Menthol is a common additive in tobacco products. The tobacco industry maintains that menthol is added as a flavour.1 However, there are many concerning effects of added menthol, beyond changing the flavour of the tobacco product. Menthol masks the harshness of smoke, increases addiction and facilitates uptake of smoking in young people. Menthol cigarettes are also marketed to and used disproportionately by specific groups of people such as African Americans.2 Regulation of menthol has seen its use in tobacco products banned in some countries and localities, with evidence that these bans are followed by drops in smoking prevalence and declines in sales of tobacco products.
12.7.1 Use of menthol in tobacco products
Menthol is a carbon-based compound that can be produced synthetically or isolated from mints such as peppermint and corn mint. Menthol is added to the tobacco filler of cigarettes or to the cigarette filter. It is present in amounts of up to 1.6% of the weight of tobacco in cigarettes sold in Australia ( Table 12.5.2 in Section 12.5).3 When these cigarettes are smoked, menthol is vapourised and is detected in the smoke.4 Menthol can be found in cigarettes that are not branded as menthol cigarettes (described herein as non-mentholated), but at lower concentrations.5, 6 Menthol is also added to the tobacco used in some cigars, pipes, roll-your-owns, waterpipes and smokeless tobacco.2, 7 Some bidis and kreteks may also contain menthol.8, 9
Menthol was first added to tobacco products in the 1920s and 1930s but became popular and widespread from the 1950s. Its rising popularity coincided with increased use of cigarette filters as well as aggressive marketing of menthol products.6, 10, 11 Prior to 1956, menthol cigarettes were often sold as ‘’throat’’ cigarettes, to be used when a cough or a cold prevented the use of other brands.10 In more recent years, advertising for menthol cigarettes has focused on their 'smoother'/ 'fresher' smoke, although there have been secondary marketing points concerning implied ‘healthiness’ or reduced harm.12
From having a low percent of the market until the 1950s, menthol cigarettes eventually rose in popularity to having 28% of the market share in the United States by 1978 and remain popular in the contemporary market.10 Data from the US in 2015 show that mentholated products made up 32.5% of cigarettes, 0.2% of cigarillos, 19.4% of little cigars, 0.7% of chewing tobacco, 57% of moist snuff and 88.5% of snus.13
12.7.2 The effects of added menthol in tobacco products
Studies of cigarette smoking indicate that menthol is a problematic additive in tobacco products.14 People who smoke menthol cigarettes are more likely to show signs of nicotine dependence than non-menthol smokers.15-17 Menthol smokers have lower rates of quitting, especially so for African American smokers.16 Some studies have shown that menthol smokers have their first cigarette each day sooner after waking up, compared to smokers of non-mentholated cigarettes, which can indicate increased withdrawal symptoms. Menthol cigarettes are preferred over non-mentholated by younger people, perhaps due to the smoother taste during smoking initiation. Menthol smokers may smoke fewer cigarettes per day but they have similar mortality rates to smokers of non-mentholated cigarettes.14
This section examines the potential biological mechanisms that underpin these effects of menthol on smokers.
12.7.2.1 Increasing the addictiveness of tobacco products
Menthol modifies the effects of nicotine on the brain
Nicotine binds to nicotinic acetylcholine receptors on the cell surface of neurons (nerve cells) in the brain. Under normal conditions, nicotinic acetylcholine receptors respond to a brain signalling molecule called acetylcholine, but nicotine hijacks these receptors, producing an aberrant effect on the brain. Binding of these receptors to nicotine leads to neuron activation, causing a release of dopamine in the brain and a subsequent feeling of euphoria.14
Nicotine acetylcholine receptors are referred to as a ‘family of receptors’, meaning that a number of similar proteins make up a multi-protein complex that binds to its targets. Functional nicotine acetylcholine receptors in the brain contain five subunits, consisting of alpha and beta subunits. There are numerous types of alpha and beta subunits that are used in a ‘mix and match’ way. Which subunits are forming the receptor complex can modify the response of the receptor to nicotine.
