Health inequities and flavored tobacco

Explore information related to health inequities in the tobacco industry and flavored tobacco sales in Massachusetts.

Racial inequities

Historically, the tobacco industry has intentionally targeted menthol tobacco products to Black Americans through various advertisement and marketing techniques. Studies show disproportionate point-of-sale tobacco marketing in Black neighborhoods [1] and that inequity grows when looking at marketing of menthol tobacco; there are often more menthol advertisements, greater menthol availability, and lower menthol prices in communities of color [2-4].

The targeting of menthol tobacco products to Black Americans has contributed to disproportionately high menthol use among Blacks who use tobacco. Studies show that menthol cigarettes may be biologically more addictive and increase dependency more than non-flavored cigarettes [5-7]. This may lead to greater smoking intensity and increased difficulty quitting.

Racial inequities in menthol tobacco targeting and use call for revised policies around their sales.

Targeting to youth

The tobacco industry targets flavored products to youth and young adults, increasing initiation to and potential future use of these products. In addition to the known carcinogenic effects of tobacco, this is harmful because nicotine use in adolescence can harm parts of the brain that control attention, learning, mood, and impulse control. Studies have found that youth who use flavored tobacco may be more likely to continue using tobacco products in the long term compared with youth who do not use flavored products [8,9].

To combat youth tobacco use, the Family Smoking Prevention and Tobacco Control Act was passed in 2009. This law banned flavored cigarettes in the US, except for menthol. In addition, this law did not include flavored cigars, smokeless tobacco, or e-cigarettes.

In the years since this act, e-cigarettes have surpassed traditional cigarettes as the most prevalent product used by youth. E-cigarettes are available in thousands of different flavors, which is harmful because flavors may lower perception of the harmfulness and addictiveness of nicotine products [10].

An Act Modernizing Tobacco Control

On June 1, 2020, An Act Modernizing Tobacco Control took full effect in Massachusetts (MA). This law contains the following provisions:

• Restricts the sale of all menthol and other flavored tobacco products (including vape products) to adult-only smoking bars for on-site consumption only
• Restricts the sale of all vape products with a nicotine concentration of more than 35 mg/ml to adult-only retailers and smoking bars
• Imposes a 75% excise tax on all vape products
• Requires that health care insurers cover at least one FDA-approved cessation product at no out-of-pocket cost

For more information about the law, please visit: 2019 Tobacco Control Law | Mass.gov

1. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A systematic review of neighborhood disparities in point-of-sale Tobacco marketing. Am J Publ Health. 2015;105(9):e8-e18. doi: 10.2105/AJPH.2015.302777
2. Henriksen L, Schleicher NC, Dauphinee AL, Fortmann SP. Targeted advertising, promotion, and price for menthol cigarettes in California high school neighborhoods. Nicotine Tob Res. 2012;14(1):116-121. doi:10.1093/ntr/ntr122
3. Kurti MK, Schroth KRJ, Ackerman C, Kennedy M, Jeong M, Delnevo CD. Availability of menthol cigarettes in Oakland, California after a partial flavor ban. Prev Med Rep. 2020;20: 101200. Published 2020 Sep 18. doi:10.1016/j.pmedr.2020. 101200
4. Kephart L, Song G, Henley P, Ursprung WWS. The association between neighborhood racial composition and menthol cigarette pricing in Boston, MA. Health Place. 2019;58:102144. doi:10. 1016/j.healthplace.2019.102144 9. U.S. Department of Health and Human Services, National Cancer Institute. The 2014-2015 Tobacco Use Supplement to the Current Population Survey. https://cancercontrol.cancer.gov/ brp/tcrb/tus-cps/results/2014-2015: Current Population Survey: Tobacco Use Suppl File; 2017.
5. Rising J, Alexander L. Marketing of menthol cigarettes and consumer perceptions. Tob Induc Dis. 2011;9(suppl 1):S2. Published 2011 May 23. doi:10.1186/1617-9625-9-S1-S2
6. Wickham RJ. How menthol alters Tobacco-smoking behavior: A biological perspective. Yale J Biol Med. 2015;88(3):279-287. Published 2015 Sep 3.
7. Giovino GA, Villanti AC, Mowery PD, et al. Differential trends in cigarette smoking in the USA: Is menthol slowing progress? Tob Control. 2015;24(1):28-37. doi:10.1136/tobaccocontrol2013-051159
8. Villanti AC, Johnson AL, Ambrose BK, et al. Flavored tobacco product use in youth and adults: findings from the first wave of the PATH Study (2013‒2014). Am J Prev Med. 2017;53(2):139‒151. https://doi. org/10.1016/j.amepre.2017.01.026.
9. Dai H, Hao J. Flavored electronic cigarette use and smoking among youth. Pediatrics. 2016;138(6):e20162513. https://doi.org/10.1542/ peds.2016-2513.  
10. Cooper M, Harrell MB, Pérez A, Delk J, Perry CL. Flavorings and Perceived Harm and Addictiveness of E-cigarettes among Youth. Tob Regul Sci. 2016 Jul;2(3):278-289. doi: 10.18001/TRS.2.3.7. Epub 2016 Jul 1. PMID: 27722185; PMCID: PMC5049876.