What Will It Take to Achieve Equity in Policies Restricting Menthol and Other Flavored Nicotine and Commercial Tobacco Products?

Recent social movements and protests across the globe (eg, police brutality and state-sanctioned violence, labor/living wage, environmental injustice), coupled with the COVID-19 pandemic and the economic fallout, have exposed the harmful effects of structural racism, colonization, and other forms of oppression (ie, institutional privilege and power, principles of white supremacy) on population and public health. It has become critical to understand and intervene on the ways in which structural racism, colonization, and commercial determinants of health contribute to nicotine and commercial tobacco-related disparities and inequities.^1–4 Equity as it relates to racial and social justice means recognizing that due to long-standing injustices not all people or communities start at the same place. But it does not stop there. Equity is a process that requires redistributing power, resources, and opportunities to remedy injustices and create fair outcomes for all populations. Policies can play an important role in remedying injustice, protecting population health, and shaping equitable health outcomes.

Policies restricting the retail sale of menthol cigarettes and other flavored nicotine and commercial tobacco products (ie, e-cigarettes, cigarillos, hookah) are often touted as a potential health and racial equity and social justice intervention. This is due to unjust marketing practices by the commercial tobacco industry and disproportionate use of flavored nicotine and commercial tobacco among many socially disadvantaged population groups (eg, people who are Black and/or African American, American Indian and/or Alaska Native, women, youth, people who identify as LGBTQ+ [lesbian, gay, bisexual, transgender, queer or questioning]).^5–11

The call to ban flavors in tobacco has increasing momentum on the global level. The World Health Organization’s Framework Convention on Tobacco Control implementation guidelines for Articles 9 and 10 note that “From the perspective of public health, there is no justification for permitting the use of ingredients, such as flavoring agents, which help make tobacco products attractive.”¹² Around the world, many countries have banned various types of flavored tobacco including Brazil, Canada, Ethiopia, the European Union (28 Member States), Finland, Niger, Mauritania, Moldova, Senegal, Singapore, Turkey, and Uganda.¹³ For example, Canada’s experience in banning menthol and other flavored tobacco products provides a blueprint for other countries,¹⁴ for instance, by building momentum at the subnational level, focusing on youth use, and closing loopholes. However, even in these successful global efforts, relatively little attention has explicitly been paid to the equity implications of these policies with primary rationale for these policies being to protect young people and public health generally.¹³

In the United States, the Food and Drug Administration proposed rules to ban menthol in cigarettes and flavors in cigar products nationwide, specifically citing their potential to “reduce health disparities and promote health equity.”^15,16 In the absence of a federal ban, almost 400 U.S. localities restrict the sale of flavored nicotine and commercial tobacco products, with variation in comprehensiveness.¹⁷ Massachusetts and California have a statewide policy restricting all flavors, including menthol, in all or almost all nicotine and commercial tobacco products with relatively minor retailer exemptions (eg, exemptions in California policy for hookah, premium cigars, and pipe tobacco).¹⁷ These local and statewide policies currently cover roughly 35% of the U.S. population, and vary widely as to flavor types, nicotine and commercial tobacco products, and retailers covered. Thus, evaluations of such policies also vary. For example, a prior study¹⁸ of local U.S. regulations on the sale of flavored nicotine and commercial tobacco products showed that strong policies, which included restrictions on the sale of menthol cigarettes, were not equitably reaching women, youth, Black and/or African American, Hispanic and/or Latine, American Indian and/or Alaska Native populations (eg, the restrictions were less likely to cover areas with higher proportions of these socially disadvantaged population groups). Additionally, most U.S.-based evaluation studies focus on youth nicotine and commercial tobacco use, sales data, or retail compliance, but few cover cessation or combustible tobacco use among adults in relation to flavor bans.¹⁹ Even fewer studies examine equity impacts, or the extent to which flavor bans can reduce disparities in nicotine and commercial tobacco use for those from socially disadvantaged populations. When the voices, lived experiences, and perspectives of those most impacted by menthol cigarettes and other flavored nicotine and commercial tobacco products are excluded from many evaluation studies, the outcome is continued harm, structural racism in tobacco regulatory science, nonequitable distribution of resources, and interventions that are not sustained and do not support people who want to quit using nicotine and commercial tobacco products.

Prior commentaries^1,20,21 have called for a health equity view on flavor policies. This supplement takes one further step in starting to fill these equity gaps and shedding light on the racial and social justice implications of policies restricting flavored nicotine and commercial tobacco. The topics addressed in this issue include: (1) actual equity impacts of flavor restrictions on nicotine and commercial tobacco use; (2) hypothetical equity impacts; (3) retail impacts; and (4) community and stakeholder perceptions of flavor policies.