Menthol changes the effects of nicotine on the brain via several mechanisms:
1) Menthol increases the number of some nicotine acetylcholine receptor subunits in the brain, which may change the sensitivity of the brain to nicotine.18, 19
2) Menthol changes the stoichiometry of the nicotine acetylcholine receptors; i.e. it changes the range of subunits making up the receptors. Different subtypes of the receptor have different sensitivities to nicotine and different desensitisation rates. Nicotine can bind to different forms of its receptor in the brains of people who smoke menthol compared to non-menthol cigarettes, thereby modifying nicotine reinforcement mechanisms.14
3) Menthol can enhance the euphoric effects of nicotine by causing dopamine release after exposure to smaller amounts of nicotine.14
4) Menthol can alter nicotine metabolism, essentially increasing its bioavailability (making it remain in the body for longer, see Section 12.6.2.1). This increases the length of time that nicotine can affect the brain.20, 21 However, the effect of menthol on nicotine metabolism seems counterintuitive, since faster metabolism of nicotine predicts greater dependence and poorer cessation.14, 22, 23 More research is required to understand the effects of the increase in bioavailability of nicotine caused by menthol.
Menthol may enhance nicotine absorption through the lungs
‘Cold’ receptors (sensory nerve endings) in the upper airways detect cold air, leading to a depressive effect on breathing. The menthol in tobacco smoke can stimulate the activity of the same cold receptors in the upper airways and may also increase cool sensations in the lungs. This can lead to breath-holding, and subsequently a greater opportunity for exposure and transfer of the contents of the lungs into the blood. These changes may lead to a greater exposure of nicotine, potentially increasing addictiveness.24
12.7.2.2 Increasing the attractiveness of tobacco products
Flavouring
Cigarettes and other tobacco products with sufficient menthol added during their manufacture often have a recognisable menthol taste. Menthol is designated as a characterising flavour of cigarettes.24 Characterising flavours are defined as a ‘clearly noticeable smell or taste other than one of tobacco, resulting from an additive or a combination of additives, including, but not limited to, fruit, spice, herbs, alcohol, candy, menthol or vanilla, which is noticeable before or during the consumption of the tobacco product.’25 Characterising flavours are important strategic concepts in tobacco product regulation; they are banned in cigarettes and roll-your-owns in the European Union by the European Tobacco Products Directive 2014/40/EU25 and in Canada and a few other countries (see Section 12.7.7.2 below). Characterising flavours, with the exception of menthol, are also banned in the US26 .27
Masking the harshness of smoke
Menthol in smoke stimulates a ‘cooling’ sensation in the mouth and throat, which reduces the harsh feeling of smoke , as described in Section 12.7.2.1 above.24, 28 Menthol also has analgesic properties and may reduce feelings of pain in the upper airways that occurs due to the harshness of smoke.14 Menthol can therefore mask harshness of smoke, facilitating smoking in people who would otherwise be irritated by it.
Analysis of tobacco industry documents uncovered industry research showing that menthol reduces negative sensory characteristics associated with smoking in those that cannot tolerate the harshness of smoke.29
12.7.2.3 Health effects of menthol tobacco products
Menthol is not a carcinogen and has no known toxicity at the concentration used in cigarettes.30 There are no known pyrolysis or combustion products of menthol with toxicity. At higher concentrations, menthol may have toxic and irritant effects, especially to the eyes.
Menthol affects the addictiveness of cigarettes, leading to increased uptake of smoking and decreased quitting (see Section 12.7.4). Therefore, at a population level the use of menthol by tobacco companies has caused considerable harm to health. A study that modelled the harm caused by menthol cigarettes in the US from 1980 to 2018 estimated that the use of menthol cigarettes was responsible for slowing down the decline in smoking prevalence by 2.6 percentage points (so that prevalence was 13.7% rather than 11.1% in 2018) and was responsible for 10.1 million extra smokers, three million life years lost and 378,000 premature deaths in the US from 1980 to 2018.31
Nicotine and nicotine biomarker (cotinine, see Section 12.5.6) levels do not differ in the saliva of menthol and non-menthol cigarette smokers. However, young adult daily menthol smokers have slower rates of nicotine metabolism, indicating that nicotine stays in the body for a longer period of time.21
A number of studies have examined the overall profile of people who smoke menthol compared to non-menthol cigarettes. On average, menthol smokers smoke slightly fewer cigarettes per day.32, 33 Former menthol smokers have slightly higher weight, and are over twice as likely to have visited the emergency room due to asthma, compared to former smokers of non-mentholated cigarettes.32 Despite smoking fewer cigarettes on average, there was otherwise no difference in health care utilisation33 or mortality rates of menthol smokers compared to smokers of non-mentholated cigarettes.14, 34
The presence of menthol in cigarettes affects the tobacco microbiota (the range of microorganisms present), by changing the types of bacteria present in the tobacco.35, 36 The health impacts, if any, of these changes are currently unknown.
