What happens after menthol cigarette bans are enacted
This diagram demonstrates the direct and distal effects of a menthol cigarette ban over time. Comprehensive restrictions on menthol tobacco products increase retailer compliance, consumer risk perceptions, and cessation efforts, while also reducing the availability of menthol cigarettes. It traces pathways where menthol bans reduce the availability of menthol cigarettes and lower menthol cigarette use, associated with reduced nicotine dependence and poor health outcomes such as smoking-attributable mortality. By examining these effects, stakeholders can pair bans with robust public support, wide coverage and enforcement of restricted products, and timely smoking cessation support to maximize public health benefits.
Cited references
Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics
Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics
Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics
Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics
Of 539 local jurisdictions in California, 24 cities or counties had adopted a local flavor ordinance by January 1, 2019, which represents an 11-fold increase from two jurisdictions that adopted ordinances prior to the April 2015 campaign start. The first comprehensive flavor ordinance was adopted by Unincorporated Yolo County in October 2016. By the end of 2017, only two comprehensive flavor ordinances had been adopted in California. In 2018, four more comprehensive ordinances passed, so that by January 1, 2019, one in four local flavor ordinances were comprehensive (see Table 2).
While products with ambiguous flavor names were also significantly less prevalent in flavor ordinance jurisdictions compared to matched no-ordinance jurisdictions (cigarillo/cigar wraps: 53.9% vs. 78.1%)
They did another round of data gathering in Minneapolis (but not St Paul) because compliance with new ban was so bad
In Minneapolis between rounds 1 and 3, there was a significant reduction in the per cent of stores that sold tobacco with ambiguous flavours names such as ‘TaTa’ and ‘Blue’ (80.5% vs 61.5%)
In Saint Paul, there was no significant change in the per cent of stores that sold products with ambiguous flavour names (67.6% vs 81.1%).
In Minneapolis between rounds 1 and 2, the average per cent of flavoured tobacco inventory per store decreased significantly while the average per cent of unflavoured tobacco inventory increased significantly
In Saint Paul, the average percentages of flavoured and menthol tobacco inventory per store decreased significantly between rounds 1 and 2 while the percentage of unflavoured tobacco inventory increased.
In addition, the NYC Department of Finance’s (DOF) Sheriff’s Office regularly inspected tobacco retailers for compliance with the city’s cigarette excise tax, including searches of retailers’ premises for hidden packs of untaxed cigarettes. Stakeholders reported that DOF found flavored cigars hidden with untaxed cigarettes
No products with ambiguous names or replacement menthol tobacco were observed in the overall sample.
No products with ambiguous names or replacement menthol tobacco were observed in the overall sample.
A total of 7458 tobacco retail licenses were issued during October 2018-August 2019 (pre-flavor ban period), and a total of 7026 tobacco retail licenses were issued during October 2020-August 2021 (post-flavor ban period), representing an overall 5.8% decline in licenses.
While the number of existing retailers that were issued renewed licenses increased by 9.5% (5627 during October 2018-August 2019 and 6163 during October 2020-August 2021)
the number of new tobacco retail licenses issued decreased by 52.9% (1831 during October 2018- August 2019 and 863 during October 2020-August 2021).
Overall, the decrease in total tobacco retail license density across counties in the state of Massachusetts was 7.78 per 100,000 population.
Overall, the decrease in new tobacco retail license density across counties in the state of Massachusetts was 17.15 per 100,000 population.
Between the first and last rounds of compliance checks, violations for sale of tobacco to a minor decreased by 12 percentage points to 2%
In Providence, trends in the percentage of unique explicit-named flavoured cigarillo UPCs (‘sales share’) appear to drop from the prepolicy to the postpolicy period while trends in the share of concept-named and tobacco flavoured cigarillo UPCs appear to increase over these periods
Our analysis revealed no association between policy implementation and changes in the number of or trends in available tobacco-named cigarillo UPCs
Compared with a national comprehensive FTP retailer ban, which would eliminate FTP sales, a tobacco specialty store only exemption, on average, would result in 6.02% of FTP retailers (0.23 FTP retailers per square mile) remaining per Census tract. If both tobacco specialty stores and alcohol outlets were exempt, on average 14.25% of FTP retailers (0.57 FTP retailers per square mile) would remain per Census tract.
