FDA turns harsh light on menthol cigarettes to snuff them out

The Food and Drug Administration's latest steps toward eliminating the nation's tobacco use could lead a surge in smokers turning to physicians' offices as they try to kick the habit, some public health experts say.

On July 23, the FDA released its independent evaluation on the public health effects of menthol cigarettes. The agency found that menthol use likely is associated with increased smoking initiation by youth and young adults and is linked to greater addiction than cigarettes without menthol.

The same day, the FDA issued an Advance Notice of Proposed Rulemaking to obtain additional information on potential regulatory options for menthol cigarettes.

Although it's not clear what the regulatory action could entail, tobacco control expert Cristine Delnevo, PhD, MPH, is among those optimistic that it might involve a ban on menthol flavoring in cigarettes.

Should menthol be banned, “physicians need to be aware that there's going to be an increased number of patients showing up who will likely be trying to quit smoking,” said Delnevo, co-leader of the Cancer Prevention and Control Program at Rutgers Cancer Institute of New Jersey.

She highlighted a survey of 465 U.S. adults 18 and older who smoke menthol cigarettes that found 38.9% would quit the habit if the FDA banned menthol. The findings were published in the November 2012 issue of the American Journal of Public Health.

A menthol ban “will create a pretty powerful teachable moment, when doctors' advice to quit and their assistance to help [patients] quit will be even more impactful” than in the past, Delnevo said.

For now, however, primary care physicians play a critical role in continuing to educate patients who smoke about the harms of the habit and informing them of smoking cessation tools, said Georges Benjamin, MD, executive director of the American Public Health Assn.

He recommends that doctors ask patients who smoke what types of cigarettes they use. For patients who smoke menthol-flavored products, physicians should tell them that data show that smoking menthol makes it harder to quit smoking, Dr. Benjamin said.

He added that particular attention should be paid to young people and minority communities, because tobacco companies tend to market menthol products to those groups, Dr. Benjamin said.

In 2009, 83% of African-American smokers used menthol-flavored cigarettes, compared with 32% of Hispanic, 31% of Asian-American and 24% of white smokers, Dr. Benjamin said in a commentary he co-wrote that was posted online June 28 in The Partnership at Drugfree.org. The organization is a drug abuse prevention, intervention, treatment and recovery resource for parents and caregivers.

“One-third of the lives saved by eliminating menthol cigarettes and causing menthol smokers to quit will be African-American,” the commentary said.

Just as concerning is that more than 40% of young smokers use menthol cigarettes compared with 30% of adult smokers, said Mitchell Zeller, director of the FDA's Center for Tobacco Products.

Menthol has a cooling effect that some health experts worry masks the harshness of tobacco smoke, thus making it easier for young people to start the habit, Zeller said.

Doctors' important role

Assessing the public health impact of menthol-flavored cigarettes is part of the Family Smoking Prevention and Tobacco Control Act, which became law in 2009.

The FDA first examined the issue in March 2011, when its Tobacco Products Scientific Advisory Committee issued a report that said removing menthol from cigarettes would benefit public health. The expert panel reviews and evaluates safety, dependence and health issues relating to tobacco products and provides recommendations on such matters to the commissioner of Food and Drugs.

Shortly before the 2011 report was released, the tobacco companies Lorillard Inc. and R.J. Reynolds filed a lawsuit in federal court in Washington against the FDA alleging that several committee members had financial conflicts of interest. U.S. District Court Judge Richard Leon has allowed the lawsuit to proceed despite the FDA's motion that it be dismissed.

Many of the nation's major tobacco companies did not comment on the FDA's latest evaluation of menthol cigarettes.

Altria Group Inc., the parent company of Philip Morris USA, said it had just received information on the FDA's evaluation and will be reviewing it.

Health advocacy organizations, including the American Cancer Society Cancer Action Network, have come out in strong support of the FDA banning menthol from cigarettes.

“The science is clear that menthol cigarettes pose a threat to public health,” said Christopher W. Hansen, president of the Cancer Action Network. “We urge the FDA to take swift action to ban them.”

Although the American Medical Association at this article's deadline had not commented on the FDA's latest action, the Association sent a letter in July 2010 to the FDA recommending that the agency “ban the use and marketing of menthol as a harmful added ingredient in tobacco products.”

Should the FDA decide to move in that direction, a key challenge it will face is the strong opposition from the tobacco industry, Dr. Benjamin said.

The industry probably will start by disputing the science, then argue that people have a right to choose the type of cigarettes they want to smoke, and that children aren't targeted, Dr. Benjamin said.

He added, “This could go on for years.”

In the meantime, physicians need to remember that they're in a unique position to speak to people who smoke and to smokers' families about the dangers of the habit and ways to quit, Zeller said.

“There's so much the entire health care community can be doing to help tobacco users become tobacco-free,” he said. “And it starts with [a] conversation.”