Abstract
Menthol in cigarettes increases nicotine dependence and decreases the chances of successful smoking cessation. In New York City (NYC), nearly half of current smokers usually smoke menthol cigarettes. Female and non-Latino Black individuals were more likely to smoke menthol-flavored cigarettes compared to males and other races and ethnicities. Although the US Food and Drug Administration recently announced that it will ban menthol cigarettes, it is unclear how the policy would affect population health and health disparities in NYC. To inform potential policymaking, we used a microsimulation model of cardiovascular disease (CVD) to project the long-term health and economic impact of a potential menthol ban in NYC. Our model projected that there could be 57,232 (95% CI: 51,967–62,497) myocardial infarction (MI) cases and 52,195 (95% CI: 47,446–56,945) stroke cases per 1 million adult smokers in NYC over a 20-year period without the menthol ban policy. With the menthol ban policy, 2,862 MI cases and 1,983 stroke cases per 1 million adults could be averted over a 20-year period. The model also projected that an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers, could be saved over a 20-year period due to the implementation of a menthol ban policy. Results from subgroup analyses showed that women, particularly Black women, would have more reductions in adverse CVD outcomes from the potential implementation of the menthol ban policy compared to males and other racial and ethnic subgroups, which implies that the policy could reduce sex and racial and ethnic CVD disparities. Findings from our study provide policymakers with evidence to support policies that limit access to menthol cigarettes and potentially address racial and ethnic disparities in smoking-related disease burden.
Highlights
[26] there is promising evidence of the effectiveness of a menthol cigarette ban, the long-term health and economic costs of these types of cigarette bans are unclear. It is uncertain whether this ban will have similar effects among groups who experience tobacco-related health disparities, [27] racial and ethnic minorities, a group targeted by the tobacco industry for the sale of menthol cigarettes and known to disproportionally use menthol cigarettes. [14]
[46] In New York City (NYC), the prevalence of menthol smoking among people who currently smoke is about 50% with the highest prevalence observed among non-Latino Black individuals (84%) and the lowest prevalence among nonLatino White individuals (26%)
[36] Findings from our study show a reduction in cardiovascular disease (CVD) morbidity and an increase in related healthcare cost savings over a 20-year period with the implementation of a menthol ban in NYC
Summary
Smoking is the leading preventable cause of premature death worldwide [1,2,3] and increases the risk for many adverse health outcomes including cancer, heart disease, stroke, and chronic obstructive pulmonary disease (COPD). [4,5,6] While overall smoking prevalence has decreased over the past two decades in the United States (US), there has been an increase in menthol cigarette sales and use among current smokers. [7,8,9] There is strong evidence that menthol in cigarettes increases nicotine dependence and decreases the chance of successful smoking cessation. [7, 10, 11]Menthol cigarette use is prevalent among females, youth, and people of color in the US, likely due in part to aggressive tobacco industry marketing and promotion to these communities. [7, 12,13,14] Women are more likely to smoke mentholflavored cigarettes than men. [13] More than 50% of youth that smoke cigarettes smoke menthol-flavored cigarettes. [15] Almost one-third of current menthol smokers are Black compared to only 3% of non-menthol smokers who are Black. [16] Health advocacy agencies have come out strongly against the sale of flavored cigarettes because of their predominance of use among marginalized populations. [17, 18] The World Health Organization (WHO) recommends banning the use of menthol in cigarettes and other tobacco products in an effort to decrease the prevalence of smoking and improve population health. [19, 20] The US Food and Drug Administration (FDA) recently announced that it will ban menthol—the last allowable flavor—in cigarettes. [21]Beginning in January 2017, the province of Ontario, Canada, banned the use of menthol-flavored tobacco products. [22] Evaluation studies of this ban show a significant reduction in the sales of cigarettes in Ontario and an increased rate of quitting among daily and occasional menthol smokers. [22,23,24] New York City (NYC) has considered implementing a similar policy, building on its ban of non-mentholflavored tobacco products; [25] legislation was introduced in 2019 but, in the face of opposition, was not put to a vote. [26] there is promising evidence of the effectiveness of a menthol cigarette ban, the long-term health and economic costs of these types of cigarette bans are unclear. [17, 18] The World Health Organization (WHO) recommends banning the use of menthol in cigarettes and other tobacco products in an effort to decrease the prevalence of smoking and improve population health. [29, 30] Since the prevalence of menthol cigarette use varies significantly across different sex and racial and ethnic groups, a second aim is to examine how the potential ban may differentially affect individuals across sex and race and ethnicity, including whether or not the policy would reduce disparities in health outcomes and healthcare costs between groups We use CVD as the outcome of interest, as it is the leading cause of death in the US and NYC, and smoking is one of the most important risk factors for CVD. [28] In addition, there are stark sex and racial and ethnic disparities in CVD risk factors in NYC and across the country. [29, 30] Since the prevalence of menthol cigarette use varies significantly across different sex and racial and ethnic groups, a second aim is to examine how the potential ban may differentially affect individuals across sex and race and ethnicity, including whether or not the policy would reduce disparities in health outcomes and healthcare costs between groups
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