MPH 503 Module 7 Health Equity and Tobacco Policy Example

Menthol, Equity and the Law: Weighing a State Ban Through a Justice Lens

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Master of Public Health Program, Aspen University

MPH 503: Health Policy and Ethical Issues in Public Health

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Menthol, Equity and the Law: Weighing a State Ban Through a Justice Lens

Health equity means that everyone has a fair opportunity to attain their full health potential. Public health policies can advance or undermine equity depending on who benefits and who bears the burdens. This paper applies an equity analysis to a proposed ban on the sale of menthol cigarettes in a composite state, a policy whose supporters frame it as a matter of racial justice and whose critics raise concerns about enforcement.

The Proposal

The composite state's bill would prohibit retail sale of menthol cigarettes and all flavored tobacco products, with penalties applying to retailers and wholesalers, not to individuals who possess or use the products. The bill's sponsors cited the disproportionate harm menthol has caused in Black communities and the product's role in starting young people smoking. Retailers would have six months after enactment to clear inventory before compliance checks began, and the bill directed the health department to publish plain-language guidance for store owners.

Why Menthol Matters

Menthol cools the throat and masks the harshness of smoke, making cigarettes easier to start and, evidence suggests, harder to quit. For decades, tobacco companies marketed menthol brands heavily in Black neighborhoods and publications. Most Black adults who smoke use menthol cigarettes, a far higher share than among White adults who smoke.

Measuring the Harm

A simulation study reproduced smoking trends among African Americans from 1980 to 2018 and then removed menthol's effects on starting and quitting. It attributed 1.5 million new smokers, 157,000 premature smoking-related deaths and 1.5 million life-years lost among African Americans to menthol cigarettes over that period. African Americans make up about 12% of the population but bore 41% of menthol-related premature deaths and half of the life-years lost (Mendez & Le, 2022).

Tobacco Use Today

National survey data for 2021 show that an estimated 46 million US adults, 18.7%, currently used a tobacco product, with 11.5% smoking cigarettes. Use was higher among people with lower incomes, those enrolled in Medicaid or uninsured, people with disabilities and adults experiencing serious psychological distress (Cornelius et al., 2023). Tobacco-related harm therefore concentrates among groups already facing disadvantage.

Equity Impact Assessment

An equity impact assessment asks who benefits, who is burdened and how harms can be reduced. The table summarizes the analysis.

The Enforcement Concern

Some civil rights advocates have worried that a menthol ban could lead to more police contact with Black residents if enforcement reached individual users. That concern is rooted in real history. The bill addresses it by limiting penalties to businesses that sell the products and by stating that possession and use are not offenses. An equity analysis treats enforcement design as central, not an afterthought.

Autonomy and Paternalism

Critics also argue a ban is paternalistic, removing adults' choice. Supporters reply that the menthol market was shaped by targeted marketing, that most smokers began as adolescents and that most adults who smoke want to quit. Public health law recognizes that regulating products and marketing is a traditional and legitimate use of state power, distinct from punishing individuals (Gostin & Wiley, 2016).

Supporting People Who Smoke

A ban alone leaves current menthol smokers to quit abruptly. Equity requires support: free nicotine replacement and prescription medications, a state quitline with culturally tailored counseling, and partnerships with Black churches, community health workers and clinics serving Medicaid patients. Tobacco tax revenue could fund these services.

Community Voice

Equity also concerns who shapes policy. The sponsors held hearings in affected communities and included Black health organizations in drafting. Community engagement improves policy design and builds legitimacy, particularly when a policy is framed as benefiting a specific population. Hearing directly from former smokers who had tried and failed to quit menthol cigarettes also shaped the cessation provisions.

Monitoring Equity Outcomes

The state should track smoking and quitting rates by race, income and region, cessation service use, retailer compliance and any enforcement-related complaints. Publishing results would show whether the ban narrowed disparities and would reveal any unintended harms quickly. Data from the state's behavioral risk survey and youth tobacco survey can serve as the baseline.

Recommendation

The analysis supports the menthol and flavored tobacco sales ban, with enforcement limited to retailers, a clear statement that users face no penalty, a six-month transition, free statewide cessation support and public reporting of equity outcomes.

Federal Action

The Food and Drug Administration has proposed product standards to prohibit menthol as a characterizing flavor in cigarettes, in 2022, but no final rule has taken effect. States and cities therefore act on their own; Massachusetts and California have adopted statewide restrictions on flavored tobacco sales including menthol. State action can protect residents while federal policy remains unsettled, although cross-border purchases limit its reach.

Industry Tactics

Opposition to menthol restrictions has included funding for groups that frame bans as harmful to Black communities and advertising that emphasizes illicit markets. Understanding who funds an argument is part of evaluating it. Public health analysts should weigh arguments on their merits while noting when messaging aligns with the commercial interests of manufacturers who profit from menthol sales.

Youth Protection

Flavors play a major role in youth initiation. Candy, fruit and mint flavors make first use more pleasant, and many young people who begin with flavored products go on to regular use. Removing flavors therefore protects the next generation as well as current smokers, and it applies equally across all groups of young people regardless of neighborhood or income.

Conclusion

A menthol ban illustrates how public health policy can address inequities created by decades of targeted marketing. Evidence of disproportionate harm to African Americans and of higher tobacco use among disadvantaged groups supports action. Designing enforcement to avoid policing harms, funding cessation and listening to affected communities are what turn the policy from well-intended into genuinely equitable.

References

Cornelius, M. E., Loretan, C. G., Jamal, A., Davis Lynn, B. C., Mayer, M., Alcantara, I. C., & Neff, L. (2023). Tobacco product use among adults: United States, 2021. MMWR. Morbidity and Mortality Weekly Report, 72(18), 475-483. https://doi.org/10.15585/mmwr.mm7218a1

Gostin, L. O., & Wiley, L. F. (2016). Public health law: Power, duty, restraint (3rd ed.). University of California Press.

Mendez, D., & Le, T. T. T. (2022). Consequences of a match made in hell: The harm caused by menthol smoking to the African American population over 1980-2018. Tobacco Control, 31(4), 569-571. https://doi.org/10.1136/tobaccocontrol-2021-056748