If no FTP sales restrictions existed nationwide (ie, ‘status quo’), the overall FTP availability across Census tracts was 20.88 per 100000 total population (figure 1A). Under a national FTP sales restriction that exempts tobacco specialty stores only, the average FTP availability across Census tracts would reduce to 1.49 FTP retailers per 100000 population (figure 1B). Exempting both tobacco specialty stores and alcohol outlets would result in an average of 3.77 FTP retailers per 100000 population
If no FTP sales restrictions existed nationwide (ie, ‘status quo’), the overall FTP availability across Census tracts was 20.88 per 100000 total population (figure 1A). Under a national FTP sales restriction that exempts tobacco specialty stores only, the average FTP availability across Census tracts would reduce to 1.49 FTP retailers per 100000 population (figure 1B). Exempting both tobacco specialty stores and alcohol outlets would result in an average of 3.77 FTP retailers per 100000 population
When stratifying by store type, there was a statistically significant greater decrease in any FTP availability among policy-area convenience stores than among comparison-area convenience stores (p
Smokers who did not make a quit attempt before bans were less likely than those who made a pre-ban quit attempt to make a quit attempt at follow-up
Smokers who did not make a quit attempt before bans were less likely than those who made a pre-ban quit attempt to make a quit attempt at follow-up
Smokers with no plans to quit before bans were also less likely than those with plans to quit before bans to make a quit attempt at follow-up.
Menthol smokers who said they would quit in the event of a ban were more likely to have attempted to quit in the previous 12 months than those who said they would not
In Canada, menthol or capsule smoking was more common among participants who reported being a little or very addicted to cigarettes than those who reported not being addicted (3.1% vs 1.3%; AOR, 1.02; 95% CI, 1.00-1.03; P = .01) (Table 2)
In England, there was little evidence for any associations between cigarette consumption or dependence and menthol or capsule smoking (Table 2).
In the US, menthol or capsule smoking was more common among those who smoked on at least 20 of the past 30 days vs otherwise (38.1% vs 32.7%; AOR, 1.07; 95% CI, 1.01-1.13; P = .03)
In the US, menthol or capsule smoking was more common among those ... who smoked 2 to 5 (37.9%) or more than 5 (38.5%) cigarettes per day than those who smoked 1 or fewer (29.8%) (2-5 vs 1 cigarettes per day, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1 cigarettes per day, AOR, 1.10; 95% CI, 1.03-1.18; P = .007) [C1] United States [/C1]
In the US, menthol or capsule smoking was more common among those ... who reported urges to smoke every or most days vs less often (38.0% vs 30.3%; AOR, 1.08; 95% CI, 1.02-1.14; P = .006) (Table 2) [C1] United States [/C1]
Any menthol or capsule smoking in the past 30 days was also associated with a greater number of consumption and dependence indicators in all 3 countries than the usual brand measure (Table 2).
Any menthol or capsule smoking in the past 30 days was also associated with a greater number of consumption and dependence indicators in all 3 countries than the usual brand measure (Table 2).
Any menthol or capsule smoking in the past 30 days was also associated with a greater number of consumption and dependence indicators in all 3 countries than the usual brand measure (Table 2).
Any menthol or capsule smoking in the past 30 days was also associated with a greater number of consumption and dependence indicators in all 3 countries than the usual brand measure (Table 2).
However, event study analysis showed increases in each NRT product sales in two quarters before the policy change in Massachusetts, indicating preintervention increases in NRT product sales (online supplemental figure S2).
Compared with the comparison states, the unadjusted 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts increased by 505.10 (95% CI 83.01 to 927.19; p=0.02) pieces for gums
Compared with the comparison states, the unadjusted 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts increased by 505.10 (95% CI 83.01 to 927.19; p=0.02) pieces for gums and 393.96 (95% CI 175.01 to 612.90; p
The adjusted 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased by 643.11 (95% CI 365.33 to 920.89; p
The adjusted 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased by 643.11 (95% CI 365.33 to 920.89; p
There was no statistically significant change in patch NRT sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states after the policy was implemented.
By redefining the after-policy period to include the period of anticipation (1 January 2020 to 13 June 2020), we estimated higher increases in the sales of NRT products for gums (887.80 pieces; 95% CI 633.80 to 1141.80; p
By redefining the after-policy period to include the period of anticipation (1 January 2020 to 13 June 2020), we estimated higher increases in the sales of NRT products for gums (887.80 pieces; 95% CI 633.80 to 1141.80; p
By redefining the after-policy period to include the period of anticipation (1 January 2020 to 13 June 2020), we estimated higher increases in the sales of NRT products for gums (887.80 pieces; 95% CI 633.80 to 1141.80; p
Non-flavored little cigars saw no significant change over time or between categories, and while vape pens were less available over time in Category 1 cities, there was no difference when compared with Category 2 cities.
