A Sacrificial Lamb?

By: Phil Gardiner, Dr. P.H.

On a vote of 326 to 102, the United States House of Representatives voted overwhelmingly to pass the Waxman/Warner bill (HR 1108) and give the Food and Drug Administration (FDA) authority to regulate tobacco products. At the same time, the original language, which had exempted menthol from the list of prohibited addictives, was modified to mandate that an FDA scientific advisory committee study the effects of menthol flavoring and issue a recommendation within one year. FDA also would have to produce an action plan on the advertising and promotion of menthol and other cigarettes to young people, particularly those in minority communities (1). Behind this last-minute change is a series of developments that propelled menthol, in the course of a two-month period, to the center of the national debate around FDA regulation. Below, we explore why menthol is an issue, what happened to make it a national issue and what is the road ahead.

Menthol: The African American Cigarette of ‘choice’
Why is menthol an issue? Mentholated cigarettes comprise about 25% of the overall tobacco market, making it by far the leading additive marketed in cigarettes and other tobacco products (2). Menthol, when added to tobacco masks the harshness of the tobacco smoke, and many scientists speculate that this allows for the deeper inhalation of the poisonous products in cigarette smoke (3). Not only is menthol a mild analgesic, but functions as a bronchodilator, expanding the airways to the lungs to ensure the maximum entry of tobacco smoke (4). It should be noted that all cigarette and tobacco products have menthol in them, 0.003% for non-mentholated cigarettes; 0.1 - 0.45% for mentholated smokes (5). This is also true of pipe tobacco and “roll your own” tobacco. And while these scientific facts are salient in and of themselves, it is the politics of menthol that has made it an issue.

Overwhelmingly, menthol cigarettes are the brand of choice of African Americans. And this choice was created by the tobacco industry itself.

“Today, over 70% of African American smokers prefer menthol cigarettes, compared with 30% of White smokers. This unique social phenomenon was principally occasioned by the tobacco industry’s masterful manipulation of the burgeoning Black, urban, segregated, consumer market in the 1960s. Through the use of television and other advertising media, coupled with culturally tailored images and messages, the tobacco industry ”African-Americanized’’ menthol cigarettes. The tobacco industry successfully positioned mentholated products, especially Kool, as young, hip, new, and healthy. During the time that menthols were gaining a large market share in the African American community, the tobacco industry donated funds to African American organizations hoping to blunt the attack on their products. . . .Unfortunately, the long-term impact of the industry’s practice in this community may be partly responsible for the disproportionately high tobacco-related disease and mortality among African Americans generally and African American males in particular” (6).

The disproportionately high mortality from tobacco related diseases was captured succinctly in the 1998 Report of the Surgeon General (7): (CHD = Coronary Heart Disease; CVD = Cerebrovascular Disease)

Across the board, African Americans are dying at disproportionate rates from tobacco related diseases compared to other racial and ethnic groups. Let’s be clear, even though these figures are from a decade ago, the situation has not changed one bit. American Cancer Society data from 2007 shows the same disparity (8):

Today, even though Kool has receded in prominence and Newport has ascended as the main menthol brand, still African Americans disproportionately smoke menthols. Here in lies the politics of the question. The tobacco industry does not want to potentially disrupt African American consumption of its product by agreeing to remove menthol from cigarettes. And with the organized African American tobacco-control and research community not being part of the negotiations on FDA oversight, this issue was not central to the deliberations. However, in a series of unexpected and stunning developments, menthol not only made the front pages of the leading papers around the country, but became a discussion on the floor of the House of Representatives.

The Gathering Storm
The harbinger that menthol was on the national agenda was a May 13th article on the front page of The New York Times: “Cigarette Bill Treats Menthol with Leniency” (9). Stephanie Saul’s article, in which she interviewed key members of the African American tobacco-control movement, exposed for the first time this burning issue to a larger public that menthol was getting a free pass. Unlike cloves, cinnamon, etc, being banned, which MF Bowen reported on in a previous Burning Issues article, FDA at the Crossroads, menthol would be exempt (10). Make no mistake, the tobacco industry understood full well why they wanted menthol exempt: Menthol cigarettes are by far the most popular cigarettes among African Americans. To outlaw the use of this additive would seriously undermined big-tobacco market share among this key tobacco-consuming group.

Robert G. Robinson captured the matter succinctly: “I think we can say definitively that menthol induces smoking in the African-American community and subsequently serves as a direct link to African-American death and disease,” said Robinson, who retired two years ago as an associate director in the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC) (9).

Following The New York Times’ article, a flurry of activity surrounded this issue, much of it spearheaded by the National African American Tobacco Network and its Executive Director Bill Robinson. One result was an unprecedented move by seven former U.S. Secretaries of Health, Education, and Welfare to pen an open letter to the Congress, strongly urging the Senators and House members to ban menthol from cigarettes (11). Some of the language was quite pointed, and I quote it at length:

“The bill bans the use of all artificial or natural flavors in cigarettes—except menthol. Since menthol is by far the most popular “flavor” for cigarettes, that’s a loophole big enough for a herd of wild animals to romp through and trample the health of African Americans.”