12.7.3 Consumer perceptions of menthol tobacco products
Menthol tobacco products are a very popular choice among smokers, with over 32% of cigarettes sold in the US and 20% of little cigars being mentholated.13 Reasons for adults choosing menthol cigarettes include ‘tasting better’, ‘soothing the throat’, ‘easier to inhale’ and ‘easier to inhale deeply’.37 An Australian study has shown that people who smoke menthol cigarettes are more likely to experience these as favourable sensory experiences, including feeling smooth, being soothing on the throat, fresh-tasting and clean-feeling, than non-mentholated products.38
Tobacco industry documents detail industry studies showing that menthol smokers, particularly women, perceive the aroma of menthol cigarettes as more socially acceptable than that of non-menthol products.39 Tobacco industry research also indicates that menthol smokers perceived that these products signalled social group belonging.40
Many people who smoke menthol cigarettes perceive them as easier to smoke and less harmful than smoking non-mentholated cigarettes.41, 42 Studies in Australia and New Zealand also show that many smokers hold the misperception that menthol cigarettes are less harmful than non-mentholated.37, 38, 43-45 Advertising and branding are likely to have played a role in driving this misperception. Prior to the 1950s, menthol cigarettes were advertised as having health benefits. Since this time, menthol cigarettes have been described by words such as ‘fresh’ and imagery such as snowfields, beaches and rainforests.37 There is some evidence that misperceptions of lower harmfulness are strengthened by the experience of the sensations of smoothness created by mentholated smoke.30
12.7.4 Menthol cigarette use by specific groups of people
Menthol cigarettes are more popular among specific demographics. Compared to White and Hispanic smokers in the US, African American people are more likely to smoke menthol cigarettes. A 2010 study of over 280,000 people (20–65 years old) from 2003 to 2007 found that 70% of African American smokers used menthol cigarettes compared to 20% of White smokers and 25% of Hispanic/Latino smokers.46 A 2015 study estimated that 84.6% of non-Hispanic black/African American smokers were menthol users.47 Menthol cigarettes were predicted to be responsible for 1.5 million new smokers, 157,000 premature deaths and 1.5 million life-years lost among African Americans over the period from 1980 to 2018.48 Similar proportions were found by numerous other studies in the US.30 American smokers were also more likely to smoke menthol cigarettes if they were female49 or younger (as described in Section 12.7.5). Furthermore, menthol smokers were more likely to have lower education levels and lower incomes compared with smokers who used non-mentholated cigarettes.30 Menthol cigarette use may also differ according to sexuality and/or gender. A study of adult LGBT smokers in the US showed a 1.31-fold higher odds of smoking menthols than their non-LGBT counterparts.50 Among LGBT smokers, 36.3% were menthol users.50
Targeted advertising campaigns since the 1960s are likely to have contributed to the disproportionate use of menthol cigarettes used by African American people.10 There is also evidence of targeted marketing to LGBTQIA+ people,51 women, and young people.52
A genetic propensity to experience heightened bitter taste perception may modestly increase the preference for menthol cigarettes in people with specific variants of the TAS2R38 bitter taste receptor gene.53, 54 A variant of a gene called MRGPRX4, found solely in people with African ancestry, was strongly associated with menthol smoking in a US cohort. This gene produces a receptor found on the cell surface of sensory nerve cells believed to be involved in pain detection. There was a 5-to 8-fold increase in the odds of menthol cigarette use in people with the gene variant. However, even in African people, this gene variant is relatively uncommon, meaning that its presence cannot account for most of the strong preference of African American smokers for menthol cigarettes.55
12.7.5 Effects of menthol on smoking initiation and cessation
