As the Biden administration moves closer to banning menthol cigarettes and flavored cigars, major health organizations are pushing to get the word out to Black smokers that help is available for those who want to quit.
The vast majority of menthol smokers in the U.S., 85%, are Black, according to the Campaign for Tobacco-Free Kids. In 2020, nearly 81% of Black smokers used menthols, compared to 34% of white smokers, data from the Centers for Disease Control and Prevention found.
The disparity is the result of decades-long advertising practices from the tobacco industry, which specifically targeted menthol cigarettes to Black communities, said Carol McGruder, co-chair of the African American Tobacco Control Leadership Council, an anti-tobacco public health and advocacy group.
Compared to regular cigarettes, menthols are notoriously addictive and particularly difficult to quit. The rate at which menthol smokers successfully quit is lower than that of nonmenthol smokers, and Black menthol smokers may be even less successful than other groups, according to the CDC.
But across the country, programs that help smokers quit are being underused, as smokers try to quit cold turkey or by taking medications prescribed by their doctor with little to no counseling, said Jennifer Folkenroth, the American Lung Association’s national senior director of tobacco programs.
There is a need, Folkenroth said, for more trained and certified facilitators in Black communities, like churches, “to really assist these quitters in their journey to freedom.”
More than 45,000 Black people die from smoking each year, according to the Campaign for Tobacco-Free Kids.
These include mothers, fathers, grandparents and other Black people who are instrumental in strengthening the community, McGruder said. “When we lose those people, it destabilizes the familial unit, it destabilizes the church, and it destabilizes our community.”
What makes menthol cigarettes so addicting?
There’s a simple reason menthol cigarettes are so appealing: their mint flavor, said Sven-Eric Jordt, an associate professor of anesthesiology, pharmacology and cancer biology at the Duke University School of Medicine.
To start, menthol has a cooling effect that suppresses coughing and makes tobacco smoke less irritating to the throat, making it easier to inhale, said Jordt, who is also a research project director and teaching faculty member at the Tobacco Center of Regulatory Science at the Yale School of Medicine.
Mint can also act as a “very strong” behavioral cue, he said. “When people or smokers smell mint, or something like that, they develop this craving to basically smoke the next cigarette.”
Nicotine, the addictive chemical in tobacco products, binds to receptors in the brain to release dopamine, a neurotransmitter and hormone that plays a role in various bodily functions, including pleasure and motivation, Jordt said. The menthol flavoring in cigarettes creates greater nicotine dependence by enhancing the effects of nicotine on the brain, therefore making it more addictive, according to the CDC.
“It’s also a fact that it’s harder to quit smoking with menthol cigarettes,” Jordt said. “Why that is — it’s still unclear. But this behavior has been observed in many studies as just harder to quit.”
‘Something had to change’
Millie Martinez was 15 when she was introduced to menthol cigarettes. It was the 1980s and she was a high school student in New York City.
“I started being part of the crowd and I just started smoking my Newport menthol cigarettes — and I got hooked,” said Martinez, who is now 55 and lives in the Bronx. “It was downhill from there. Once you start, it’s very difficult to stop.”
Martinez said she had tried to quit but couldn’t. She knew something had to change after visiting her infant grandson in March.
“It really bothered me” that she smelled like cigarettes, Martinez said, and she didn’t want her grandson exposed to the scent.
Martinez said that around May she came across an advertisement on Craigslist for a cessation program offered by Truth Initiative, a nonprofit that pushes for bans on tobacco products and also supports programs to help people quit. She joined its Ex Program online in June, and finally put down her last cigarette a month later.
Shireat Nelson, of West Columbia, South Carolina, also started smoking menthol cigarettes as a teenager. Now 59, Nelson tried her first cigarette when she was 14, as a middle-schooler in Connecticut.
“One night, some friends of mine said, ‘Do you want a cigarette?’” Nelson said. “And I thought, ‘If I take this cigarette, it’s going to be permanent.’ It was in my mind. Maybe it was just mental — but from that moment on, I continued to smoke.”
Nelson said she joined the American Lung Association’s in-person support groups in June after learning about the program through a friend, who currently has lung cancer. Nelson smoked about six cigarettes a day during the week and 10 a day on the weekend, she said.
After attending eight cessation sessions, Nelson said she picked up her last menthol cigarette on July 13 and hasn’t smoked since.
“I am so grateful,” she said about the cessation program. “It was the absolute best thing [that] ever happened to me.”
Quitting menthols
While research indicates it’s harder for people to quit menthol cigarettes, the bedrock approaches to quitting remain the same, according to Amanda Graham, Truth Initiative’s chief of innovations and an adjunct professor of medicine at the Mayo Clinic College of Medicine and Science.
The core components of treatment — drugs to help with nicotine cravings, social support and what’s called skills training — are similarly applicable to both menthol users and general tobacco users, Graham said.
