Lessons to be Learned About Menthol from Lung Cancer Mortality Rates

 

For years we have seen a battle over the banning of menthol cigarettes.  On one side are prohibitionists, who believe that society’s ills can be cured by proscribing specific behaviors and products.  Opposing a ban are libertarians and those civil rights advocates who fear that prohibition would promote illegal sales and consumption, particularly in the African-American community. 

I have commented several times on who smokes menthols (here, here, here and here); this column was precipitated by a March 22 New York Times article by Sheila Kaplan, “Menthol Cigarettes Kill Many Black People.”

The best way to look at smoking-related deaths is to examine lung cancer mortality rates (LCMRs), expressed as deaths per 100,000 people per year.  The CDC Wonder website provides tools for investigating deaths for the period 1968-2022, including age-standardized rates, so that researchers can compare all of these years, which had different population distributions.

The chart shows LCMRs for Black and White men and women in the U.S.  Keep in mind that these mortality rates are latent with respect to smoking, stemming from smoking rates 20 years earlier.  For example, when LCMRs peaked for both Black and White men around 1990, that reflected high smoking rates from around 1970.

The most striking finding here is that while the LCMR for Black men was similar to that of White men in 1968, the rate for the former skyrocketed, peaking in 1989-90 at 367.  However, after that, the rate plummeted every year except one.  If menthol was the cause of smoking among Black men, then it didn’t persist.  By 2022, the LCMR among Black men was still higher than that among White men, but the gap was much narrower. 

It’s hard to specify menthol as a major factor, as the LCMR decline was just as impressive as the LCMR increase.  If, as prohibitionists claim, menthol is easier to start and harder to quit, we wouldn’t see this impressive reversal.

LCMRs were very similar among Black and White women until around 2000, after which rates among White women were somewhat higher.  

Also, note that LCMRs did not peak among women until over a decade after they peaked among men, and women experience much more of a plateau, from around 2000 to 2003.  And we still haven’t seen a sharp decline among women yet.

In 2012, FDA Center for Tobacco Products scientist Brian Rostron published a study finding “evidence of lower lung cancer mortality risk among menthol smokers compared with nonmenthol smokers at ages 50 and over in the U.S. population.” (here).  These results were in agreement with two previous studies (here and here).

FDA officials consistently portray a menthol ban as a corrective response to the tobacco industry’s presumptive targeting of African-Americans.  But, as I wrote previously, far more Whites smoke menthol.  As for who has been “disproportionately impacted,” Black men have the highest LCMRs of all four groups, but Black women have the lowest.

 

 

 

Timeless Knowledge from an Insightful Mathematician

 

I recently read on X (Twitter) a tribute to the book, “A Mathematician Reads the Newspaper,” by John Allen Paulos. 

The author is a professor of mathematics at Temple University, and his bio, here, is impressive.  The book, still in print and available on Kindle, was originally published in 1995.  More importantly, it remains relevant today, especially, as the reviewer put it, if you want to “become smarter and a better consumer of information who will not fall into [the] many traps of the media.”

I don’t recall having contact with Paulos, but his tome includes these two insightful paragraphs:

“More than 400,000 Americans die annually from the effects of smoking, but there is some intriguing evidence that the number could be drastically reduced by the widespread use of smokeless chewing tobacco.  Professors Brad Radu [sic] and Philip Cole recently published a note in Nature in which they claimed that the average life expectancy for a thirty-five-year-old smokeless tobacco user would be fifteen days shorter than that for a thirty-five-year-old smoker.  This is in contrast to 7.8 years lost by smokers.  The authors estimate that a wholesale switch to smokeless tobacco would result in a 98 percent reduction in tobacco-related deaths.

“Since a small amount of tobacco lasts all day, tobacco companies would likely oppose smokeless chewing tobacco.  There has already been strong opposition to it from some antismoking groups because of an increase in the risk of oral cancer (which is much rarer than lung cancer, emphysema, and heart disease).  I suspect that another reason is a certain misguided sense of moral purity – not unlike opposing the use of condoms because, unlike abstinence, they’re not 100 percent effective.  If the numbers presented here are confirmed, however, recommending a switch to smokeless tobacco for those smokers (and only those) who can’t quit would seem like sound public policy.”

Paulos has a knack for interpreting numbers, and he understands the “misguided sense of moral purity” that has dominated tobacco policy – and killed millions of smokers – for nearly 30 years.

 

 

*Nota bene: Phil Cole and I never claimed that a “wholesale switch” to smokeless would result in a 98 percent reduction in smoking-related deaths, as that would not have accounted for residual deaths from former smoking among those switchers.  Rather, we based the 98 percent reduction on the following premise: “If, instead of smoking, smokers had used smokeless tobacco.”  It is a subtle but crucial distinction, but it does not detract from the huge risk reduction available to individual smokers who switch.

 

Video on the Bad Science That Keeps Smokers Smoking, and Dying

 

I recently participated in a panel discussion about tobacco harm reduction (THR) at the Tobacco Merchants Association meeting.  While assembling my powerpoint presentation, I recalled that I presented to this group 18 years ago, in 2006, what was likely their first introduction to THR. 

To view my 10-minute primer on bad science – then and now – watch this video, starting at the 26-minute mark.  I discuss the genesis of the myth that smokeless dip and chew products present a high risk for mouth cancer (discussed extensively in this blog by searching for “Winn”), and my THR team’s attempts to correct fatally flawed vaping research articles.    

I’m happy to provide the slides upon request.