Consistent evidence supports a role for menthol cigarettes in promoting the initiation of smoking in young people, above the extent of non-mentholated cigarettes.16 It is likely that the cooling sensation of menthol on the upper airways aids the transition to smoking, reducing irritation in the throat. A systematic review of studies on initiation of smoking concluded that there was a strong association between youth and smoking of menthol cigarettes compared to adult use of menthols.16 Numerous studies have demonstrated a higher prevalence of menthol than non-menthol use in younger people and an age gradient where younger smokers were more likely to smoke menthols.16, 47 Young people who recently started smoking were more likely to use menthol cigarettes than those who have smoked for longer than one year.16, 56 Longitudinal studies have also shown that young people who start smoking menthol cigarettes were at greater risk of progressing to regular smoking and nicotine dependence than those who start with non-mentholated cigarettes.57, 58
The smoking of menthol cigarettes is associated with reduced smoking cessation. This is consistent with biological evidence that menthol can increase the addictiveness of tobacco products described in Section 12.7.2.1. There is evidence that smokers of menthol cigarettes are more dependent on nicotine and experience increased emotional attachment to cigarettes compared to people who smoke non-mentholated cigarettes.59
Longitudinal studies measuring smoking cessation have shown that people who smoke menthol cigarettes have a lower rate of cessation than people who smoke non-mentholated cigarettes. African American and Latino people who smoked menthols were less likely to quit compared to people of the same ethnicity who smoked non-menthol cigarettes.60, 61 Young people who smoked menthol cigarettes had a higher chance of intending to continue smoking than nonmenthol cigarette users.62 In White people, the use of menthol cigarettes has led to significantly lower odds of maintaining continuous abstinence and maintaining postpartum smoking abstinence (in women) compared to use of non-mentholated cigarettes.63, 64 A systematic review of randomised controlled trials for smoking cessation described five studies that found significantly reduced cessation among menthol smokers compared to non-menthol smokers.16 This review concluded that cessation is reduced in non-Hispanic White people as well as in racial and ethnic subgroups of menthol smokers compared to non-menthol smokers, despite increased quit attempts of menthol smokers.16 A later meta-analysis of 19 cessation studies in the US did not find a significant association between menthol use and cessation overall (i.e. in combined data for all groups of people); but did find that among African Americans, menthol users were significantly less likely to quit than users of non-menthol products (OR 0.88).17
12.7.6 Use and perceptions of menthol cigarettes in Australia
Menthol cigarettes were traditionally promoted as a 'feminine' cigarette within the Australian market. Unsurprisingly, more women than men in Australia have smoked menthol cigarettes in the past.65 Alpine, manufactured by Philip Morris, was strongly marketed to younger women in particular, prior to the current regime of advertising bans and was also 'stealth marketed' to young women at fashion events after the bans were in place.66-69 Alpine was also sold in packets of 15 cigarettes, which may have appealed to younger smokers with less money.65
Menthol cigarette popularity may have declined in Australia from 1980 to 2008.65 About 20% of female smokers aged 19–29 years used menthols in the 1980s, but this reduced to less than 10% by 2008. In women over 30 years (women who had been in their teens prior to 1990), this proportion fell from 25% to just less than 20%.65 More recent data from a national online panel study in 2019 found that 25.2% of the current smokers taking part in the research study were current users of menthol cigarettes. Smokers in the study who were aged 18 to 29 years were three and a half times more likely to be current menthol smokers (34.0%) compared to those aged 50 to 69 years (12.8%. Likewise, smokers aged 30 to 49 years were more than two and a half times more likely to be current menthol smokers (28.4%) than those aged 50 to 69 years (add %) .38
Australian secondary students are exposed to menthol in crushable capsules. Five percent of secondary students had tried flavour capsule cigarettes in 2017, which would mostly be menthol flavour.70 Students who used flavour capsules multiple times were more likely to have recently smoked (in the past week or month), consistent with menthol promoting a progression to regular smoking. Those who had smoked previously were more likely to agree that 'some brands of cigarettes are easier to smoke than others' if they had tried a flavour capsule cigarette.70 See Section 10.8.4.1 for more information about menthol ‘crushball’ capsules in cigarette filters.
