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.

 

 

 

Menthol Cigarettes & Race – FDA Fudges the Facts

 

After announcing its intention to ban menthol cigarettes two years ago, the FDA has finally submitted its final rule to the Office of Management and Budget for Executive review.  Meanwhile, the Washington Post is reporting that the ban will be delayed until sometime in 2024 due to “political concerns” around Black smokers’ preference for and access to this flavor. 

In 2018, I answered the question, “Who smokes menthol cigarettes?”, using the 2015 National Health Interview Survey (NHIS).  Although federal officials claim that menthol cigarettes pose an existential threat, they only collect information on the topic every few years in the NHIS, their main instrument for tracking smoking.  The numbers were updated in the 2022 survey.

In 2015, the NHIS reported there were 36.5 million U.S. smokers.  By 2022, that number was down to 28.8 million, an impressive decline of 21%.  Table 1 reflects menthol cigarette popularity.

 

Table 1. Number (millions) of Smokers in the U.S., According to Whether They Usually Smoke Menthol or Not, NHIS 2015 and 2022
Usually Smoke Menthol	2015	2022	Percent Change
Yes	10.7	9.9	-7.5
No	25.8	18.9	-26.7
All	36.5	28.8	-21.1

 

There is no question that the decline in usual menthol smokers lagged behind that in non-menthol smokers.  The numbers don’t tell us how many started and stopped (or died trying), but they do indicate that the menthol cigarette market was not as fragile as that for non-menthol cigarettes.

When we look at the same data according to race in the next table, we see that the number of White women menthol smokers fell the most, followed by White men and Black women.  Unfortunately, the number for Black men stayed the same, and the number for other races increased from 0.8 to 1.2 million.

 

Table 2. Number (millions) of Menthol Smokers in the U.S., NHIS 2015 and 2022
Race/Gender	2015	2022	Percent Change
White women	3.8	3.2	-15.8
White men	2.7	2.5	-7.4
Black men	1.8	1.8	0
Black women	1.6	1.5	-6.3
Others	0.8	1.2	+50
All	10.7	9.9	-7.5

 

From this table we see that White women and men account for over half of menthol smokers (32% and 25% respectively), while Black men and women together account for only about a third (18% and 15% respectively).

Let’s see how lung cancer mortality rates (LCMR) and deaths from CDC data compare for the periods 2012-2016 and 2018-2021.  The rate is the number of deaths per 100,000 population per year (among persons 45+ years), so it’s the best way to compare different-sized groups.  The number of deaths per year is related to both the rate and the size of the group.

Table 3. Age-adjusted LCMR (per 100,000 persons per year) and number of deaths from lung cancer, 2012-2016 and 2018-2021
	2012-2016		2018-2021
Race/Gender	LCMR	Deaths	LCMR	Deaths	LCMR Percent Change
Black men	184	9,916	139	8,687	-24
White men	151	74,228	118	64,983	-22
White women	102	61,247	84	55,693	-18
Black women	93	7,032	74	6,486	-20
Others	*	4,487	*	5,182
All		156,910		141,031

 

While Black men had the highest LCMR in both periods, this group saw the steepest decline.  Keep in mind that Black men don’t have the highest LCMRs because they smoke menthol; it is because they smoke more than White men and women, while the latter groups smoke more than Black women.  In other words, smoking KILLS, but menthol doesn't.

FDA officials consistently portray a menthol ban as a corrective response to the tobacco industry’s targeting of African-Americans, yet 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, at almost half the rate of the former.  Comparing the two survey periods, LCMRs dropped around 20% for all four groups. Still, over 140,000 Americans die from lung cancer every year. 

 

 

 

A Tribute to the Epidemiologist Who Predicted and Documented Cancer’s 30-Year Decline

 

The U.S. National Cancer Institute recently launched a public relations campaign to increase its funding in fiscal year 2025, from $10 billion to $11.5 billion.  Arguing for the increase, NCI director Dr. Monica M. Bertagnolli notes that there are “two million new cases of cancer diagnosed each year” in the U.S., even as she acknowledges that “there are more than 18 million cancer survivors” living today.  As shown in the chart at left, cancer kills far fewer Americans now than it did in 1990, the peak year for U.S. cancer mortality.  In fact, the decline has been virtually continuous for over 30 years. 

This extraordinary trend was first brought to light by University of Alabama at Birmingham epidemiologist and professor Dr. Philip Cole.  In his 1996 article in the American Cancer Society’s flagship journal, Cancer, Dr. Cole attributed the decline in cancer deaths primarily to reductions in smoking that had begun in 1965, and to improvements in diagnosis and treatment.  He predicted that “the decline…is likely to continue for at least 20 years and may accelerate.” (my emphasis)

Dr. Cole and I published a follow-up study in the Journal of Clinical Oncology in 2001, demonstrating that if lung cancer had never existed, the death rate in the U.S. from all other forms of cancer would have declined continuously, starting in 1950. 

Dr. Cole was a world-renowned epidemiologist whose insightful analysis three decades ago has proven prescient.  He passed away on September 6.

I met Dr. Cole in 1993 when I asked the director of the UAB Comprehensive Cancer Center to comment on my draft medical article laying out the scientific foundation for smokeless tobacco as a substitute for cigarettes (a public health strategy unheard-of then, now called tobacco harm reduction). He told me to contact Dr. Cole, the chairman of epidemiology at UAB who was revered in the cancer epidemiology field as an exceptional data-driven scientist.  I’m sure the director suspected that Dr. Cole would quickly eviscerate my thesis.  When I delivered the draft to Dr. Cole, I included a red pen and told him to feel free to “bleed” all over the text.  

Three weeks later, having dissected my piece every which way, he called to say that he had rarely had another faculty member bring him a completely novel idea in epidemiology.  He offered to help me, and that support – which required me to produce more than 20 additional drafts – not only contributed immeasurably to getting my article published in the American Journal of the Medical Sciences, but it continued for a remarkable 30 years and resulted in coauthoring 36 publications in medical/scientific journals and book chapters with him. 

I acknowledged Dr. Cole’s invaluable assistance in my book, For Smokers Only: How Smokeless Tobacco Can Save Your Life, which was published in 1995.  As I wrote, by that time, he had “served as a collaborator on projects related to this idea for the past two years. In this short period he has challenged me to write — even more fundamentally to think — with precision, clarity and refinement about many important facets of the tobacco issue.”  Dr. Cole wrote a foreword for my book in 1995, which illustrates his literary talent.    

Dr. Cole’s authoritative voice articulating the causes of cancer has gone silent.  I dedicate this post to Dr. Cole, his extraordinary life, his incredibly productive career, and his personal guidance and friendship.

 

  Dr. Philip Cole, 1938-2023