Menthol: Facts, stats and regulations

The chemical compound menthol makes cigarettes easier to smoke and harder to quit. Menthol creates a cooling effect, reduces the harshness of cigarette smoke, and suppresses coughing. Those effects may make menthol cigarettes more appealing to young, inexperienced smokers, and research shows that they are more likely to addict youth. Because African Americans use menthol cigarettes at higher rates, menthol also contributes to health inequities.

Menthol-flavored e-cigarettes, as well as other nicotine-containing products like pouches and lozenges, are also a concern. Among high school students who used flavored e-cigarettes in 2021, nearly 30% used menthol e-cigarettes. And with menthol e-cigarette sales on the rise, there are concerns that menthol in tobacco products most popular with young people are playing a role in addicting a new generation to nicotine.

WHAT IS MENTHOL?

• Menthol is a chemical compound extracted from peppermint or corn mint plants or created synthetically. It reduces the harshness of cigarette smoke due to its characteristic cooling effects on the mouth and throat. It also suppresses the coughing reflex, which makes inhaling smoke from cigarettes more tolerable.
• Menthol was first added to cigarettes in the 1920s and 1930s, and became widespread in the 1950s and 1960s.
• Although most cigarettes contain some menthol, certain brands use menthol in greater quantities, making it detectible as a characterizing flavor. Tobacco manufacturers market and advertise those brands as “menthol cigarettes.”  
• Current law prohibits the use of characterizing flavorings in cigarettes, except for menthol. Public health groups have urged the Food and Drug Administration to ban menthol cigarettes for over a decade. After being sued for inaction on this issue, the FDA reported in April 2021 that it plans to move forward to remove menthol from cigarettes and all flavors, including menthol, from cigars.
• Although the FDA effectively banned certain cartridge-based flavored e-cigarettes products in 2020, menthol was one of the many exemptions to the policy. The FDA is currently deliberating on whether menthol e-cigarettes currently on the market are appropriate for the protection of public health.

PATTERNS OF USE IN THE U.S.

• In 2018, 6.85% of people aged 12 or older used menthol cigarettes.
• Menthol cigarettes are slowing the reductions in overall cigarette smoking rates. From 2005 to 2015, the decline in cigarette consumption was greater for non-menthol cigarettes than menthol cigarettes.
  • Between 2005 and 2015, non-menthol cigarette use among those 18+ decreased overall from 14.7% to 9.6%, according to research published in 2020. For the same group and timeframe, menthol cigarette use decreased overall from 5.3% to 4.4% — a much slower rate of decline, indicating that menthol cigarettes are slowing the decline of tobacco use in the U.S. And although use of menthol cigarettes significantly decreased for groups including women, 18- to 24-year-olds, 35- to 54-year-olds, non-Hispanic Whites, participants with high school degrees/GEDs, those with higher incomes, and those living in the northeast, there were greater decreases in the same groups for non-menthol cigarettes.
  • Menthol cigarette use remained stable or did not significantly decrease among males, adults ages 25–34 and 55+, American Indians/Alaskan Natives, and Hispanics between 2005 and 2015.
  • Menthol smoking prevalence now exceeds non-menthol smoking prevalence among both youth and young adults.
• Research shows an association between menthol tobacco use and mental health symptoms:
  • Tobacco users who currently used menthol-flavored tobacco products reported anxiety and depression at higher prevalence than non-menthol tobacco users.
  • Menthol cigarette use was correlated with more lifetime psychiatric hospitalizations in a study of young adult smokers with severe mental illness.
  • Among individuals with substance abuse disorders, more than half (53.2%) of smokers used menthol cigarettes, compared to 30% of smokers in the general population who did so.
• Youth remain the age group most likely to use menthol cigarettes.
• Among current cigarette smokers (those who have smoked in the past 30 days), 39.9% used menthol cigarettes in 2018, compared to 38.8% from 2012 to 2014 and 35% from 2008 to 2010.
• Menthol cigarette smoking is more prevalent among youth, female smokers, racial and ethnic minorities, sexual minorities and those with mental illness.
• African American smokers predominantly use menthol cigarettes. In 2018, 85% of African American smokers aged 12 and older preferred menthol cigarettes.
• Menthol cigarette use is significantly lower among youth whose parents had at least a college degree compared to those with less education. Young people also exclusively used menthol cigarettes at significantly lower rates if their annual household income was high and if they lived in a home that was owned rather than not.

