Mentholated Cigarettes, African Americans, the FDA and the Fight Back

1. Mentholated Cigarettes, African Americans, the FDA and the Fight Back Phillip S. Gardiner, Dr.PH. Social and Behavioral Sciences and Nicotine Dependence Research Administrator, Tobacco Related Disease Research Program (TRDRP) University of California Office of the President The ABC�s of the FDA and the Black Community African American Tobacco Control Leadership Council Webinar May 26, 2011 Watts Health Corporation Los Angeles, California

2. Cancer Incidence Rates* by Race and Ethnicity, 1999-2003 Overall, cancer incidence rates are higher in men than women. Among men, African Americans have the highest incidence followed by white, Hispanic, Asian American/Pacific Islander, and American Indian/Alaskan Natives. Racial differences in cancer incidence among women are less pronounced; white women have the highest incidence rates followed by African American, Hispanic, American Indian/Alaskan Native, and Asian American/Pacific Islander women. Note: Rates for populations other than white and African American may be affected by problems in ascertaining race/ethnicity information from medical records. This is likely to result in reported incidence rates that are lower than true incidence rates. In addition, the SEER cancer registries providing incidence data for American Indian/Alaska natives may not be representative of these populations in other parts of the country. For example, American Indians/Alaskan Natives in the Southwestern areas covered by SEER have much lower rates of smoking and lung cancer than American Indians/Alaskan Natives in the Northern plains states. Overall, cancer incidence rates are higher in men than women. Among men, African Americans have the highest incidence followed by white, Hispanic, Asian American/Pacific Islander, and American Indian/Alaskan Natives. Racial differences in cancer incidence among women are less pronounced; white women have the highest incidence rates followed by African American, Hispanic, American Indian/Alaskan Native, and Asian American/Pacific Islander women. Note: Rates for populations other than white and African American may be affected by problems in ascertaining race/ethnicity information from medical records. This is likely to result in reported incidence rates that are lower than true incidence rates. In addition, the SEER cancer registries providing incidence data for American Indian/Alaska natives may not be representative of these populations in other parts of the country. For example, American Indians/Alaskan Natives in the Southwestern areas covered by SEER have much lower rates of smoking and lung cancer than American Indians/Alaskan Natives in the Northern plains states.

3. Cancer Death Rates*, by Race and Ethnicity, 1999-2003 Overall, cancer death rates are higher in men than women in every racial and ethnic group. African American men and women have the highest rates of cancer mortality. Asian American and Pacific Islander men and women have the lowest cancer death rates, about half the rate of African American men and women, respectively. Note: Rates for populations other than white and African American may be affected by problems in ascertaining race/ethnicity information from medical records. This is likely to result in reported death rates that are lower than true death rates. Overall, cancer death rates are higher in men than women in every racial and ethnic group. African American men and women have the highest rates of cancer mortality. Asian American and Pacific Islander men and women have the lowest cancer death rates, about half the rate of African American men and women, respectively. Note: Rates for populations other than white and African American may be affected by problems in ascertaining race/ethnicity information from medical records. This is likely to result in reported death rates that are lower than true death rates.

4. Age Adjusted Death Ratesper 100,000 (Males, 1992-1994) (RSG, 1998) AA AIAN AAPI W Hispanic Oral Cancer 7.7 2.6 3.3 3.0 2.4 Esophagus 11.4 3.2 2.7 4.4 2.8 Lung Cancer 81.6 33.5 27.9 54.9 23.1 CHD 138.3 100.4 71.7 132.5 82.7 CVD 53.1 23.9 29.3 26.3 22.7

5. Age Adjusted Incidence Rates (All sites and Lung) per 100,000 (Females and Males, ACS 2007) AA AIAN AAPI Whites Hispanic All Sites M 639.8 359.9 385.5 555.0 444.1 F 383.8 305.0 303.3 421.1 327.2 Lung Cancer M 110.6 55.5 56.6 88.8 52.7 F 50.3 33.8 28.7 56.2 26.7

6. Age Adjusted Mortality Rates (All sites and Lung) per 100,000 (Females and Males, ACS 2007) AA AIAN AAPI Whites Hispanic All Sites M 331.0 153.4 144.9 239.2 166.4 F 192.4 111.6 98.8 163.4 108.8 Lung Cancer M 98.4 42.9 38.8 73.8 37.2 F 39.8 27.0 18.8 42.0 14.7

