Easier to Start, Harder to Stop: Menthol’s Nefarious Impact

Amy Cohn, PhD, is a faculty member and Director of Training at the TSET Health Promotion Research Center and is an Associate Professor in the Department of Pediatrics at the University of Oklahoma College of Medicine and the Stephenson Cancer Center.

Tobacco Stops With Me spoke with Dr. Cohn to learn more about her work studying the science behind menthol and how it makes tobacco products easier to start and harder to quit. We also asked about the proposed FDA rules that would significantly reduce the amount of nicotine in cigarettes:

Menthol has been linked to high rates of smoking initiation and progression. Its cooling, minty, refreshing taste helps mask the harshness and bitterness of inhaled tobacco smoke. It creates a numbing feel in the mouth and increases young people’s impression that menthol is less harmful than traditional cigarettes. Flavored products in general are more attractive to young people because they are already familiar with those flavors from other products like candy, gum and chocolate.

Research is still ongoing as to why menthol products are harder to quit, but if we go back to the aspect that makes it appealing, it has been hypothesized that the pleasant minty/cooling sensations in the mouth and throat (also called “throat hit”) can heighten the experience of cigarette smoking beyond nicotine ingestion alone. This new sensation on top of the nicotine hit could make it extra hard to stop.

menthol cigarettes

What about the FDA proposal to ban menthol in cigarettes and little cigars, and why was it not extended to e-cigarettes, even after a huge surge in menthol vape sales post-flavor ban?

There are a variety of different factors. In 2009, the FDA did ban all flavors from cigarettes except menthol. This current discussion is not new, it’s been ongoing for a while. In January of 2020, the FDA did issue an enforcement action on refillable pods for e-cigarette pods.

A major concern regarding a menthol ban in e-cigarettes is the ability of consumers to shift to other flavors. There are “concept flavors” like “jazz” for example, that don’t actually reflect known flavors and are extremely difficult to ban. This is the strongest language we’ve seen regarding a menthol ban, but it could take years before implementation.

The FDA is also exploring the idea of reducing the amount of nicotine in cigarettes – is this likely to occur? What are some benefits of low nicotine products?

In 2019, the FDA released a comprehensive plan that included reducing the nicotine amount in cigarettes. They also recommended the increased use and availability of NRTs to help people transition to low nicotine options. So, this has been long in the works. It’s my understanding that the FDA does have an intention to do this, and they have the research to back up the claim that low nicotine cigarettes lead to lower usage, promote smoking cessation and harm reduction.

This regulatory action may also deter initiation and uptake of cigarettes by reducing their overall appeal to younger users. Previous clinical trials report reductions in cigarettes per day, biomarkers of toxicant exposure and increases in smoking quit attempts among adult and adolescent smokers using very low nicotine cigarettes. However, there are still lots of unknowns: will this help current smokers reduce their overall tobacco use (in addition to cigarettes), will this reduce youth smoking, will youth/younger users switch to other tobacco products instead of low nicotine cigarettes, etc.?

One of my colleagues just finished a study examining the impact of low nicotine cigarettes on youth smoking rates. My understanding is this: there don’t seem to be any adverse effects of having low nicotine cigarettes on the markets, and these products don’t induce more youth smoking or use of other tobacco products.

Has any research looked at what might happen to tobacco usage rates if they were non-addictive (low nicotine)?

There is little evidence that other tobacco use rates change significantly when there are low nicotine cigarettes on the market. We are currently working on a study looking at the subjective appeal and reinforcing aspects of menthol and non-menthol low nicotine cigarettes. We want to know if the presence of menthol in low nicotine cigarettes still makes these low nicotine cigarettes more appealing than non-menthol cigarettes.

What changes do you believe would be most beneficial to combat tobacco addiction?

I would like to see stronger regulations on flavors or even a complete ban on all flavors, including menthol. We’re still doing research to see what happens when we ban flavors, including unintended consequences, like use of other tobacco products or more frequent or intense use of tobacco products.

menthol banned

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Published by Tobacco Stops With Me on July 30, 2021