Australian menthol-smokers were more likely than non-menthol smokers to describe menthol cigarettes as having favourable sensory experiences, including feeling smooth, being soothing on the throat, fresh-tasting and clean-feeling. They were also more likely to perceive that these favourable sensations were less damaging and more enjoyable than cigarettes with harsher feeling smoke.38 Young women smokers in Australia perceive that menthol capsule had a positive effect on their smoking, creating a fresh and improved taste, and that ability to personalise their smoking experience.71
12.7.7 Regulation of menthol in tobacco products
12.7.7.1 Aims and approaches to regulating menthol in tobacco products
Regulating menthol in tobacco products is recommended by the World Health Organization (WHO). The guidelines for implementing articles 9 and 10 of the Framework Convention on Tobacco Control (FCTC) recommend prohibiting or restricting ingredients such as menthol that may be used to increase palatability in tobacco products.72 The WHO Study Group on Tobacco Product Regulation (TobReg) recommends considering a ban on the use of flavours, including menthol, in harmful combusted products.73 In an advisory note from 2016, TobReg unequivocally recommended banning the use of menthol and its analogues, precursors or derivatives in cigarettes and possibly all tobacco products.74
Relatively high amounts of menthol are added to “mentholated” tobacco products, producing a characteristic menthol flavour for the consumer.3 However, low amounts of menthol are often found in products that are not described in their branding as having menthol.5, 6, 74 Subsequently, there are various different options available for regulating for menthol in tobacco products.According to the WHO, potential strategies for regulating menthol include:75
- a ban on the use of menthol as a characterising flavour,
- a ban on all use of menthol in the production of tobacco products,
- a ban on all products with a perceived menthol flavour or visible menthol identifiers,
- a ban on menthol within a specific category of products,
Many jurisdictions that have prohibited menthol have done so by prohibiting its use as a flavour, usually in specific subsets of tobacco products, such as cigarettes and cigars.76 In an advisory note from 2016, TobReg recommended banning menthol in tobacco products but did not differentiate between different approaches.74
12.7.7.2 International progress in banning menthol in tobacco products
Bans on menthol use in tobacco products have been enacted in numerous countries and local jurisdictions. Brazil was the first country to pass a national law banning the addition of menthol in tobacco in 2012, however industry interference has prevented implementation of this ban.77 In 2015, Ethiopia was the first country to enact a national law banning the manufacture and supply of menthol, as part of its ban of flavoured products in 2015.78 The Canadian province of Nova Scotia was one of the first jurisdictions (in 2015) to ban menthol as a flavour and Canada implemented a national ban of menthol flavour in cigarettes and most cigars in 2017.75 Studies have shown that such bans lead to cessation attempts and cessation success among menthol smokers, and reductions in total smoking prevalence have also been measured after implementing menthol bans (see Section 12.7.7.3). The tobacco industry have made considerable effects to delay and circumvent menthol bans, as described below in Section 12.7.7.4.
Australia
Currently, there is no regulation on the use menthol or sale of tobacco products containing menthol in Australia. Menthol flavour and menthol capsules remain common in Australian cigarettes and other tobacco products. In November 2022 the Australian Minister for Health announced plans to introduce new legislation with the aim of reducing smoking rates in Australia. Preventing the use of menthol and other additives was signalled as being part of this new legislation.79
Canada
Although flavours were banned in cigarettes in Canada in 2009, and in most cigars in 2015, menthol was exempt from that ban.80 With increasing evidence that menthol promotes smoking uptake and progression in youth-, seven Canadian provinces implemented bans on the sale of menthol in tobacco across all product categories.75 Nova Scotia was the first province in the world to ban menthol as a flavour in tobacco products—in 2015—with six other Canadian provinces following in the next couple of years.81 The exemption for menthol at the national level was removed in a 2017 amendment to the Tobacco Act, effectively banning throughout Canada use of menthol as a flavour in cigarettes and most cigars, as well as promotion of menthol in tobacco packaging.75, 80
European Union
The sale of flavoured cigarettes and roll-your-own tobacco, including those with menthol flavour, was banned in the European Union (EU) by the second Tobacco Products Directive.82 The wording of the directive prohibits selling tobacco products with a ‘characterising flavour’. Along with other flavours, menthol is also banned in filters, papers, packages, capsules or any technical features allowing modification of the smell or taste of the tobacco products concerned. Some EU countries have implemented stronger regulations upon menthol, with Germany and Finland banning it as an additive in 202083, 84 and Hungary announcing a ban of any amount of menthol in cigarettes.85
The implementation of the ban of menthol in the EU was postponed due to protests and interference from the tobacco industry.86 The legal challenges ultimately failed, but a long lead-in time saw the implementation of the ban delayed until 2020.85
United Kingdom
The 2014 TPD2 ban on flavoured and menthol cigarettes included the United Kingdom (UK) until it left the European Union at the end of 2020. The flavour ban was transposed into UK law with any future amendments to be made by the UK government85 and therefore enacted in 2020.