“The important elements of engaging menthol tobacco users are sort of the context in which the intervention is delivered,” she said. This includes acknowledging that they’re using a menthol product or that they may be from a racial or ethnic minority in which menthol use is more prevalent — and making sure that the imagery reflects the population most likely using the product, she added.
One tool, nicotine replacement therapies, includes nicotine patches and gums, among others. These products contain lower amounts of nicotine than cigarettes and help smokers wean.
Jordt, of Yale, said one method with the clearest results is Chantix, an oral drug that mimics nicotine by binding to the same receptors in the brain but causes a weaker response. This, in turn, leads to weakened withdrawal symptoms, he said.
The American Lung Association said that for menthol smokers, it advises higher doses of nicotine replacement therapies, and puts a heavier emphasis on occasional menthol smokers.
“Menthol users tend to smoke less cigarettes and less frequently, yet, are breathing in deeper, holding in the breath longer,” Folkenroth said. “So, it’s a misconception among menthol users, in particular, that they are occasional smokers, when in fact, their tobacco dependency levels — their actual nicotine levels — are extremely high. That misconception many times will kind of deter some of the nicotine replacement therapy dosing.”
The association’s Freedom From Smoking programs focus on all tobacco products, but the organization also holds intensive training for facilitators to deliver courses “where we take a deeper dive into how the curriculum can be delivered specifically for menthol users,” Folkenroth said.
It may include a combination of nicotine replacement therapies, such as a 21 milligram nicotine patch paired with 2 milligram nicotine gums or lozenges. This method gives quitters “higher amounts of nicotine to then slowly taper down off that nicotine given that they have more severe levels of addiction itself,” she said.
Graham said that “nicotine addiction is wicked” and abruptly quitting can be the most uncomfortable way to quit. Withdrawal symptoms, she added, “can be pretty intense, especially during the early days, as your body is weaning off of withdrawal.”
Quitting in a more comfortable way increases the likelihood that people “will stick with it and be successful,” she added.
Social support
All experts emphasized the importance of support while quitting.
Both Martinez and Nelson agreed.
Martinez said she tried to quit smoking on her own last year after her grandson was born, but it only lasted two days because “it’s something that’s hard to do,” she said. Having access to The Ex Program’s online community of counselors, along with others trying to quit smoking, made Martinez feel like she had people “cheering me on,” she said.
Nelson said she also tried to quit smoking on her own with her husband, who also is a former smoker. The first time she tried to quit was about 20 years ago when both she and her husband went cold turkey. They both became hostile with each other and their efforts only lasted 48 hours.
“It was really bad,” Nelson said.
Over the years Nelson said she tried multiple medications, including Chantix and Wellbutrin — an antidepressant that’s also used to help people quit smoking — but none were successful. After going back to school in 2005 to become a health care worker, Nelson said she would wear nicotine patches at work but would take them off when she went home to continue smoking.
Nelson’s struggle with quitting affected her self-esteem and made her upset. At one point Nelson begged God to “please just take the desire from me,” she said.
While the journey hasn’t been easy, she said the support she receives from the program she joined has helped prevent her from falling back into her old habits. She regularly practices strategies of journaling and also attends a monthly dinner with others in her program. But it’s the encouragement from the group facilitators that continues to motivate her even when she wants to give up.
“One of the facilitators just kept saying, ‘You can do this. I know you can do this.’” Nelson said. “I’m literally crying, and I’m telling her, ‘I don’t think I can do it,’ and she just kept telling me I could.”
Ensuring access to cessation programs
As the Food and Drug Administration’s proposed ban is reviewed by the White House, leaders say they aren’t cheering just yet. Natasha Phelps, director of equity-centered policies at The Center for Black Health and Equity, said the ban is long overdue but “we’re so far from the finish line.”
The group, in addition to supporting policies calling for menthol bans, works with partners and government agencies to ensure their tobacco cessation funding allows grantees to focus on the systemic racism that drives tobacco-related health disparities, Phelps said. One of its current projects, which is funded by the Department of Health and Human Services’ Office of Minority Health, is looking at best practices for transportation policy, since many Black neighborhoods lack transportation to healthier retail outlets and medical care to access quitting programs, she added. The organization is also working with communities to help push for Medicaid expansion to consistently cover the cost of cessation medications.
Research shows that the effects of banning menthol cigarettes would be swift. Folkenroth of the American Lung Association said that within the first 13 to 17 months of the FDA’s proposed menthol rule taking place, an estimated 923,000 smokers would quit, including an estimated 230,000 Black people.
Folkenroth anticipates that the menthol ruling will take place before Christmas. Until then, the American Lung Association will continue to advocate for change, she said.
“One thing that we can all do is really help to remind the White House that there are sufficient resources out there,” Folkenroth said, “specifically for Black people to help quit menthol. No one’s going to be left behind. No one is going to be left without anything to help them and their addictions.”
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