YOUTH AND YOUNG ADULTS

Young people use menthol tobacco products, including cigarettes and e-cigarettes, at disproportionally high rates, which could facilitate nicotine addiction.

CIGARETTES

• Menthol reduces the harshness of cigarette smoke, which may appeal to young, inexperienced smokers.
• Preference for menthol among cigarette smokers remains inversely correlated with age: 49.7% of 12-17-year-old cigarette smokers used menthol compared to 29.2% of those 65 years old or older in 2018.
• Longitudinal studies show that initiation with menthol cigarettes facilitates progression to established cigarette use among young smokers.
• In young people, using menthol cigarettes and cigars first is associated with continued cigarette use. Data from nationally representative samples show that the youngest cigarette smokers use menthol at the highest rates (Figure 1).
• In 2021, 150,000 middle and high school students used menthol cigarettes, based on the National Youth Tobacco Survey. 38.8% of middle and high school students who used cigarettes used menthol cigarettes.
• A nationally representative study found that, among youth and young adults, non-menthol cigarette prevalence declined from 2004 to 2010. By contrast, menthol cigarette prevalence remained constant among youth and increased among young adults over this period.

E-CIGARETTES

• Flavors are a top reason why young people begin using e-cigarettes. Research shows that mint and menthol e-cigarette use among high school users rose from 16% in 2016 to 57.3% in 2019. Among high school JUUL users, 67.5% reported that their preferred flavor was mint or menthol. Another study, conducted before JUUL pulled its other flavors from the market, found that mint was one of the most popular flavors among high school student JUUL users, but that menthol was less so. Study authors caution that leaving mint and menthol flavors on the market undermines the purpose of removing flavors — which is to prevent kids from using e-cigarettes at all.
• In 2021, 470,000 middle and high school students used menthol-flavored e-cigarettes in the past 30 days, according to the NYTS.
• Among high school students who currently used any type of flavored e-cigarettes, in 2021, 29.8% used menthol-flavored e-cigarettes.
• Menthol-flavored e-cigarettes continue to rise in popularity. By March 2020, menthol-flavored e-cigarette sales had risen to an all-time high of 57.7% market share.

MINORITY GROUPS

CIGARETTES

• Menthol cigarettes disproportionately harm African Americans. Among African Americans over 1980-2018, menthol cigarettes were responsible for 1.5 million new smokers, 157,000 smoking-related premature deaths and 1.5 million life-years lost, according to a 2021 study published in Tobacco Control. While African Americans constitute 12% of the total U.S. population, these figures represent, respectively, 15%, 41% and 50% of the total menthol cigarette-related harm.
• Most African American youth smokers use menthol cigarettes. From 2008 to 2010, 94.9% of African American youth current smokers used menthol cigarettes. Other racial and ethnic groups used them in lower numbers, including just over half — 51.3%— of white youth current smokers.
• From 2008 to 2010, menthol cigarette use among young adult current smokers (ages 18 to 25) was 93.9% among African Americans, compared with 36.3% among whites, 47.3% among Hispanics and 49.7% among Asian- Americans.
• Menthol and non-menthol cigarette use among adolescents fell by more than half between 2012 and 2020. From 2018-2020, 0.95% of Black American adolescents smoked menthol cigarettes in the past 30 days, about half of the 1.98% of non-black adolescents who smoked menthol cigarettes. Menthol use went down for Black American adolescents but not significantly as it did for adolescents who were white, Hispanic, or other race/ ethnicities. From 2018–2020, 56% of Black American adolescents who had smoked in the past 30 days used menthol cigarettes, compared with 47% for all other adolescents. From 2012–2014, a majority of both Black American (68%) and all other adolescent smokers (51%) used menthol cigarettes.
• In 2020, 51% of lesbian and gay smokers and 46% of bisexual smokers used menthol cigarettes, compared with 39% of heterosexual smokers.