Actual Equity Impacts of Flavor Restrictions on Nicotine and Commercial Tobacco Use

After policies are enacted, analyses examining environmental and contextual factors such as tobacco retailer density are critical to determine which areas may need additional enforcement so as to ensure equitable outcomes. Dove and colleagues²² examined youth e-cigarette use before and after policy implementation of flavor restrictions in the Bay Area of California. They found that overall flavor restrictions had an effect of reducing youth e-cigarette use in communities with low tobacco retailer density, but not high tobacco retailer density. Additionally, youth living in communities with high tobacco retailer density were more likely to identify as Hispanic and/or Latine, Asian and/or Pacific Islander, or have parents with lower education levels, potentially leading to inequitable impacts of flavor restrictions in high tobacco retailer density areas. Kyriakos et al.²³ examined the impact of menthol cigarette bans in Canada and England on youth commercial tobacco use. They found that awareness of the policies among youth who had ever used menthol cigarettes was relatively limited, but among those who were aware, they reported smoking less or quitting due to the bans. After the policy, among those who used cigarettes in the past 30 days, odds of use of factory-made menthol cigarettes and use of menthol accessories were higher among Black individuals and those from other non-White racial and ethnic backgrounds than among White youth. These types of analyses of surveillance data show promise to understand to what extent and for whom are flavor policies working or not working. Increasing awareness of the policy, increasing enforcement on manufacturers of menthol cigarettes, as well as limiting the availability of menthol accessories could be valuable strategies to ensuring equitable impact and avoiding policy loopholes.

Hypothetical Equity Impacts of Flavor Restrictions on Nicotine and Commercial Tobacco Use

Freitas-Lemos et al.²⁴ compared the effect of restrictions on cigarette and e-cigarette flavors among people who smoke cigarettes with lower (<50 000) and higher (≥50 000) annual income. In a between-group, within-subject repeated-measures design, participants completed purchasing in the Experimental Tobacco Marketplace. Results suggest that cigarette flavor restrictions affect cigarette purchases depending on participants’ usual cigarette flavor; e-cigarette flavor restrictions do not impact cigarette or alternative tobacco purchases; cigarette and e-cigarette flavor restrictions do not differentially affect people who smoke cigarettes based on income categories and, therefore, would not advance equity among lower- and higher-income people who smoke cigarettes. Osborn and colleagues²⁵ conducted an online survey to determine if cigar flavor restrictions would have an equitable impact on young adult sexual gender minority (SGM) women who currently use cigarillos. They found that when faced with potential restrictions on flavored cigarillo products, SGM women were 6.0 times as likely to say that they would not continue use of cigarillos compared to cisgender heterosexual women. White et al.²⁶ conducted a survey and semistructured interviews with Black people who smoke menthol cigarettes to explore cessation motivations and barriers on quit intentions following a hypothetical flavor ban. This mixed-methods analysis indicated that Black people who smoke who endorsed “information on health hazards” as a major motivation to quit were more likely to reduce/quit smoking, and less likely to switch to electronic cigarettes or purchase banned products from illicit markets, following a flavor ban. Emerging themes from interviews suggest that testimonials from people who quit smoking are a key information source for Black people who smoke menthol cigarettes.

Retail Impacts of Policies Restricting Flavors in Nicotine and Commercial Tobacco

Kong and colleagues²⁷ conducted retail audits and geospatial analyses in Washington, DC, neighborhoods before a flavor restriction policy was passed. This analysis showed that explicit flavor descriptors of fruit, alcohol, and sweet/dessert flavors were more prevalent in neighborhoods with more Black residents. Additionally, “concept descriptors,” which indicated flavored products but did not have an explicit flavor name, were also more common in neighborhoods with more Black residents. If not included in flavor restriction policies and enforcement of those policies, these types of concept descriptors (eg, “wild rush,” “jazz”) have the potential to undermine the equity impacts of flavor policies since some neighborhoods would still have flavored products under alternate names. In Los Angeles County, California, Mei and colleagues²⁸ conducted telephone interview surveys to examine menthol cigarette-related knowledge, attitudes, and practices of licensed commercial tobacco retailers in neighborhoods with more Black residents, following a comprehensive flavor ban. This cross-sectional analysis found that most retailers reported knowing about the local menthol ban and believing that customers who buy menthol cigarettes would stop smoking altogether following the ban. Yet, half reported offering price promotions for menthol cigarettes, suggesting retail availability of menthol cigarettes after the ban. Study findings demonstrate the importance of and need to engage retailers in communities disproportionately impacted by menthol cigarettes.

