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Cigarette Smoking: Still the Leading Cause of Preventable Death

Updated: Sep 1

Some Steps Might Reduce the Tobacco Burden

Although only about 13 percent of Americans smoke cigarettes, cigarette smoking remains the leading cause of preventable death in the U.S., causing about 480,000 deaths every year. That’s more deaths than are caused by the combination of HIV infection, illegal drug use, alcohol use, motor vehicle injuries, and firearm-related incidents, according to the Centers for Disease Control and Prevention (CDC).

Cigarette smoking is especially devastating to marginalized communities, including people with low levels of education, low income, and mental illness, because their rates of smoking tobacco are higher than rates among more advantaged groups. As important as socioeconomic status is in determining lifespan, a recent study showed that cigarette smoking was more than three times as potent a factor for how long someone lives. As the authors of the study put it, “Health care practitioners cannot modify their patient’s wealth, but they should continue to discourage smoking. Wealth may be associated with longevity, but just don’t smoke.”

Policy makers and public health officials may think that the tobacco wars are over because of the steep decline in the number of people who smoke in the U.S. over the past several decades, but clearly smoking remains a major public health issue that needs our considerable attention. Two public debates about ways to curb smoking are prominent now, one about the use of menthol-flavoring in cigarettes and the other about electronic cigarettes (also called e-cigarettes or vaping) and both deserve our attention.

Get Menthol Out of Combustible Cigarettes

The Food and Drug Administration (FDA) is now poised to ban menthol flavoring from combustible tobacco products. This comes after long and fraught debate and industry counter-pressure. Back in 2009, Congress gave the FDA regulatory authority over tobacco products and banned all cigarettes with "characterizing flavors" except menthol. Congress specifically ordered FDA to examine the risks and benefits of banning menthol cigarettes, thus opening years of lobbying and argument. Princeton University professor Keith Wailoo, author of the book “Pushing Cool: Big Tobacco, Racial Marketing, and the Untold Story of the Menthol Cigarette,” recently detailed the history of the cynical campaign by the tobacco industry to keep menthol-flavored cigarettes on the market.

Menthol-flavored cigarettes are especially popular among Black smokers and are more difficult to quit than non-menthol-flavored cigarettes (image: Shutterstock).

Wailoo explains in his New York Times op ed piece that menthol cigarettes “account for more than one-third of cigarette sales in the United States and are especially dangerous because the menthol enhances nicotine’s already potent addictive effects.” The tobacco industry originally marketed menthol as offering health benefits for smokers, something that is patently untrue. Most troubling is the fact that menthol cigarettes are particularly popular among Black smokers, leading the tobacco industry to direct marketing efforts of their products to the Black community. “When Congress voted in 1970 to ban national television and radio ads for cigarettes…” Wailoo writes, “industry records reveal how tobacco companies gradually pivoted to Black periodicals and intensified urban billboard advertising.”

Today, menthol cigarettes are smoked “by more than 18 million people ages 12 and over. Among Black smokers, 85 percent smoke menthol cigarettes, compared with 30 percent of white smokers.” While overall cigarette smoking rates have decreased in the U.S., the market share for menthol flavored cigarettes has continued to increase, with, according to multiple studies, evidence that menthol “increases initiation, facilitates progression to regular smoking, increases dependence and decreases the likelihood of smoking cessation, especially among African American smokers.”

A new study, based on the Canadian experience of banning menthol flavoring in cigarettes, estimates that a U.S. ban would lead to 789,724 daily smokers quitting smoking, including 199,732 Black smokers. The upcoming ban on menthol-flavored cigarettes in the U.S. is therefore a wise policy decision that should save thousands of lives. It is sad that over a decade has elapsed since Congress first gave the FDA authority to regulate tobacco products to this point that menthol is finally about to be banned.

The E-Cigarette Debate Rages On

We have many tools available to help people quit smoking combustible tobacco products like cigarettes, cigars, and pipes. Even brief counseling by healthcare providers, like primary care doctors and nurses, has been shown to be effective. Various nicotine replacement products are available, many on an over-the-counter basis. Two medications, bupropion and varenicline, are FDA-approved prescription drugs for assisting cigarette cessation, but they are underutilized.

E-cigarettes are also used by many people to stop smoking combustible tobacco products, but where they fit in is controversial. Although studies show that people often ask their doctors for help quitting smoking, most physicians are under the incorrect impression that all tobacco products are equally harmful. Nicotine, the main ingredient in e-cigarettes, does not increase the risk for cancer as far as we now know. That makes e-cigarettes far less harmful than combustible tobacco products, yet a recent study found that “Most physicians (60.1%) endorsed the belief that all forms of tobacco were equally harmful and that cessation from all tobacco use was the best approach…” In fact, numerous studies suggest that e-cigarettes can be an effective tool for quitting combustible cigarette smoking, such as a recent study involving pregnant women.

E-cigarettes can be used to help combustible tobacco smokers quit, but they are controversial because of their use by adolescents (image: Shutterstock).

The controversy surrounding e-cigarettes centers on the fact that nicotine is an addictive substance and that many young people vape, despite laws prohibiting sale of e-cigarettes to them. Just as menthol seems to make combustible cigarettes more palatable to many people, many vapers appear to like flavored e-cigarettes. This has led to calls to ban all flavoring in e-cigarettes to make them less attractive to adolescents, a move that is opposed by those who urge broader use of e-cigarettes by adults who want to stop smoking combustible cigarettes. In a piece in the New England Journal of Medicine, Abigail S. Friedman and Kenneth Warner recently wrote that “…smokers who vape non-tobacco-flavored e-cigarettes appear to be more likely to quit using combustible tobacco than those who vape tobacco-flavored e-cigarettes.”

Friedman and Warner go on to offer several suggested moves to reduce the likelihood that young people will buy flavored e-cigarettes while at the same time maintaining their availability for adults who want to use them to quit smoking tobacco products. They point out that “Smokers use e-cigarettes in their smoking-cessation attempts more than any medication approved by the [FDA]. Moreover, compared with people who don’t use e-cigarettes, people who use e-cigarettes daily have significantly higher odds of quitting smoking.”

The benefits of quitting tobacco smoking are abundantly clear. Banning menthol-flavoring in cigarettes is an obvious decision. More complex is how to regulate e-cigarettes. Certainly, we need to educate healthcare providers that they are safer than combustible tobacco products and can be used to assist in quit attempts.

In fact, given that smokers often consult with their doctors about quitting, it seems imperative that we redouble our efforts to encourage primary care physicians and other healthcare providers to be more aggressive about determining who among their patients smokes and who might be ready to quit. How many healthcare providers focus on the answer to the question “do you smoke” by asking follow-up questions that help determine the extent of their patients’ smoking habits, what they have already tried in order to quit, and whether they are read to try again? Why don’t more physicians prescribe bupropion and especially varenicline, the more effective of the two prescription medications for smoking cessation?

Finally, how do we make clear to healthcare providers that not all tobacco products are equally harmful and that e-cigarettes may be helpful for patients who are unable to quit smoking by other means?

Nearly half a million Americans will die this year because they smoke, with the highest percentage represented by underserved Americans. This must be seen as a tragedy and unacceptable. It should not have taken this long to ban menthol. It should not take any longer for the health professionals’ community to recognize that smoking remains a dominant public health threat for which there are evidence-based solutions.

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