E-CIGARETTES

• African American young adults between the ages of 18-34 were less likely to use non-tobacco and non-menthol flavored e-cigarettes than white respondents, according to research published in Drug and Alcohol Dependence in 2018.
• White youth were dual users of e-cigarettes and menthol cigarettes at higher rates compared to African American youth (2.2% vs. 0.3%).

HEALTH EFFECTS

Menthol cigarettes offer no health benefit to smokers, and, in fact, are easier to start smoking and more difficult to quit than regular cigarettes. Truth Initiative agrees with the Tobacco Products Scientific Advisory Committee that menthol cigarettes pose a threat to public health above and beyond that posed by regular cigarettes.

• Menthol flavoring contributes to addiction in youth smokers.
• Recent research points to multiple mechanisms that may play a role in the addictive potential of menthol. Menthol fundamentally alters nicotine receptors, masks the adverse sensory properties of tobacco products (which ultimately may enhance nicotine intake and drive relapse), and alters nicotine metabolism, increasing its bioavailability, according to a 2020 review published in Nicotine & Tobacco Research
• Adolescent menthol smokers show significantly higher levels of nicotine dependence, tolerance and emotional attachment to cigarettes, compared to non-menthol smoking peers, according to a 2020 study.

CIGARETTES

• There are no health benefits associated with smoking menthol cigarettes, compared with smoking non-menthol cigarettes.
• Menthol cigarettes are as dangerous to an individual’s health as non-menthol cigarettes, and menthol cigarette smokers are as likely to experience premature morbidity and mortality as non-menthol cigarette smokers.
• Menthol cigarettes were responsible for 10.1 million extra smokers, 3 million life years lost and 378,000 premature deaths between 1980 and 2018, according to a 2021 study published in Tobacco Control. Menthol cigarettes were also responsible for slowing down the decline in smoking prevalence by 2.6% (from 13.7% in 1980 vs. 11.1% in 2018).
• Adult menthol smokers report taking less time to have their first cigarette after waking than non-menthol smokers. Time to first cigarette is an important indicator of nicotine addiction. Scientific evidence establishes that adult menthol smokers are less likely than non-menthol smokers to successfully quit smoking despite greater quit intentions and quit attempts. Studies show significantly reduced rates of quitting among African American and Hispanic menthol smokers compared with non-menthol smokers.
• Adolescent menthol cigarette smokers were more likely to smoke more frequently and be more dependent on cigarettes compared to non-menthol cigarette smokers. Adolescents who smoked menthol cigarettes were less likely to report intentions to quit in the next year, a finding that runs counter to trends in adult menthol smokers.

E-CIGARETTES

• In menthol-flavored e-cigarettes, there are health concerns related to pulegone — a compound found in prepared oil extracts of certain mint plants. Pulegone is a known carcinogen, and the tobacco industry has in the past reduced the amount of this compound in menthol tobacco products as a result of toxicity concerns. The FDA banned pulegone as a food additive in 2018, yet studies have identified that substantial amounts of this additive are found in mint and menthol e-liquid in the U.S. — raising concerns about the potential toxicity of these popular flavors.
• Young people who vape fruit-, menthol-, and mint-flavored e-cigarettes with higher nicotine concentrations had greater nicotine dependence compared to those who used e-cigarettes with lower nicotine levels, according to a 2021 Truth Initiative study.

MARKETING IN THE U.S.

• Menthol makes up a large portion of the cigarette market in the U.S.: 37% in 2020, up from 26% in 2000.
• The tobacco industry has a well-documented history of developing and marketing mentholated brands to racial and ethnic minorities and youth.
• In a national sample of U.S. tobacco retailers, price promotions for the Newport brand of menthol cigarettes were nearly twice as common in neighborhoods with the highest proportion of Black residents, and prices for Newport cigarettes were cheaper in neighborhoods with the greatest proportion of youth, Black residents, and lower-income households.
• Young people living in areas with lower incomes, higher proportions of racial/ethnic minorities, and higher smoking rates in D.C. had 7.2 times the odds of being exposed to flavored tobacco marketing, compared with those not living in those communities according to a 2021 Truth Initiative study published in the Annals of Behavioral Medicine.
• Tobacco stores in Washington, D.C. neighborhoods with higher percentages of Black residents had more marketing for flavored tobacco products — especially for flavored cigars — compared to neighborhoods with lower percentages of Black residents, according to a 2022 study published by the University of Kentucky College of Medicine in collaboration with Truth Initiative researchers.
• Similar marketing trends were seen in California, where tobacco retailers in neighborhoods with greater proportions of Black residents were significantly more likely to advertise menthol cigarettes compared to stores in neighborhoods with the lowest proportion of Black residents, according to a 2021 study published in Tobacco Control. The study also found that Newport cigarettes were about 25 cents cheaper in neighborhoods with higher proportions of Black residents, compared to stores with the lowest proportion of Black residents.
• Evidence from tobacco industry documents shows that the industry studied smokers’ menthol preferences and manipulated menthol levels to appeal to a variety of smokers, including adolescents and young adults.
• Evidence from tobacco industry documents also shows that tobacco companies specifically targeted African Americans with menthol cigarette advertising.
• A 2011 review found that menthol marketing is higher in publications and venues that appeal to African American audiences.
• Numerous studies show targeted marketing of menthol cigarettes at the point of sale in African American communities throughout the U.S.

