Discussing the FDA’s Proposed Ban on Menthol Cigarettes with Kirsten Skelly

In April 2022, the U.S. Food and Drug Administration (FDA) proposed new national program standards that would ban the production and sale of menthol cigarettes. In this interview, Kirsten Skelly, Program Manager for the Rhode Island Department of Health Tobacco Control Program, provides an overview of this proposed ban, its significance, and the potential implications it would have in Rhode Island.

Could you start by telling us a bit about the Rhode Island Department of Health (RIDOH) Tobacco Control Program and your role within the program?

Thank you so much to the RIPRC for inviting me to participate in this interview. I would first like to clarify that when we reference ‘tobacco’ in our discussion here today, we are referring to commercial tobacco and not the sacred and traditional use of tobacco by some American Indian communities.

As Program Manager, I oversee the Rhode Island Department of Health Tobacco Control Program (TCP) in effectively addressing the public health needs of Rhode Islanders while meeting the goals of our funding through the CDC, Office on Smoking and Health, and the State. I oversee budget development, monitor our program’s performance, and make decisions with the team and partners on how we carry out strategic plans. Our program has six full-time staff members: myself, a Nicotine, Substance Use, and Addiction Treatment Coordinator, a Policy and Partnerships Specialist, a Youth and Young Adults Coordinator, an Evaluator, and a Communications Coordinator. The mission of the program is to protect and promote health and prevent chronic disease and death among all Rhode Islanders using a comprehensive approach to reduce tobacco and nicotine initiation, use, and exposure to second and third-hand smoke.

The current goals of our program are to: 1) Prevent initiation of tobacco and nicotine use among youth and young adults; 2) Promote quitting among adults and youth; 3) Eliminate exposure to secondhand smoke; and 4) Advance health equity by identifying and eliminating commercial tobacco product-related inequities and disparities. We look to achieve these goals by working within communities and with community partners to help educate providers, retailers, decision-makers, and the general public, especially youth, on the harmful effects that tobacco and nicotine can have on health. Our program activities focus on prevention of starting to use tobacco and nicotine and helping those that are looking to quit. For those trying to quit or help someone quit, we have educational materials and easily accessible resources available, like the state-sponsored Rhode Island Nicotine Helpline (1-800-QUIT-NOW) or www.QuitNowRI.com. There are also resources specific to youth through the My Life My Quit program at ri.mylifemyquit.org/.

In late April 2022, the U.S. Food and Drug Administration (FDA) proposed new national program standards that would ban the production and sale of menthol cigarettes. Could you provide some background regarding this proposed ban on menthol cigarettes and how this came about?

On June 22, 2009, the Family Smoking Prevention and Tobacco Control Act was signed into law, giving the FDA authority to regulate the manufacture, distribution, and marketing of tobacco products. A ban on cigarettes with characterizing flavors, except menthol and tobacco, was initiated by the FDA. In March 2010, the FDA’s Tobacco Product Scientific Advisory Committee (TPSAC) reviewed available evidence on menthol cigarettes and later published its recommendations on menthol, concluding “removal of menthol cigarettes from the marketplace would benefit public health in the United States.”

Since 2013, leading national public health advocates, including the African American Tobacco Control Leadership Council and the Center for Black Health & Equity, engaged in advocacy and legal proceedings urging the FDA to exercise its regulatory authority to protect public health by prohibiting menthol as a characterizing flavor in cigarettes. On April 28, 2022, the FDA filed a Notice of Proposed Rulemaking (NPRM) with two proposed product standards to: 1) Prohibit menthol as a characterizing flavor in cigarettes; and 2) Prohibit all characterizing flavors (other than tobacco) in cigars.

What are some of the goals of the proposed ban and why is it significant? Which communities are most impacted by menthol cigarettes and why is this the case?

Smoking any kind of cigarette, including menthol, is harmful and increases risk for serious illness and death. Menthol conceals the harsh taste of tobacco and makes inhaling smoke easier. Menthol interacts with nicotine in the brain to enhance nicotine’s addictive effects and makes it more difficult for people to quit smoking. Menthol cigarettes also contribute to tobacco-related health disparities. For example, smoking-related illnesses are the number one cause of death in the African American community, surpassing all other causes. According to the Center for Black Health & Equity, the tobacco industry historically maintains a menthol-centered strategy to establish a strong presence in Black and African American communities, counterproductive to public health efforts. The majority (85%) of African Americans who smoke use menthol cigarettes as compared to 30% of Caucasian counterparts. The CDC likewise finds that the tobacco industry’s aggressive marketing of menthol products contributes to higher percentages of menthol cigarette smoking as well as a disproportionate burden of related harms amongst the African American community.

Restricting menthol products could help to prevent initiation and progression to regular smoking and tobacco use among youth, as 81% of youth who ever tried tobacco started with a flavored product, and youth who initiate smoking with menthol cigarettes are more likely to become everyday smokers later in life. According to the CDC, youth are more likely to try a menthol cigarette as their first cigarette, rather than non-menthol.

Research shows that use of menthol cigarettes has perpetuated disparities among other groups. For example, according to the CDC, the tobacco industry markets menthol cigarette use among the LGBTQ+ community. Approximately 36% of smokers who identify as LGBTQ+ report smoking menthol cigarettes compared to 29% of straight people who smoke. The Campaign for Tobacco-Free Kids cites that 47% of smokers experiencing poverty use menthol cigarettes, compared to 36% of smokers with an income more than twice the federal poverty threshold. Literature suggests that those with behavioral health conditions, namely severe psychological distress, use menthol at a higher rate than those without mental health conditions.