7. Age-Adjusted Lung Cancer Deaths Rates African and White American Males. (Morbidity and Mortality Weakly Reports (MMWR) 42: 863-866. 2003)

8. African American Menthol Use Skyrockets 1953 5% 1968 14% 1976 44% 1990 >80% Roper, B.W. (1953). A Study of People�s Cigarette Smoking Habits and Attitudes Volume I. Philip Morris, Bates No. 2022239249. MSA, Inc. (1978) The Growth of Menthols, 1933 -1977. Brown & Williamson, Bates No. 670586709-785. RSG, 1998.

9. From Whence Blacks and Menthol Today, over 70% of African American smokers prefer menthol cigarettes, compared with 30% of White smokers. This unique social phenomenon was principally occasioned by the tobacco industry�s masterful manipulation of the burgeoning Black, urban, segregated, consumer market in the 1960s. (Gardiner, 2004)

10. Tobacco Industry�s Assault on the African American Community (1960s &70s) 91% of Advertising Budget for TV (B&W) Use of Male Actors with more Black features Tripled Cigarette Advertising in Ebony �Menthols got a brand new bag� Cool Jazz; Cool Lexicon Philanthropy (Gardiner, 2004)

14. KOOL Cigarette Packs PRODUCT INFORMATION: Limited time availability Unique packaging, developed by artist familiar with Hip Hop culture Consumers are encouraged to collect the four different packs which, when put together, make a hip hop �mural� Images include familiar hip-hop images: a rapper, 2 DJs, dancers, concert/partygoers.Point of Sale Poster Package messaging: each of the four different packs contains information The special cigarette package markets the event which by design appeals to youth. The new colorful KOOL cigarette packs feature images of hip-hop DJ�s, performers and dancers designed to attract the attention of young black and other hip hop and rap fans. Kool has also announced that it will market and distribute other �point of sale� hip-hop products and material. Previous studies have shown that 75 percent of adolescents shop at convenience stores at least once a week, and they are more likely than adults to be influenced by convenience store promotions.PRODUCT INFORMATION: Limited time availability Unique packaging, developed by artist familiar with Hip Hop culture Consumers are encouraged to collect the four different packs which, when put together, make a hip hop �mural� Images include familiar hip-hop images: a rapper, 2 DJs, dancers, concert/partygoers.Point of Sale Poster Package messaging: each of the four different packs contains information The special cigarette package markets the event which by design appeals to youth. The new colorful KOOL cigarette packs feature images of hip-hop DJ�s, performers and dancers designed to attract the attention of young black and other hip hop and rap fans. Kool has also announced that it will market and distribute other �point of sale� hip-hop products and material. Previous studies have shown that 75 percent of adolescents shop at convenience stores at least once a week, and they are more likely than adults to be influenced by convenience store promotions.

15. Percent Menthol Cigarette Use among Past Month Cigarette Smokers Aged =18 Years, by Race/Ethnicity: 2004-2008 (NSDUH, 2004-2008) 

16. The Ultimate Candy Flavoring; Menthol Helps The Poison Go Down Easier Chief Constituent of Peppermint Oil; Minty-Candy Taste, Cooling Sensation; activates taste buds; increases throat grab Anesthetic effects; Mimics Bronchial Dilatation ; Masks the Harshness of Smoking Independent Sensory Activation Neurotransmitters Increases Salivary Flow; Transbuccal Drug absorption Greater Cell Permeability (Ferris, 2004; Benowitz, 2004)

17. FDA Oversight of Tobacco Products June 22nd 2009, President Obama signed into law H.R. 1256: Family Smoking Prevention and Tobacco Control Act Broad Authority to Regulate Tobacco Products and their promotion Allows FDA to require changes to tobacco products to protect the public health �

18. Menthol A Sacrificial Lamb

19. Menthol: A Missed Opportunity cigarette or any of its component parts (including the tobacco , filter, or paper) shall not contain, as a constituent (including a smoke constituent) or additive, an artificial or natural flavor (other than tobacco or menthol) or an herb or spice, including strawberry, grape, orange, clove, cinnamon, pineapple, vanilla, coconut, licorice, cocoa, chocolate, cherry, or coffee, that is a characterizing flavor of the tobacco product or tobacco smoke. (HR 1256, Sec. 907, (a) (1)

20. The Push Back Cigarette Bill Treats Menthol with Leniency�. Stephanie Saul�s NY Times Article (May 13, 2008) National African American Tobacco Prevention Network and other on the ground activists spearheaded agitation work Joseph Califano, Louis Sullivan and seven former U.S. Secretaries of Health authored a stinging open letter to House and the Senate members.

