How’s the Menthol Ban Working Out?

I have written previously about menthol, which is not only a flavoring. There is credible scientific study suggesting that it enhances the effect of nicotine and thereby increases the addictiveness of cigarettes. Adolescents and Black adult smokers favor mentholated cigarettes, so a ban might disproportionately improve their health.

Banning menthol in cigarettes might prevent you from smoking at all, or get you to quit, or get you to switch to an e-cigarette or non-mentholated cigarette – the first two results are best, changing brands or switching to e-cigarettes not so much. A previous study from Canada, where a partial menthol ban was in place, demonstrated

• Bans effectively reduced menthol tobacco purchases.
• Hoarding of menthol prior to bans
• No alteration in non-menthol sales
• Significant reduction in youth purchases with substitution of regular cigs
• In adults, less substitution more evasion to tribal sales
• No effect on sales or quitting behavior

Four years later...

There has been a complete ban on menthol cigarettes in Canada since October 2021. The new study uses wholesale cigarette sales as their underlying dataset, comparing sales between 2010 and 2018 with sales in the first five months of this year. They reported the percentage change in sales month to month.

• Sales of menthol cigarettes decreased to 0 – there was compliance with the law – unsurprising, after all, we are talking about Canadians
• Overall cigarette sales declined by 4.6%
• There were no significant declining sales before the ban and a non-significant decline after the ban.

The graph shows the change in Ontario. The blue and red lines show the trend in sales. In this instance, sales decreased by 6.3% (again statistically not significant), but to be fair, a decrease is good.

The study has two limitations. First, we do not know which smokers are buying fewer or no cigarettes. We do not have a good measure of how many menthol cigarette smokers were in Canada. More importantly, the sales figures do not include cigarette sales by Indigenous people, whose nations are exempt from Canada’s cigarette ban.

To take a deeper look, we can turn to a study looking at Ontario province a little over a year after its menthol ban. This study involved roughly 1000 participants surveyed before and a year after the ban with self-reported data on smoking, attempts at cessation, and quitting. The participants were more frequently female, over age 30, smoking a pack or less daily.

• 21% smoked menthol cigarettes daily – usually, less than a pack daily and they tended to be younger, female, non-white, and have more than high school education. 46% were occasional menthol smokers with a similar demographic.
• At the one-year follow-up, 5% of those occasional users and 22% of those daily menthol users reported buying menthol cigarettes. “The primary source for purchasing menthol cigarettes was on First Nations Reserves….” It is not surprising that smokers found a way around the ban.
• The initiation of the ban did encourage menthol smokers to quit – they made almost twice as many attempts as non-menthol smokers. Nicotine addiction is hard to break. 63% tried to stop, compared to 43% of non-menthol smokers. 24% actually quit at one year, compared to 14% of their non-menthol contemporaries.
• Quitting more frequently occurred in those who took the ban as an opportunity to quit, 38%. Compared to those who said they would switch to a non-mentholated brand, 15%, or the 19% who said they would seek contraband, i.e., First Nation cigarettes.

My takeaway is that for cigarettes, diminished availability by a ban in this case or by increased pricing through taxation reduces smoking by moving the less committed (addicted?) smokers to quit.

“We would expect that a menthol ban would have an even greater impact in at-risk subpopulations such as the youth and young adults in an environment in which there was less availability of any flavored tobacco or nicotine products.” 

To the extent that a ban on menthol would promote the uncertain to quit and reduce the number of individuals starting to smoke, it is a reasonable policy choice in optimizing population health. It is not a panacea, and the data suggests that it does little to move those with hard-core nicotine addiction. In the “battle” to end tobacco use, menthol bans, at least in Canada, are a small victory – we should take them when we can.

Source: Analysis of Wholesale Cigarette Sales in Canada After Menthol Cigarette Bans JAMA Network Open DOI: 1001/jamanetworkopen.2021.33673

Ban on menthol-flavoured tobacco products predicts cigarette cessation at 1 year: a population cohort study BMJ DOI: 10.1136/ tobaccocontrol-2018-054841