How the Menthol Cigarette Ban May Affect the African American Smoking Paradox

The FDA’s ban on menthol cigarettes is expected to have a disproportionate effect on Black smokers. The FDA announcement of the ban last week said that nearly 85% of Black smokers smoke menthol cigarettes compared with 30% of White smokers. Results of a Canadian study of menthol cigarette ban in seven provinces there found that most (60%) menthol cigarette smokers switch to nonmenthol cigarettes. Even so, a sizable majority (about 20%) quit smoking. Extrapolating from that study, last week’s FDA announcement projected that the menthol ban could lead to as many as 923,000 smokers quitting, including 230,000 African Americans.

This would all seem to be good news for reducing lung cancer deaths among Black Americans. Smoking is the most leading cause of lung cancer, and lung cancer is the leading cause of cancer death in Black men and women. The American Cancer Society’s most recent Cancer Facts & Figures for African Americans report estimated that 16,550 Black Americans died from lung cancer in 2019.

The menthol ban may also have an effect on various aspects of what some researchers have called the “African American smoking paradox.” A 2016 review paper on the subject in the journal Nicotine & Tobacco Research identified four elements of the paradox:

• Despite the social disadvantage, Black young people do not start smoking earlier than young people in other racial and ethnic groups.
• Despite social disadvantage, smoking prevalence is lower among Black young people than the prevalence among other groups.
• The low initiation and prevalence rates among Black young people do not translate into low smoking rates among Black young adults. “Black/African Americans lose their advantage relative to whites in young adulthood,” wrote Pebbles Fagan, Ph.D., M.PH., and her colleagues.
• Lower prevalence and lower intensity (fewer cigarettes per day) do not translate into lower rates of smoking-related disease, including lung cancer.

Pebbles Fagan

Menthol cigarettes may explain several aspects of African American smoking paradox, Fagan and co-authors wrote. At high concentrations, menthol can reduce the irritation and sensitivity to the bitter flavor of nicotine. They point to evidence that sensitivity to bitter taste is an inherited trait and that Black Americans are more like to inherit the trait. The sensitivity to bitterness may explain low initiation and prevalence among Black young people. The sensitivity tends to wane with age, however, which in combination with the masking effects of menthol may explain why the smoking rates among Black young adults “catch up” with those for other groups.

Studies do not show that menthol causes cancer, but it may increase nicotine dependence and therefore make quitting more difficult. Fagan and her colleagues moot the possibility that menthol interacts with nicotine and makes it more available. They also mention that menthol may blunt pain signals, resulting in delayed diagnosis and care for the conditions caused by smoking.

Menthol cigarettes are just one of many possible explanations for the African American smoking paradox, Fagan and her co-authors acknowledge. But they also point to the marketing of menthol cigarettes to Black Americans: “The role of marketing of menthol cigarettes to blacks/African Americans and marketing’s role in the African American smoking paradox cannot be understated.”

Marketing messages for menthol cigarettes differed from those for nonmenthol cigarettes and increased the prevalence of smoking among African Americans and among young people and the population in general, they said.