21. The Push Back �To make the pending tobacco legislation truly effective, menthol cigarettes should be treated the same as other flavored cigarettes. Menthol should be banned so that it no longer serves as a product the tobacco companies can use to lure African American children. �We do everything we can to protect our children in America, especially our white children. It�s time to do the same for all children.�(Califano, et al., 2008)

22. The Push Back Congressional Black Caucus (CBC). By late June, Donna Christensen (D V.I.) took the lead in writing the menthol amendment. Harvard researchers, publishing in the American Journal of Public Health, (Kreslake, et al., 2008) documented that the tobacco industry has been manipulating the dose of menthol in cigarettes to ensure the uptake and continued use, especially by the young people and other vulnerable populations for many years.

23. The Result: Amended FDA Bill `(e) Menthol Cigarettes- `(1) REFERRAL; CONSIDERATIONS- Immediately upon the establishment of the Tobacco Products Scientific Advisory Committee under section 917(a), the Secretary shall refer to the Committee for report and recommendation, under section 917(c)(4), the issue of the impact of the use of menthol in cigarettes on the public health, including such use among African Americans, Hispanics, and other racial and ethnic minorities. (HR 1256, Sec. 907 (e) (1)

24. Tobacco Products Scientific Advisory Committee TPSAC established August 2009 12 members; 3 tobacco industry (non-voting) Public Hearings: March, July, September, October and November 2010 Report delivered to the FDA in March of 2011 http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/default.htm

25. TPSAC Report: Some Key Findings "Removal of menthol cigarettes from the marketplace would benefit public health in the United States.� Increases Initiation Retards Cessation among African Americans �menthol cigarettes are marketed disproportionately to younger smokers� and �disproportionately marketed per capita to African Americans.�

26. Toward a Broader the Definition of Harm Harm is not mainly a chemical, toxicological or an epidemiological question Narrow definition aids the tobacco industry Ultimately, harm can only be determined by making a multifaceted assessment and calculation of the impact of menthol cigarettes at the population level, on the public�s health. At bottom, it�s a Social Justice Issue.

27. Reasons to Ban Menthol Menthol cigarettes are starter products for Youth Middle School smokers more likely to use menthol cigarettes Those smoking less than a year more likely to be a menthol smoker; and youth use more flavored cigarettes (Hersey, 2004; SAMSHA, 2009; Klein, 2007) Menthol cigarettes have greater addiction potential given their Unique Sensory Stimulation Properties �Throat grab� associated with menthol similar to that of nicotine Reduces harshness; stimulates cold receptors and taste buds; mild analgesic effect; sensation of deeper inhalation; candy-minty taste ; classic re-enforcer (Ferris et al, 2004) The Ultimate Candy Flavoring: It helps the poison go down easier

28. 28 Are Mentholated Cigarettes a Starter Product for Youth? �2002 NYTS[Percentages for youth smoking a usual brand of cigarettes.] Hersey, 2006 �Less Experienced� smokers in middle school are more likely to smoke menthol (p = 0.002) The same pattern exists for smokers in high school (but n.s.)