Could you speak to some of the ways that the proposed ban on menthol cigarettes could have impacts in terms of health equity and social justice?

RIDOH recognizes that social, environmental, and economic structures shape usage outcomes. The evidence provided could demonstrate potential benefits from this proposed rule such as addressing health inequities, reducing disease and death from combusted commercial tobacco use, reducing youth initiation and addiction, and increasing the number of smokers who reach their quit goals. A report from the Tobacco Products Scientific Advisory Committee shows that if menthol cigarette sales were prohibited, 39% of all people who smoke menthol cigarettes and 47% of Black and African Americans who smoke menthol cigarettes would quit.

Benefits could also come from the proposed rule on restricting characterizing flavors in cigars. According to the CDC, the tobacco industry’s increased marketing of cigars to targeted groups has increased prevalence of use among youth. Cigars often have flavorings and are sold as a single stick, making them appealing to youth and easier to use.

Nationally, where are we now with this effort and what can we expect to see happen within the coming months/years?

After the Notice on April 28, the FDA conducted public listening sessions and gathered public commentary through August 2. Once all the comments have been reviewed and considered, the FDA will decide whether to issue final product standards.

How is the RIDOH Tobacco Control Program currently engaging in this effort?

We recognize this effort takes a community-based, comprehensive approach. During 2021, to continue education and build statewide capacity regarding preventing tobacco and nicotine related health disparities with a youth and equity focus, TCP collaboratively funded and hosted training workshops with Tobacco Free Rhode Island and Health Resources in Action regarding equity in tobacco and vaping work. More than 80 invited participants engaged virtually from across the state including representatives from RIDOH, the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), Health Equity Zone (HEZ) agencies, Regional Prevention Coalitions, youth and young adults, behavioral health agencies, policy advocates, local municipalities, and non-profit agencies. Participants committed to continued collaborative partnerships for addressing tobacco, nicotine, and vaping public health outcomes with an equity approach. Ongoing development of our programs continues, with a focus on racial equity, increasing engagement with authentic partnerships, and tobacco and nicotine flavors as priority topics.

The Rhode Island Department of Health (RIDOH) public comment on the FDA Tobacco Product Standard for Menthol in Cigarettes can be found here and the RIDOH public comment on the FDA Tobacco Product Standard for Characterizing Flavors in Cigars can be found here.

If this ban were to be enacted nationally, what would implementation/enforcement of the ban look like for the state? How does RIDOH plan to support those with SUDs in dealing with this potential change?

RIDOH TCP would continue to provide education, support, and information as well as monitor data trends. While the enforcement is not a role of the Tobacco Control Program, the FDA made it clear in its notice of rulemaking that it cannot and will not enforce against individual consumers for possession, use, or purchase of menthol cigarettes or flavored cigars. FDA enforcement would only address manufacturers, distributors, wholesalers, importers, and retailers that are not in compliance.

TCP continues to promote treatment to help Rhode Islanders who have formed a dependence on nicotine quit. It is never too late to get benefits from quitting smoking or vaping. The majority of smokers want to quit, however quitting smoking is extremely difficult. Of the 13.5% of Rhode Island current cigarette smokers, nearly 59% want to quit. Rhode Island Nicotine Helpline data indicate that 45% of Helpline participants that smoke use menthol cigarettes. Compared to adults who smoke non-menthol cigarettes, adults who smoke menthol cigarettes make more attempts to quit smoking and have a harder time quitting.

There are free resources available to Rhode Islanders who are interested in learning more about quitting. Whether you are thinking about quitting, are not yet ready to quit, or have already quit, the Rhode Island Nicotine Helpline can help you each step of the way. The Helpline is free for all Rhode Islanders regardless of insurance status or income. Help is available from trained tobacco treatment specialists in multiple languages by web or phone, any time day or night. The Helpline offers specialty programs that support populations disproportionally harmed by tobacco, including those who smoke menthol. At the time of this Provider Profile, the menthol program includes additional Nicotine Replace Therapy support and rewards for completing coaching sessions. As a program, we look to provide easier access to resources and education on evidence-based quit support and treatment, particularly with populations that show a disparity of use or lack of access.

What are some of the ways that people can stay informed and/or get involved in this effort?

One of the best ways to stay informed and get involved is through Tobacco Free Rhode Island (TFRI). TFRI is a statewide network of organizations and individuals united to reduce tobacco and nicotine use—the leading cause of preventable disease and death in Rhode Island. Information on how to get involved can be found at tobaccofree-ri.org/.

Are there any other messages regarding this effort that you would like to share with substance use prevention providers throughout the state?

With the purpose of reducing the use of tobacco and nicotine, we continue to partner in promoting cessation or quit support programming. There are many excellent resources available, including:

The CDC continues to provide guidance on best practices to help someone achieve a quit and as a program, we continue to look to find collaborative ways to best reach priority populations with messaging and resources. My email is kirsten.skelly@health.ri.gov and more information can be found on our website for those who would like to connect. Thank you again to the Rhode Island Prevention Resource Center.

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