POLICY IN THE U.S.

• The 2009 Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration the authority to regulate tobacco products. The law specifically prohibits the use of characterizing flavorings in cigarettes, except for menthol. Nonetheless, it preserves the FDA’s regulatory authority to ban menthol.
• In April 2021, the FDA reported that, in response to a 2013 citizen’s petition and a lawsuit, it plans to move forward to remove menthol from cigarettes and all flavors, including menthol, from cigars. The FDA indicated that it will issue product standards to remove menthol within one year of the announcement. The FDA recently backed up that promise with a statement claiming that they were “on track” to issue these proposed rules in spring 2022.
• The FDA also has the authority to regulate e-cigarettes, including flavored e-cigarettes. In 2020, the FDA issued an enforcement policy that effectively bans flavored cartridge-based e-cigarettes other than menthol, but allows other e-cigarette products, such as e-liquids and refillable tanks, disposable e-cigarettes and all menthol-flavored e-cigarette products and e-liquids, to remain on the market. In 2022, the FDA continues to review applications from e-cigarette manufacturers seeking to demonstrate that their products are appropriate for the protection of public health. To date, the FDA has denied the marketing applications for more than 1 million e-cigarette products, but applications for menthol-flavored e-cigarettes are pending.
• Thus far, the FDA’s activities on menthol include:
  • The Tobacco Products Scientific Advisory Committee (TPSAC) was required by the Tobacco Control Act to conduct a review of menthol cigarettes’ effect on youth and other vulnerable populations. The committee published a report in March 2011, concluding that “the removal of menthol cigarettes from the marketplaces would benefit public health in the United States.”
    • Lorillard Tobacco Company (now R.J. Reynolds Tobacco Company) challenged the integrity of the TPSAC in a lawsuit against the FDA, alleging that several experts the agency appointed to the committee were conflicted and therefore must be removed. The judge in the case sided with Lorillard and prohibited the FDA from using the TPSAC menthol report. The FDA appealed, and, in January 2016, the D.C. Circuit reversed the district court’s decision, allowing the agency to rely on the TPSAC menthol report to take action to regulate menthol tobacco products.
• In April 2021, the FDA announced plans to move forward to remove menthol from cigarettes and all flavors, including menthol, from cigars.
  • In July 2013, the FDA published its own report that also concluded that the removal of menthol cigarettes from the market would improve public health. At the same time, the FDA requested public comment seeking additional information to help the agency make informed decisions about menthol in cigarettes.
  • Five years later, in March 2018, the FDA again requested public comment on the role that menthol in tobacco products plays in attracting youth, in the likelihood of quitting smoking, and in the use of other tobacco products, including cigars and e-cigarettes.

STATE AND LOCAL POLICIES

While many localities have prohibited flavored tobacco products in some way, most of these exclude menthol, mint or wintergreen. However, several localities do include menthol in their flavor bans. As of December 31, 2021, 100 jurisdictions have fully comprehensive policies that prohibit sales of all types of flavors across all products, including menthol/mint/wintergreen tobacco products, at all retailers. Despite research showing that menthol cigarettes are easier to start smoking and harder to quit, only 2.17% of the U.S. population is covered by a comprehensive state or local flavored tobacco sales restriction.