“ . . . by failing to ban menthol, the bill caves to the financial interests of tobacco companies and discriminates against African Americans—the segment of our population at greatest risk for the killing and crippling smoking-related diseases. It sends a message that African American youngsters are valued less than white youngsters.

“To make the pending tobacco legislation truly effective, menthol cigarettes should be treated the same as other flavored cigarettes. Menthol should be banned so that it no longer serves as a product the tobacco companies can use to lure African American children.

“We do everything we can to protect our children in America, especially our white children. It’s time to do the same for all children.”

This letter really got the ball rolling and forced the hand of the Congressional Black Caucus (CBC). By late June, representatives of the 43 members CBC along with Louis Sullivan and Joseph Califano were in negotiations with Representative Waxman to alter the FDA oversight bill to included language that would give the FDA authority to ban menthol (11). Clearly, not all in the CBC were for not exempting menthol, but evidently those favoring a ban won the day.

Independent of the political struggle in Washington, Harvard researchers, publishing in the American Journal of Public Health, documented that the tobacco industry has been manipulating the dose of menthol in cigarettes to ensure the uptake and continued use, especially by the young people and other vulnerable populations for many years (12).

Taken together the national news coverage; the letter from the seven former Secretaries’ of Health; the work of the NAATN; the involvement of the Congressional Black Caucus; and the release of the Harvard study forced a major amendment to the FDA oversight Bill.

The Next Step
Many would argue that a menthol ban should have been part of the legislation from the beginning. African American tobacco-control activists have asserted that since Black people were not at the negotiating table, this issue did not move to the center of discussions. On the other hand, the Campaign for Tobacco Free Kids, one of the main tobacco-control proponents at the table with Philip Morris, felt that the tobacco industry would back away from any deal for FDA oversight that included a ban on menthol in cigarettes and other tobacco products. In any event, the compromise brokered on Capital Hill sets the agenda for all players on this issue in the immediate next period.

As was stated at the outset, whether the Bill passes the Senate this session or next and assuming House and Senate conferees leave the compromise in place, it will mean that tobacco control activists will have at least a year to get menthol banned from cigarettes. Who will make up the FDA scientific advisory committee is still to be determined. The political gamesmanship exhibited by the letters from the past Secretaries of Health will have to be repeated several-fold to ensure that the issue of menthol remains an important and controversial topic.

Tobacco researchers and advocates have already set their sights on a national conference to summarize the scientific and the political issues surrounding this thorny topic. Preparations are underway to convene this gathering at Howard University in Washington D.C. in the fall of 2009. It was felt that holding such a gathering at a historic Black college campus was appropriate, given the disproportionate carnage faced by African American from tobacco-related diseases.

The next few years will be crucial in determining the use of menthol in cigarettes in the United States. The conclusion to this story is not yet written; we can all play a role in determining the outcome.

References
1. Saul, S. “House Votes to Let FDA Regulate Tobacco.” New York Times, July 31, 2008.

2. Giovino, G. et al. “Epidemiology of menthol cigarette use.” Nicotine & Tobacco Research; Vol. 6 Sup (1): 67-81, Feb., 2004.

3. Garden, S. and Faulkner, R. “Role of mentholated cigarettes in increased nicotine dependence and greater risk of tobacco-attributable disease.” Preventive Medicine; Vol. 38 (6):793-798, Jun., 2004.

4. Ahijevych, K. and Garrett, B. “Menthol pharmacology and its potential impact on cigarette smoking behavior.” Nicotine & Tobacco Research; Vol. 6 Sup (1): 17-28, Feb. 2004

5. Hopp, R. Menthol: Its origins, chemistry, physiology and toxicological properties.” Recent Advances in Tobacco Science, 47th Meeting of the Tobacco Chemists’ Research Conference; Vol 19, Oct., 1993.

6. Gardiner, P. “The African Americanization of menthol cigarette use in the United States.” Nicotine & Tobacco Research; Vol. 6 Sup (1): 55-65, Feb., 2004.

7. U.S. Department of Health and Human Services. “Tobacco use among U.S. racial/ethnic minority groups-African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders and Hispanics: A report of the surgeon general, Office on Smoking and Health, Centers for Disease Control and Prevention, 1998.

8. American Cancer Society, 2007

9. Saul, S. “Cigarette Bill Treats Menthol with Leniency.” New York Times, May 13, 2008.

10. Bowen, MF. “FDA at the Crossroads.” Burning Issues, Vol. 9 No. 3, Oct. 2007.

11. Califano, J. et al. (Letter to Representatives and Senators re: The Family Smoking Prevention and Tobacco control Act). New York Times, June 4, 2008; http://www.nytimes.com/2008/06/05/business/05TobaccoLetter.html?ref=business

12. Kreslake, J. et al. “Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults.” Am J Public Health; vol. 98(9): 1685-92, Sep 2008.