United States
In the US, the Family Smoking Prevention and Tobacco Control Act of 2009 provided the authority to the Food and Drug Administration (FDA) to regulate tobacco products, including their ingredients. The FDA subsequently prohibited the sale of cigarettes with a characterising flavour, with the exception of tobacco and menthol flavours in 2009.76 Menthol cigarettes constituted an estimated 27% of the cigarette market in the US at the time.87 A number of individual states have since enacted bans on the sales of flavoured cigarettes that are wider than the 2009 flavoured cigarette ban (see discussion below).88
After the exclusion of menthol from the flavoured cigarettes ban in 2009, the Tobacco Products Scientific Advisory Committee (TPSAC) to the Food and Drug Administration (FDA) was tasked in the same year to make recommendations on menthol cigarette regulation.89 In 2011, the TPSAC concluded that banning menthol would be in the interest of the nation’s public health. However, the Lorillard tobacco company challenged the FDA regarding this decision, claiming that some members of TPSAC had financial conflicts of interest (they received consultancy fees from companies that market tobacco cessation medications).90 Progress on banning menthol through legislation was subsequently stalled. In 2020, a group of public health bodies that included the American Medical Association and African American Tobacco Control Leadership Council and Action on Smoking and Health filed a lawsuit against the FDA. The suit claimed that the FDA’s failure to ban mentholated tobacco products was an unreasonable delay of agency action.89
In February 2020, the US House of Representatives passed a bill for the Protecting American Lungs and Reversing the Youth Tobacco Epidemic Act. This legislation, if implemented, will prohibit all flavoured tobacco products in the US, therefore prohibiting menthol cigarettes, cigars, e-cigarettes and all other tobacco products with menthol flavour.91 However, the bill must be passed by the Senate, where it will face a more difficult battle.92
In April 2021, the FDA in the US announced its commitment to a ban on menthol as a characterising flavour in cigarettes. All characterising flavours, including menthol, would also be banned in cigars.93 In April 2022 the FDA then proposed rules for banning menthol as characterising flavour in cigarettes, stating that “a cigarette or any of its components or parts (including the tobacco, filter, wrapper, or paper, as applicable) shall not contain, as a constituent (including a smoke constituent) or additive, menthol that is a characterizing flavour of the tobacco product or tobacco smoke.”94 The implementation date is not yet determined.
Multiple localities within the US have implemented bans on mentholated tobacco products. Massachusetts was the first US state to ban menthol, as part of a ban on all flavoured tobacco products. In 2017, the city of San Francisco passed legislation that prohibits the sale of all flavoured tobacco products, including menthol, which was implemented in 2018.95 As of September 2022 there were 170 localities in the US that had restrictions on sales of menthol cigarettes, in the states of California, Colorado, Illinois, Maine, Massachusetts, Minnesota, New York State and Oregon.88
In 2020, California was the second state, after Massachusetts, to pass a law banning the sale of menthol cigarettes. Bill number SB-793, states that “A tobacco retailer, or any of the tobacco retailer’s agents or employees, shall not sell, offer for sale, or possess with the intent to sell or offer for sale, a flavored tobacco product”, which includes menthol as a flavour. Implementation of this ban was delayed for over two years by the tobacco industry through the initiation of an unsuccessful referendum, as well as an unsuccessful emergency plea to the US supreme court in late 2022.96
Chile
The Ministry of Health in Chile attempted to ban menthol tobacco products in 2013 but Chile’s autonomous Office of the Comptroller General ruled that the Ministry had failed to demonstrate that menthol directly increases addiction, harm or risk. A new bill was successful in 2015 after arguing that menthol and other distinctive cigarette flavours were associated with high levels of use by Chilean youth. Although the new bill successfully passed in Chile’s Senate, as of 2020, the law had not yet been implemented.87 In response to the passing of this bill, British American Tobacco announced the closure of its operations in Chile,97 and proceeded to close some of its operations.87
Brazil
Brazil, in 2012, was the first country to pass a law specifically banning the addition of menthol (or other flavours or additives) to enhance the flavour of tobacco.77, 98 The legislation bans tobacco products that contain "synthetic and natural substances in any form (pure substances, extracts, oils, distillates, balms, among others), with flavoring properties that can impart, intensify, modify or enhance the flavor of the product" and "seasonings, herbs and spices or any substance that can impart a flavor of seasonings, herbs and spices".98 However, interference from the tobacco industry and court battles have prevented Brazil from enacting the law and implementing the ban99 (see below in Section 12.7.7.4).