Point prevalence cessation rates were similar between groups (online supplementary table 1) as were biochemical biomarkers of smoking (ie, exhaled CO and urinary cotinine concentrations), craving and withdrawal symptom severity, perceived health risks and support for a menthol ban (online supplementary table 2).
Over the 4-week period, the non-menthol group averaged modestly lower scores on all measures of perceived risk, with perceived risk of addiction (mean difference −1.38; 95% CI: −2.37 to −0.39; p = .01) and perceived risk of mouth cancer (mean difference −0.84; 95% CI: −1.66 to −0.03; p = .05) having the largest differences and the only measures for which the difference reached statistical significance (Table 1).
Over the 4-week period, the non-menthol group averaged modestly lower scores on all measures of perceived risk, with perceived risk of addiction (mean difference −1.38; 95% CI: −2.37 to −0.39; p = .01) and perceived risk of mouth cancer (mean difference −0.84; 95% CI: −1.66 to −0.03; p = .05) having the largest differences and the only measures for which the difference reached statistical significance (Table 1).
Although ratings for cigarette perceived health risks were lower in the menthol cigarette abstinence group than in the menthol cigarette non-abstinence group, statistical significance was reached for only 1 measure (i.e., mouth cancer) (Table 2).
No substantial differences among groups were found in measures of motivation or self-efficacy to quit smoking, in nicotine dependence, support for a ban on menthol in tobacco products, or on measures of perceived health risks from the products used
No substantial differences among groups were found in measures of motivation or self-efficacy to quit smoking, in nicotine dependence, support for a ban on menthol in tobacco products, or on measures of perceived health risks from the products used
No substantial differences among groups were found in measures of motivation or self-efficacy to quit smoking, in nicotine dependence, support for a ban on menthol in tobacco products, or on measures of perceived health risks from the products used
Further, we found a moderate negative correlation between the proportion of the menthol packs per census tract and the distance to exempt tobacco retailers (r = -0.66, p = .05). As the distance between census tracts and retailers increased, the proportion of menthol cigarettes decreased.
Menthol smokers were less likely to support a ban on menthol (aOR = 0.18, 95% CI: 0.08–0.43)
Menthol smokers were less likely to support a ban on menthol (aOR = 0.18, 95% CI: 0.08–0.43) and on all additives (aOR = 0.24, 0.12–0.49)
Those who reported that additive-free cigarettes are less harmful were more likely to support a ban on additives (aOR = 1.72, 1.18–2.50).
. Menthol smokers were more likely than otherwise similar nonmenthol smokers to disagree with a menthol ban (50.5% vs 31.2%; P
Menthol smokers with at least 1 recent quit attempt had twice the AOR as otherwise similar smokers who had not recently tried to quit of reporting they would rather quit than switch to a nonmenthol brand.
Controlling for individual factors (i.e., sex, annual household income, highest education level attainment, age at cigarette initiation, and nicotine dependence), participants’ perception of menthol cigarettes as harmful/risky (B=14.69, p
This study found that menthol bans likely have direct and indirect positive effects on smoking cessation among menthol smokers. Menthol bans may have the greatest impact on smoking cessation among those who are already motivated to quit before the implementation of a menthol ban.
Retailers were warned that they would be subject to permit suspension and/or administrative penalties if they did not come into compliance and were offered the opportunity to self-certify compliance by notifying the Department by text message when they had eliminated flavoured tobacco product sales and display. Routine inspections, which included the possibility of citations, started in April 2019. The SFDPH issued 83 Notices of Correction and 4 Notice of Violations between April 2019 and December 2019. Between January 2019 and December 2019, compliance was 80%.
“males, older adults, Blacks and Hispanics, those with higher levels of educational attainment, those with lower levels of household income, those with a shorter history of smoking, those who used nonmenthol cigarettes or nonflavored cigars, those who smoked less than daily, those who had moderate or high levels of dependence on smoking, and those who did not obtain cigarettes or cigars solely from local retailers were all more likely to be supportive of both bans compared with their counterparts.”
Across the surveyed countries, menthol cigarette smokers tended to be younger, more likely to be female, better educated, living with a higher household income, and smoking fewer cigarettes.
All groups were predominantly supportive of a smoking ban in restaurants, with highest support reported by menthol smokers (73.5%), and lowest by other flavoured cigarette smokers (63.3%). Almost half of all smokers supported the ban on smoking in bars and pubs, with the support varying significantly by the type of cigarette smoked (56.1% among menthol, 45.4% among other flavoured cigarette smokers).
The most divisive issue between menthol smokers and other smokers was that of banning additives, including flavourings, in cigarettes, with only 25.1% of menthol smokers supporting such a law, compared to 49.9% of other flavoured cigarette smokers.
