Tobacco Control, also presented evidence that after the ban menthol smokers made more quit attempts, were more likely to be successful, and less likely to relapse smoking.

There was no increase in smuggling, debunking another common industry claim that is used against menthol and flavored tobacco bans.

Canada banned menthol flavor itself as well as menthol analogs. This is a stronger form of regulation that the UShas done so far, which has only dealt with “characterizing flavors” rather than the flavors themselves.

Geoff Fong, senior author of the study, has provided a helpful Powerpoint slide deck summarizing the results with their implications for the USA and California. Specifically, they estimate that a US menthol ban would lead 1.4 million smokers to quit, including 393.00 African Americans. (The numbers for California are 49,000 and 12,000, respectively.)

What this means is that instructing/allowing the FDA to get rid of menthol — something Presidents Obama and Trump both blocked — would have big positive health effects immediately. Moreover, since African Americans (and other minorities) smoke menthol at higher levels than Whites, the benefit would be higher for these groups that the tobacco companies have targeted.

This paper is also relevant to California, where the tobacco companies have forced a referendum on the state flavored tobacco ban (SB793).

Here is the authors’ press release about the paper :

Canada-wide ban on menthol cigarettes leads to significant increases in quitting among smokers

Bans on menthol cigarettes across Canada from 2016 to 2017 led to a significant increase in the number of smokers who attempted to quit, smokers who quit successfully, and lower rates of relapse among former smokers, according to a new research study from the International Tobacco Control Policy Evaluation Project (the ITC Project) at the University of Waterloo.

The Canadian study, published today in the journal Tobacco Control, examined the impact of menthol bans across 7 Canadian provinces, covering 83% of the Canadian population, which banned menthol cigarettes between August 2016 and October 2017. Canada was the one of the first countries to implement a ban on menthol cigarettes, and the first country where a menthol ban has been evaluated.

Menthol is the most common flavoring for cigarettes in many countries. Menthol creates a cooling sensation, which reduces the harshness of cigarette smoke. Because of this, menthol leads to increased experimentation and progression to regular smoking among new smokers, especially among youth.

Scientific reviews conducted by the Tobacco Products Scientific Advisory Committee to the U.S. Food and Drug Administration (FDA), the FDA itself, and the World Health Organization (WHO) have all concluded that banning menthol would have significant public health benefits. The fact that the U.S. FDA has not yet banned menthol, despite the evidence, has been a concern among public health experts.

The harms of menthol cigarettes in the U.S. have been much greater among African Americans. Menthol cigarettes are smoked by 85% of African American smokers, over 2.8 times the percentage of menthols among White smokers.

A national sample of 1098 non-menthol and 138 menthol smokers participating in the ITC Canada Smoking and Vaping Survey were surveyed both before the menthol ban (in 2016) and after the menthol ban (in 2018).

The survey demonstrated three benefits of the Canadian menthol ban. Menthol smokers were significantly more likely than non-menthol smokers to attempt to quit after the menthol ban (58.7% vs. 49.0%).

Daily menthol smokers were almost twice as likely than daily non-menthol smokers to quit after the menthol ban (21.0% vs. 11.6%).

Finally, those menthol smokers who had quit smoking before the menthol ban were significantly less likely than non-menthol smokers who had quit smoking to have relapsed back to smoking.

The Canadian menthol ban also did not lead to a high level of illicit menthol cigarette purchasing, which has been a concern by regulators considering a menthol ban. Fewer than 10% of menthol smokers reported still smoking a menthol brand after the ban, with over half purchasing them from First Nations reserves, the major source of illicit cigarettes in Canada.

“Our study demonstrates the substantial benefits of banning menthol cigarettes,” said Geoffrey T. Fong, Professor of Psychology and Public Health and Health Systems at Waterloo, and Principal Investigator of the ITC Project. “The enormous success of the Canadian menthol ban makes it even clearer now that the U.S. should finally ban menthol, which the tobacco industry has used for decades to attract new smokers and to keep many of them as customers, especially among the African American community.”

“The positive effects of the Canada menthol ban suggest that a U.S. menthol ban would lead to greater benefits since menthol cigarettes are much more popular in the U.S.
From our findings, we estimate that banning menthol cigarettes in the U.S. would lead an additional 923,000 smokers to quit, including 230,000 African American smokers.”

Here is the abstract:

Objective To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018.

Methods Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey. 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans. Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting.

Results At follow-up, 59.1% of pre-ban menthol smokers switched to non-menthol cigarettes; 21.5% quit smoking and 19.5% still smoked menthols, primarily purchased from First Nations reserves. Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=1.61, 95% CI 1.03 to 2.51), and to remain quit (aOR=2.30, 95% CI 1.06 to 5.01). Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=1.72, 95% CI 0.98 to 3.01); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=2.21, 95% CI 1.15 to 4.24), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=2.81, 95% CI 1.15 to 6.85).

Conclusions Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban. Results confirm and extend evaluation of Ontario’s menthol ban across provinces covering 83% of the Canadian population.

The full citation for the paper is: Chung-Hall J, Fong GT, Meng G, Cummings KM, Hyland A, O’Connor RJ, Quah ACK, Craig LV. Evaluating the impact of menthol cigarette bans on cessation and smoking behaviors in Canada: Longitudinal findings from the Canadian arm of the 2016-18 ITC Four Country Smoking and Vaping Surveys. Tobacco Control. Epub ahead of print: 06 April 2021.https://dx.doi.org/10.1136/tobaccocontrol-2020-056259. It is available here.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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