Research provides strong evidence that local policies restricting flavored tobacco products reduce availability, marketing, and sales of such products — some of the immediate intended outcomes of the legislation, according to Truth Initiative research published in Nicotine & Tobacco Research.

As of December 31, 2021:

• Massachusetts prohibits the sale of all flavored tobacco products, including menthol, except in smoking bars.
• In California, 76 localities including Los Angeles County, Oakland, Sacramento, and San Francisco, prohibit the sale of all flavored tobacco products, including menthol.
• Five localities in Colorado, including Aspen, prohibit the sale of all flavored tobacco products, including menthol.
• Bangor, Maine prohibits the sale of all flavored tobacco products, including menthol.
• Eight localities in Minnesota prohibit the sale of all flavored tobacco products, including menthol.
• Manheim, New York prohibits the sale of all flavored tobacco products, including menthol.
• Chicago, Illinois prohibits the sale of flavored tobacco products, including menthol, within 500 feet of any city high school.

ESTIMATED EFFECTS OF MENTHOL BANS UNITED STATES

UNITED STATES

• A hypothetical ban on menthol cigarettes and cigars in the U.S. would reduce overall smoking by 15% by 2026 due to menthol smokers quitting smoking and vaping, according to study published in the British Medical Journal in 2022. The study also finds that by 2060, a national menthol ban would reduce cumulative deaths from smoking and vaping by 650,000 (5%) and save 11.3 million life-years (8.8%).
• A hypothetical menthol ban in New York City was projected to save an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers over a 20-year period.
• A study of U.S. adult menthol smokers found that a ban on menthol cigarettes or on all menthol products was effective in reducing cigarette purchases, but that tobacco marketing strategies including offering replacement products might undermine the benefits of such a ban.
• A 2018 Truth Initiative survey shows that most adults (56.4%) support a federal ban on menthol cigarettes. Support was especially strong among African Americans (60.5%) and other groups who have been targeted by the tobacco industry, including women (62.5%) and Hispanic/ Latinos (69.3%). More than 1 in 4 current menthol smokers (28.5%) favored a ban.
• Among U.S. smokers, about 25–64% would attempt to quit smoking and 11–46% would consider switching to other tobacco products, including 15–30% to e-cigarettes, in response to a hypothetical menthol ban.
• African Americans smokers were more likely to report intentions to quit (47%) compared to white individuals (34%), according to a 2020 review of effects of a menthol ban. A survey of menthol smokers in Minnesota also found that African American menthol smokers were twice as likely to report quitting intentions compared to white menthol smokers (76.0% vs. 30.3%, respectively).
• Among young adult menthol smokers (aged 18-24), 64.6% reported that they would quit smoking and not use any other products if menthol cigarettes were banned.
• Adult dual users of e-cigarettes and cigarettes who used menthol cigarettes were more likely to prefer menthol flavored e-cigarettes compared to other flavors.

INTERNATIONAL

• Menthol bans were found to reduce sales and increase smoking cessation with only partial substitution for non-menthol cigarettes, according to an international review of implemented and hypothetical menthol bans.
• A 2017 ban on menthol tobacco products in Ontario, Canada resulted in significant reduction in menthol cigarette and total cigarette sales after the ban went into effect, compared to a province without a menthol ban. Although most smokers who used menthol cigarettes before they were banned in certain provinces in Canada switched to non-menthol cigarettes, 21.5% quit smoking. Menthol smokers were 1.6 times more likely to try to quit and 2.3 times more likely to remain quit compared to non-menthol smokers. In Alberta, Canada, after a menthol ban went into effect, brands that identified as menthol before the ban were repackaged after the ban to convey that they were menthol replacements.
• A ban on menthol-flavored cigarettes went into effect in EU countries in May 2020, but bans menthol as a characterizing flavor instead of as an ingredient, applies to cigarettes but not other products, and took four years to go into effect, weaknesses which the tobacco industry exploited. For example, Japan Tobacco International (JTI), the third largest tobacco multinational, rebranded some of its menthol cigarettes in the months before the law went into effect, claiming that the products did not have the “characterizing flavor” specifically banned, though the company admitted that there is no way to know this for sure. A subsequent investigation found significant levels of menthol in JTI’s newer products.