Sunday, May 8, 2011

A Minty-fresh Stalemate on Menthol Cigarettes

The story I’m about to tell you is figuratively yesterday’s news. Literally it comes from March of 2011, from 2009 and from 2 very different Perspective pieces published online in the New England Journal of Medicine (NEJM) a few days ago. These editorials address the debate surrounding a report presented to the FDA by the Tobacco Products Scientific Advisory Committee (TPSAC), which was created two years ago and tasked with determining whether menthol cigarette pose a greater risk to public health than your standard non-minty smokes. This is a large and complex issue, which will be addressed here with a certain brevity (and perhaps even bullet points) as I am leaving for vacation in less than 24 hours.

A Committee is Born
The TPSAC was created as part of the 2009 Family Smoking Prevention and Tobacco Control Act. This legislation also banned flavored tobacco products, with the notable exception of menthol cigarettes. Instead of being part of the original ban, menthols were given temporary exemption until their hazards could be assessed by the newly-formed committee.

The Controversial Report
After a lengthy examination of peer-reviewed literature on menthol cigarettes (as well as tobacco industry submissions), the TPSAC delivered an equally lengthy report.* It stated that, because there was not consistent evidence of greater toxicity in cigarettes treated with menthol, the risk to any individual smoker was no different whether they chose a minty or unflavored product. However, considerable evidence showed that menthol smokers had a harder time quitting than non-menthol smokers. Even more problematic, menthol cigarettes were determined to make it easier for people to start smoking in the first place. By softening the taste and feel of tobacco, menthol cigarettes facilitate smoking for novices who might otherwise be deterred by these harsh sensory realities. They are the wine coolers and peppermint Schnapps-spiked hot chocolates of the cigarette world.

The Report Card
The most frequently quoted sentence from the TPSAC report is its overall recommendation, “Removal of menthol cigarettes from the marketplace would benefit public health in the United States.” Critics – such as Dr. Michael Siegel, who wrote one of the aforementioned NEJM editorials – criticized the language for being weak and for deliberately avoiding making any recommendation for a ban. The second NEJM article, written by two doctors who served on the TPSAC, defended the report stating that critics failed to understand the purpose of a scientific advisory committee. They likened the maligned quote to the 1964 Surgeon General’s report on smoking, which stated, “Cigarette Smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action.”. Okay, also a bit ambiguous, but one gets a better sense of what is being suggested. The “if, then” structure of the TPSAC recommendation fails to convey any urgency.

Mint-flavored Market
Perhaps the most interesting part of the menthol controversy is the history of the cigarette itself and how it became – in the U.S. –  a product marketed specifically to black consumers. Menthols were unleashed onto the public in the 1920’s, so the story goes, by Lloyd “Spud” Hughes, who accidentally discovered the idea after storing his own tobacco overnight in tin that also contained menthol. Spud cigarettes, with their purported breath-freshening properties, were originally marketed to the fashionable smoking elite. As the century progressed, they began to be viewed more as cough drops. One switched to soothing menthol cigarettes when stricken with a cold and then returned to their usual pack once they were on the mend.

But in the mid 20th century, the cigarettes began being targeted at the growing African American market. Cigarette manufactures not only created ads designed to appeal specifically to these consumers, they also ingratiated themselves by donating money to black community organizations and civil rights groups. By the 2000’s, menthols were the cigarette of choice among 70% of African American smokers (versus only 30% of white smokers). Given that African Americans have higher mortality rates from lung cancer than American whites, the role of menthol becomes not just a health issue, but potentially one of racial equality. In fact, Siegel suggests, the TPSAC was assigned the duty of investigating menthol cigarettes only because the exemption of menthol from the original legislation met with such strong opposition from the Black Congressional Caucus. But that’s a larger issue than can’t be tackled today, so on to…

The Bullet Points
  • Personally, I’m more for warnings than bans. Yet it does seem a bit odd that the Family Smoking Prevention and Tobacco Control Act would go through the trouble of banning something as obscure as cherry and strawberry flavored tobacco products and then exclude the one flavor that actually sells in meaningful numbers.

  • One of the weaker arguments against banning menthol cigarettes is that such a ban could create a black market for this sought after product. Seriously? (rhetorical question alert) Does anyone actually believe that menthol smokers would find drug dealers to sell them contraband cigarettes rather than just buying a non-mentholated brand they can get at their grocery store? And if black market business is such a concern, why are various recreational drugs illegal?

  • Is the FDA doing anything about Camel Crush cigarettes? Do those things still exist? They were being rather aggressively marketed when I first moved to Austin, with company representatives handing them out in downtown bars. It’s a regular cigarette that can be transformed into a menthol by simply squeezing the filter. This breaks a small menthol capsule that leaks minty fluid into the cigarette. The crushing of the capsule sounds similar to glass breaking. It just seems like a bad idea.

And now, I’m off to Europe where I’m told everyone smokes unfiltered, unflavored cigarettes and drinks hot coffee even in the middle of Summer.

* It’s over 200 pages and I don’t have time to read it right now. If you want to give it a shot, be my guest. It can be downloaded as a PDF from the FDA’s website.


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