Commentary on O'Connor et al. (2012): Planning to effectively ban menthol cigarettes
The paper by O'Connor and colleagues, ‘What would menthol smokers do if menthol in cigarettes were banned?’, suggests that a decision to ban the use of menthol in cigarettes would present both challenges and opportunities . The Tobacco Products Scientific Advisory Committee concluded that because the evidence indicates that menthol cigarettes contribute to youth uptake and make it harder to quit smoking, the ‘removal of menthol cigarettes from the marketplace would benefit public health in the United States’. The data in the O'Connor paper suggest that a number of coordinated actions—cessation assistance, enforcement and public education—will be needed to realize the full benefit on public health of a decision to prohibit the use of menthol in the manufacture of cigarettes.
It is always a little tricky to interpret smokers' responses to hypothetical questions, and there are limitations in the generalizability of findings from opt-in internet panels. None the less, results from calculations of probable price elasticity are internally consistent with smokers' reports of probable actions that they would take. Hence, in light of these data, it would be equally wrong to predict that banning menthol cigarettes would lead to rampant black market activities as to assume that if only we banned menthol cigarettes all menthol smokers would stop smoking. The tobacco industry will not go out of business—Newport is already promoting ‘Newport Red’ non-menthol cigarettes. Rather, the data suggest a modulated response, and we will be prudent to plan related actions to make a ban on menthol maximally effective.
SUPPORT FOR CESSATION ASSISTANCE
The opportunity indicated by the study is that more than a third of menthol smokers indicated that they would try to quit smoking altogether if menthol were banned, and 27% of menthol smokers said that they would smoke less than they do now—a reduction in smoking is an early step along the continuum towards cessation —and 28% of menthol smokers indicated that they were not sure what they would do, which may indicate an opening to cessation efforts. However, 15% of menthol smokers indicated that they would switch to a non-menthol brand, which suggests that without an accompanying promotion of cessation, a ban on menthol smoking would simply displace menthol with non-menthol smoking. Moreover, only 15% of menthol smokers felt that they ‘would be able to quit smoking’—indicating that cessation messages should emphasize that specific steps to promote cessation can increase efficacy. This is especially compelling because menthol smokers often find it harder to quit [4,5], and menthol smoking prevalence is particularly high in minority communities that can be financially strapped for cessation resources . It will be important to provide resources for cessation, particularly in areas with a high proportion of menthol smokers.
The other challenge is that nearly a quarter of menthol smokers indicated that they would ‘find a way to buy a menthol cigarette’, implying a willingness to obtain menthol cigarettes through illegal sources. This suggests that a need for further enforcement of laws about illegal trafficking will increase. The need for enforcement is not new; illegal sales of cigarettes cost states substantial revenues that could be drawn upon to support tobacco control and cessation programs , but enforcement is an issue that will continue to need to be addressed.
A third challenge is that 41% of menthol smokers reported that they would feel angry if menthol cigarettes were banned. Accordingly, any regulation needs to be accompanied by information explaining why the decision was made, namely that banning menthol cigarettes will help to protect newer smokers from becoming addicted. Implementation of a ban without accompanying public education would probably trigger a negative reaction that would be capitalized upon by the industry groups that promote ‘smokers' rights’.
Declaration of interests