Other countries
A directive was issued in Ethiopia to ban manufacturing, import, distribution, and sale of flavoured tobacco products of any kind from late 2015.78 Menthol was included in this ban, the first time this had occurred in any country.75, 100 Ethiopia had a low market share of mentholated tobacco products, so this ban was considered pre-emptive – that is, aimed at preventing a potential rise in use.75
Turkey has banned menthol flavour in cigarettes and roll-your-own tobacco as of 2015 and specifically prohibits flavours in capsules.76 Moldova has banned characterising flavours, including menthol, in cigarettes and roll-your-own tobacco, coming into effect in 2020.76 Uganda has banned flavours, including menthol, and Senegal has banned menthol and other characteristic aromatic agents in tobacco products.76 Singapore has banned menthol and other flavours in waterpipe tobacco.76
12.7.7.3 Evidence for the effects of international menthol bans
Research examining the effects of menthol bans in numerous jurisdictions has shown that they have been followed by changes in smoking behaviour including increased quit attempts, increased cessation and reductions in smoking prevalence as well as reductions in sales.
Evaluations of the earlier bans in specific Canadian provinces have shown increased quitting attempts and quit success among menthol smokers.81, 101, 102 A prospective study of the impact of the regional bans (2016 to 2018) found that 59% of menthol smokers were likely to switch to non-menthol cigarettes.102 Nonetheless the ban coincided with a higher rate of quit attempts and quit successes among daily menthol smokers (21.2% cessation) compared with daily non-menthol smokers (13.2% cessation). The ban may have also contributed to preventing relapse by menthol smokers who had already quit smoking. However, 19.5% of previous menthol smokers continued to use the same products, buying from First Nations reserves.102 Prospective studies in Ontario found that daily or occasional menthol smokers were more likely to quit and made more quit attempts compared with non-menthol smokers by two years after the menthol ban in that state.101, 103 A longitudinal study over seven Canadian provinces showed that the Canadian menthol ban was associated with greater percentages in quitting among menthol smokers compared to non-menthol smokers.104 There was also no detected surge in illicit cigarettes after the menthol ban was implemented.105
Since the European Union ban was only recently implemented, few studies have evaluated its effects. One study of 1,326 Dutch smokers found that the ban reduced menthol cigarette use and increased quit attempts among people who smoked menthol cigarettes prior to the ban. There was an increase of 17.3% of cessation attempts and a 12.0% increase successful cessation events in menthol compared to non-menthol smokers.106
Survey results indicate that the menthol ban has led to a substantial decrease in the proportion of young people smoking menthol cigarettes in England. The prevalence of menthol cigarette use by people aged between 16 and 19 years fell from 12.1% to 3.0% by three months after the ban.107
The rationale behind the proposed menthol ban for US cigarettes (as well as all flavours in cigars) is to significantly reduce youth initiation, promote smoking cessation and address health disparities experienced by specific communities who are far more likely to use these tobacco products.93 Evidence supporting the potential benefits of a menthol ban in the US includes a modelling study predicting that by 2050, the relative reduction in smoking prevalence would be 9.7% overall and 24.8% for Black people. This study also predicted that over 633,000 deaths would be averted, including 237,317 for Black people.108 Another study predicted that a menthol ban would avert 2,862 cases of myocardial infarction and 1,983 cases of stroke per 1 million adults over a 20-year period.109 A modelling study that took into account switching to nicotine e-cigarette use predicted a decline of 15% in overall smoking levels as early as 2026 due to menthol smokers quitting both e-cigarettes and combusted tobacco switching to e-cigarettes.110
The benefits of menthol regulation in the US are supported by research conducted in states and cities that have already implemented menthol bans. A comparison of online shopping in the US in areas with and without the menthol ban saw those in the regions with a menthol ban buying less cigarettes overall, indicating that the ban may reduce overall cigarette consumption.111 The comprehensive tobacco flavour ban in Massachusetts (that included menthol) was associated with a significant drop in the sales of menthol cigarettes and all cigarettes.112, 113 This ban did not significantly affect cross-border sales in neighbouring states where menthol cigarettes were sold.113, 114 In 2019, San Francisco implemented restrictions on the sales of flavoured tobacco, which included menthol. A survey study shortly after the ban indicated that the prevalence of all flavoured tobacco use in 18–24 and 25–34 year old people decreased, however a non-significant increase in cigarette smoking also occurred.115 This increase in cigarette smoking may have been influenced by the recent outbreak of EVALI among e-cigarette users (a respiratory illness linked to vaping—see Section 18.6.5). A later study showed that the San Francisco ban was followed by massive drops in the sales of menthol cigarettes (by 96% between pre-policy and enforcement periods) and drops in the sales of other flavoured cigarettes.116 Total tobacco sales in mainstream retailers also decreased. There was no evidence of substitution with other products that had flavour-like concepts in their names.116
