Authors: Geoffrey T. Fong, Janet Chung-Hall, Lorraine V. Craig, and Christina N. Kyriakos

Menthol cigarette bans: evidence for effective regulations

When it comes to cigarettes, menthol is not just a flavour — it is an additive that tobacco companies have used for decades to reduce the harshness of smoke, leading young people who are beginning to smoke to become addicted, and misleading those who smoke to believe that menthol cigarettes may be less harmful than “regular” cigarettes.

Menthol cigarettes have contributed uniquely to the enormous health and economic costs of smoking. They are also a threat to health equity. Across the globe, menthol cigarettes are used disproportionately by minoritized populations. For instance, menthols have been particularly devastating for Black Americans, among whom 80% of those who smoke regularly smoke menthols, compared to less than 30% of non-Blacks, thanks to decades of targeted marketing.¹

The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) supports the ban of additives that increase the attractiveness and palatability of tobacco products. The Article 9/10 partial guidelines² state that, “From the perspective of public health, there is no justification for permitting the use of ingredients, such as flavouring agents, which help make tobacco products attractive,” and that “Parties should regulate all tobacco product design features that increase the attractiveness of tobacco products, in order to decrease the attractiveness of tobacco products.”

The WHO Study Group on Tobacco Product Regulation (TobReg) in its 2016 Advisory note on banning menthol in tobacco products,³ “unequivocally recommends banning the use of menthol and its analogues, precursors or derivatives in cigarettes and possibly all tobacco products.”

Accordingly, a rising number of countries have implemented policies banning menthol and other flavours in tobacco products, including Canada, Ethiopia, the 27 European Union (EU) member states, Moldova, Nigeria, Senegal, Sri Lanka, Turkey, Uganda, and the United Kingdom (UK). Some countries have adopted legislation, but have yet to implement, such as Brazil and Mauritania, while other countries have proposed but not yet adopted legislation.

After over a decade of research and recommendations from its advisory board that menthol should be banned,⁴ the United States Food and Drug Administration (US FDA) is now expected to ban menthol in cigarettes, cigars, and combustible tobacco products by the end of 2023.⁵

The experience of countries that have already banned menthol cigarettes demonstrates its powerful impact. Our global research program—the International Tobacco Control Policy Evaluation Project—evaluated menthol bans in Canada⁶ and the Netherlands.⁷ Based on these findings, we project that the FDA’s menthol ban would lead over 1.3 million people who smoke menthols to quit, among whom over 380,000 would be Black Americans.⁸ The menthol cigarette ban would thus be one of the most impactful public health measures ever implemented in the US. The magnitude of the public health benefits of a US menthol ban would also include the positive environmental impact: we estimate that 3.77 billion cigarettes annually would no longer be littered by those who were no longer smoking.⁹

There is no doubt that the tobacco industry and its supporters will raise objections. They are already claiming that a menthol ban will lead to a flood of illicit menthol cigarettes. However, we found no evidence that illicit cigarette purchasing increased after the menthol ban in either Canada¹⁰ or the Netherlands.¹¹ To be sure, the US may be different from Canada or the European Union (EU), but it is well-known that the illicit cigarette market in the US is almost entirely due to bootlegging¹² — purchasing cigarettes from low-tax states such as North Carolina and South Carolina and selling them in high-tax states such as New York — rather than from producing illicit cigarettes. Illicit production is very unlikely to supply any more than a small percentage of the current menthol cigarette market.

Countries such as Canada, Finland and Senegal have completely banned menthol as a flavour additive in cigarettes. However, menthol is banned as a characterising flavour in most countries. The challenge with using the characterising flavour concept as the criterion for the ban is its lack of clear definition. A menthol characterising flavour is most commonly defined by the experience of a minty taste and smell, cooling sensation, and other factors during product use.

As intuitive as the characterising flavour concept may be, there are two points of concern in using it as the basis for a menthol ban. First, it is known that the receptor in the brain that is activated by menthol to produce the cooling effect (TRPM8, known as the menthol-cold receptor), is activated at levels of menthol that are below levels at which menthol is detected by humans. This means that tobacco manufacturers could add menthol to cigarettes as an additive at very low levels to achieve the desired cooling effect.

The second concern is that there are other chemicals besides menthol that can activate TRPM8, some of which are more potent in their action. There exist a number of menthol analogues or synthetics that produce a cooling sensation without imparting a menthol flavour at all ─ these additives are being used by tobacco companies. In California, where the sale of menthol cigarettes (and other tobacco and nicotine products) was banned in December 2022,¹³ R.J. Reynolds has introduced "California-compliant” cigarettes that contain no menthol but do contain the synthetic coolant WS-3.¹⁴ The sales of these cigarettes are reported to have rapidly grown since their introduction to the market in December 2022.¹⁵

Following the EU and UK ban on menthol as a characterising flavour, many new “non-menthol” brands have entered the market, which test the limits of the “characterising flavours” concept. Some of these brands, which were advertised as still offering “freshness” and promoted as replacement brands for people who previously smoked menthols, were found to be popular among Dutch adults.¹¹

Menthol bans can also be weakened in other ways. When Canada,¹⁶ the EU,¹⁷ and the UK¹⁸ banned menthol except in tobacco accessories, tobacco companies introduced menthol flavour cards, liquid drops, oils, filters, and capsules that allow users to add menthol flavour to cigarettes. We found that nearly half of Dutch adults who smoked menthols used flavour accessories after the ban.¹¹ In its proposed rule, the FDA said it would consider banning accessories that allow users to add menthol flavour to cigarettes.¹⁹

The ongoing experiences of countries that have banned menthol cigarettes and others that have proposed bans such as the US, and the EU (which in its review of the Tobacco Products Directive,^20,21 pointed to weaknesses in the characterising flavour concept in its menthol ban), have led to scientific studies on the significant public health benefits of menthol bans and industry countermeasures. Research consistently suggests that a tobacco product flavor standard should completely ban menthol as an additive rather than as a characterizing flavour across all tobacco products and components.^22,23 Jurisdictions and countries developing bans on menthol and other flavours and additives can be guided by research in this key area of tobacco product regulation.

Finally, it is important to note that menthol cigarettes may pose an even greater threat in low- and middle-income countries than in high-income countries.²⁴ An ITC study conducted in Zambia and Kenya found that the prevalence of menthol cigarettes was high in both Zambia (48%) and Kenya (19%).²⁵ Indeed, across the 25 ITC countries where the use of menthol cigarettes had been measured, Zambia had the highest prevalence of menthol cigarette use, and Kenya had the third highest prevalence.²⁶

About the authors: Geoffrey T. Fong, Janet Chung-Hall, and Lorraine V. Craig are researchers at the International Tobacco Control Policy Evaluation Project, University of Waterloo; Christina N. Kyriakos is a PhD candidate at Imperial College London. More information about the ITC Project is available at https://itcproject.org/.

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