29. Mentholated Cigarettes Use is Highest among Minority Groups�2002 NYTS [Percentages for youth smoking a usual brand of cigarettes.]Hersey, 2006

30. Reasons to Ban Menthol Bogus Health Messages; Mass Disinformation Campaign(s) Healthier alternative; soothes sore throats Refreshing; Alive with Pleasure African American smokers think menthols are healthier and safer than regular cigarettes (Tibor Koeves Assocites, 1968; Hymowitz, 1995; Richter, 2008; Unger, 2010)

31. Reasons to Ban Menthol Cessation Inhibitor; Relapse Promoter Menthol Cigarettes are Harder to Quit and easier to take back up (Harris et al, 2004; Pletcher et al, 2006; Okuyemi 2003, 2004, 2007; Gandhi et al, 2009) Not all studies (Fu et al., 2008; Hyland et al., 2002; Murray, 2007)

32. Menthol Harder to Quit! Quit Attempts % Difference Non-Menthol 38.1% Menthol 41.4% +8.8% Cessation (>3 mo.) % Difference Non-Menthol 21.2% Menthol 18.3% -13.8% (Levy, et al., 2011)

33. Reasons to Ban Menthol: It�s a Social Justice Issue! Predatory and Relentless Marketing Toward the Most Vulnerable Populations African Americans Native Hawaiians Filipinos Women Youth (Appleyard et al, 2001; Gardiner et al, 2004; Sutton and Robinson, 2004; Yerger, 2007; Healton, 2009)

34. Predatory Marketing: Prices of Cigarettes vary by Neighborhood Comparing quartile 1 (lowest) and quartile 4 (highest) proportion of A-A population in neighborhood of store Price of pack of Marlboros decreased by $0.39 Price of pack of Newport decreased by $0.51 (Clark, unpublished 2002)

37. Storefront Cigarette Advertising Differs by Racial/Ethnic Community Brookline Dorchester p-value n= 42 56 % % Retailer w/ Ads 42.9 85.7 <0.001 Small Ads 56.8 20.1 � Large Ads 2.0 23.7 � Menthol Ads 17.9 53.9 � Average Price $4.94 $4.55 � (Seidenberg, et al., 2010)

38. Menthol Cigarettes: Cheaper for African Americans For each 10% increase in the proportion of African American students: the proportion of menthol advertising increased by 5.9%, Newport promotion were 42% higher and the cost of Newport was 12 cents lower. (Association of Outlet Density with Smoking and Pack Price [17RT-0152] Lisa Henriksen, Stanford, 2010)

39. Banning Menthol will create a Black Market. Where is the Evidence? Not one scientific study No justification from exclusion in the first place Tobacco industry

40. Brazen to say the least http://mentholchoice.com/index.html

41. If Menthol Were Banned 100,000s of Lives would be saved 2010 � 2050 All Menthol Smokers Black Menthol Smokers 10% 323,107 91,744 20% 478,154 164,465 30% 633,252 237,317 (Levy, et al., 2011)

42. Blacks Support Banning Menthol Survey of 1514 never, former and current smokers % support banning menthol White 53.4 Black 68.0 Other 72.4 (Winickoff, et al., 2011)

43. Blacks Support Banning Menthol Survey of 303 never, former and current Black smokers % support banning menthol Never Smoker 83.4% Former Smoker 71.4% Current Smoker 52.8% (Winickoff, et al., 2011)

44. FDA Leaning in the right Direction? 13 candy flavoring already banned: strawberry, grape, orange, clove, cinnamon, pineapple, vanilla, coconut, licorice, cocoa, chocolate, cherry, or coffee �Almost 90 percent of adult smokers start smoking as teenagers. These flavored cigarettes are a gateway for many children and young adults to become regular smokers. The FDA will utilize regulatory authority to reduce the burden of illness and death caused by tobacco products to enhance our Nation's public health (Hamburg, 2009)

45. Apply the Same Logic to Menthol No special commissions and advisory committees No comparing lung cancer rates between vanilla cigarette users and regular cigarette users. No calls for 5, 10, or 20 more years more of research on these products Outlawed because they were starter products

46. Social Justice Issue The disproportionate marketing and targeting candy-flavored poison to African Americans and other specially oppressed sectors of our society, is out-right discriminatory and genocidal. Poorest; least informed; fewest resources; indeed the definition of preying on the most vulnerable sections of our society.

47. The Verdict Against Menthol Cigarettes: Ban It! Menthol should be banned from all tobacco products Both characterizing & subliminal Get all Candy Flavoring Out of Cigarettes Ban all menthol substitutes, as well At Bottom: It Helps The Poison Go Down Easier

48. What�s at Stake?

50. TRDRP Research for a Healthier California www.trdrp.org phillip.gardiner@ucop.edu Grant funding Scientific Conferences Dissemination of Research Findings