In 2016, the city of Chicago implemented a partial flavour product ban by prohibiting sales of all flavoured tobacco products in stores within 500 feet (~ 152 m) of schools.117 A study of menthol cigarette purchasing showed that compliance with this ban was poor. Only 57% of sampled shops in the prohibition area refused sales of menthol cigarettes. The study authors concluded that this poor compliance highlights the need for more comprehensive efforts to implement and enforce these bans.117
12.7.7.4 Tobacco industry responses to international menthol bans
The tobacco industry in Canada used numerous avenues to circumvent the ban on menthol as a flavour and the ban of the word ‘menthol’ in branding.81 For some products, the word menthol was replaced with “green”, and green and blue packaging was used to imply menthol content, in apparent attempts to keep customers.118 Flavour cards were sold as accessories, which slot into a tobacco product packet, allowing smokers to directly add menthol flavour to their products.119
Tobacco companies have undermined and circumvented the European Union (EU) ban and delayed its implementation using a number of means. Philip Morris International and British American Tobacco brought two separate claims against the second Tobacco Product Directive (TPD2), which, while ultimately unsuccessful, served to delay implementation. Tobacco companies promoted menthol products throughout the four-year delay. They have used buy-back schemes to maximise pre-ban sales of mentholated products.85 Tobacco product accessories that are sold separately are not regulated as tobacco products under the TPD2. Tobacco companies were therefore able to circumvent the ban by introducing mentholated filters, filters with menthol capsules for roll-your-own cigarettes, mentholated inserts that fit into recessed filters, menthol flavour infusion cards that can be placed into packets and menthol flavour sprays.120, 121
The UK—ahead of its impending exit from the EU—adopted its own menthol ban identical to that in place in the EU. At the time, the pre-ban market for menthol cigarettes in the UK was relatively high. There is evidence that the share of the market for menthol/menthol capsule cigarettes grew from 14% (in 2014) to 21% (in 2018) during the four-year grace period in the lead up to the ban. The tobacco industry therefore did not use the grace period to prepare for the ban, but rather sought to prolong and increase menthol use.121 Menthol cigarillos, which appeared similar to cigarettes, have also been introduced into the market since the ban.121 There is some evidence that the UK market for cigarillos is now increasing.85 As occurred in the EU, non-tobacco products, that are not regulated in the UK, have been introduced into the market promising to impart a menthol-flavour into unflavoured products. These include menthol and menthol-capsule filters for RYO and flavour infusion cards for cigarette packets.121
As described in Section 12.7.7.2 above, the tobacco industry has used litigation to delay the implementation of a national ban in the US on menthol as a cigarette ingredient, as proposed by the FDA. Opponents of the proposed national ban in the US spuriously claim that its unintended consequences would include a rise in illicit sales of these products, exacerbation of racial inequality (such as through the criminalisation of sales) or further alienation of vulnerable populations.89
Tobacco companies in the US are expected to use a variety of techniques in the future to circumvent a national menthol ban as well as promotions to increase the use of non-mentholated cigarettes.111 A day after the Californian vote to uphold the menthol ban, RJ Reynolds announced a new capsule cigarette under the Camel Crush brand, that is advertised as non-menthol. Descriptors of the new product include the words “crisp” and “tropical oasis” perhaps implying a characterising flavour, which will be illegal under the ban.122 The new products are reported to contain a chemical called WS-3 that has a cooling effect but may have less flavour.123 Major tobacco companies and online marketplaces have also launched non-tobacco products that may impart a menthol flavour on non-flavoured products. These include menthol capsules, infusion cards, menthol flavoured roll-your-own papers, flavour drops and sprays for cigarettes, flavoured filters and flavour “stones”.124
Despite the passage of legislation in Brazil to ban menthol and other flavours in 2012,98 the tobacco industry has successfully prevented this legislation from being enacted.99 Tactics to delay and subvert the bill included promotion of protests by farmers and flooding the consultation process with thousands of fraudulent submissions.99 Strategies to prevent the bill or its implementation included claims of the loss of jobs, a rise in illicit trade of tobacco, false claims of a lack of scientific evidence supporting the use of additives to increase the attractiveness of tobacco products and that the Brazilian Health Regulatory Agency has no mandate to ban additives in tobacco products.99 The ban was suspended by a Federal Supreme Court injunction in 2013 but upheld by a later Supreme Court decision in 2018. However, multiple lower court cases blocking the implementation remain to be resolved.99 Meanwhile, the number of flavoured tobacco products registered by the industry in Brazil tripled between 2012 and 2021.125
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