Community and Stakeholder Perceptions of Policies Restricting Flavors in Nicotine and Commercial Tobacco

Understanding Black Americans’ perceptions of policies restricting the sale of menthol cigarettes is warranted. Black Americans bear a disproportionate burden of menthol cigarette use, and the tobacco industry has a long history of targeting Black communities with menthol cigarettes.^1,5,7,9,29 Smiley and Felner³⁰ analyzed interview data from Black adults who smoke menthol cigarettes daily, residing in Los Angeles County, California, communities with comprehensive policies (ie, policies that restrict sales of all flavors, including menthol, across all products at all retailers). They found that participants face challenges and concerns in local menthol bans, including uncertainty regarding the rationale for banning menthol cigarettes; distrust in government; differing views on whether the ban would likely help them quit smoking menthol cigarettes; and situations in which they would purchase cross-border, online, or the illicit market. The authors recommend researchers, funding agencies, and policy makers work toward restorative justice to undo harm in order to maximize the benefits of banning menthol cigarettes. Youth and young adults are often powerful advocates in their community for gaining public support for flavor policies; however, they may not see the equity implications of such policies if they do not view tobacco as a social justice issue. Schillo and colleagues³¹ used a mixed-methods approach to explore young people’s understanding of tobacco as a social justice issue, finding that while youth and young adults perceived that tobacco companies targeted youth and were largely supportive of menthol and flavored tobacco bans, few viewed tobacco as a social justice issue. Messaging about why tobacco is centrally implicated in disparities can help to bring broader awareness of the equity impacts of flavor policies. Alongside populations with lived experience of using flavored tobacco, various stakeholders such as public health officials, clinicians, and school personnel have valuable perspectives that can shed light on the implementation of flavor policies and the extent to which they are likely to achieve their intended effects. Tan et al.³² conducted key informant interviews in Massachusetts about stakeholders’ perceptions of potential and actual unintended consequences of the statewide flavor law. Participants expressed concerns about their own roles in implementation of the policy, concerns for loss of tax revenue and cross-border sales, potential for increased cannabis use as a substitute for flavored tobacco products, and the potential that the law would not be equitably enforced, with negative consequences in racialized communities.

Summary

This supplement is an important step forward in bringing together timely, scientific evidence on evaluating flavor policies restricting flavors in nicotine and commercial tobacco through a health and racial equity, and social justice lens. The current studies have filled several gaps in the existing literature. New evaluation studies in the United States and abroad responding to a changing policy landscape need to be designed with an equity perspective from the outset. Including health and racial equity considerations in the rationale for a new policy can also facilitate this approach. This entails questions of study design such as:

• (1) co-designing evaluations with communities affected by menthol and other flavored nicotine and commercial tobacco use (eg, How are community stakeholders shaping and refining research questions?);

• (2) setting up evaluation questions from an equity lens (eg, What factors might affect inequitable enforcement of flavor bans? After policy implementation, to what extent are flavored nicotine and commercial tobacco products available and sold in retail settings across communities that have been historically targeted by the commercial tobacco industry?);

• (3) ensuring data sources, including routine surveillance surveys, cover health and racial equity questions;

• (4) ensuring sample sizes reflect the diversity of the population and are sufficient to examine equity questions, including among subpopulations and accounting for intersectionality among socially disadvantaged population groups (eg, After policy implementation, how does access to and use of flavored nicotine and commercial tobacco products vary among socially disadvantaged population groups?);

• (5) examining structural factors (eg, policy enforcement practices, racially segregated neighborhoods, commercial tobacco industry interference, data collection, and management efforts that vary across communities) that impact policy evaluation (eg, What structural factors were significant in producing the outcomes of the evaluation? How does the study design critically incorporate structural inequities?);

• (6) prioritizing study designs and methods that foster meaningful community engagement in evaluation (eg, community-based participatory research, mixed methods, photovoice);

• (7) addressing whether communities affected by menthol and other flavored nicotine and commercial tobacco use feel engaged in dissemination and implementation of study findings. It is not so much whether we as researchers think we are engaging communities (eg, How are community stakeholders, who the research outcomes will impact, bringing their perspectives to dissemination and implementation strategies?); and

• (8) examining how the policy is impacting (intended and unintended consequences) community health through availability and access to programs such as smoking cessation and tobacco treatment.

Addressing these questions, in addition to building on the innovative and impactful studies in this supplement, will further set the field on course to achieve equity in policies restricting flavors in nicotine and commercial tobacco.

Supplement Sponsorship

This article appears as part of the supplement “Achieving Equity in Policies Restricting Flavors in Nicotine/Commercial Tobacco Products by Addressing Racial and Social Justice,” sponsored by the University of California, Office of the President, Tobacco-Related Disease Research Program.

Funding

This supplement was supported by the University of California Tobacco-Related Disease Research Program (TRDRP) under award number T31IP5502A. SLS’s effort on this project was supported in part by the TRDRP under award number T31IP5502A and by the National Institute on Drug Abuse of the National Institutes of Health (NIH) under award number DP1DA058978. SWR’s effort was supported in part by the National Cancer Institute of the NIH under award number R01CA251478. The content of this paper is solely the responsibility of the authors and does not necessarily reflect the official views of the TRDRP or the NIH.

Declaration of Interests

None declared.