Tobacco Control at MD Anderson

As a child, researcher Surendranath Shastri, M.D., D.Ph., worshiped his dad. “He was a lifetime smoker, so I thought it was cool to smoke,” says Shastri. “I started smoking around age 18, about the same time I started medical school.”

By his early 20s, Shastri was smoking two packs of cigarettes a day. He lived in India, where smoking was a big part of the culture. Shastri recalls cigarettes were given as a party favor to guests at his wedding.

He knew smoking was dangerous to his own health, but that wasn’t enough to motivate him to quit, despite pleas from his wife. At the time, scientific evidence was still being gathered on the harms of secondhand smoke exposure, and that’s what finally convinced Shastri to quit.   

“When my wife told me she was pregnant with our first child, the first thing that came to my mind was, ‘I must do everything I can to take care of this baby,’” Shastri recalls. “My wife asked me to start by giving up smoking.”

Thinking about the potential effects on their unborn daughter provided strong enough motivation for him to permanently quit smoking at age 26. His daughter is now a doctor with her own children. Shastri is a physician and researcher studying health disparities in cancer, including tobacco use.

Secondhand smoke is harmful

The same year that Shastri quit smoking, the first Surgeon General’s Report dedicated to the health effects of secondhand smoke was released. We now know that secondhand smoke exposure, which includes the smoke directly from a burning cigarette as well as the smoke exhaled by someone smoking, can cause serious health problems in non-smokers, including lung cancer.

“It’s a big myth that secondhand smoke exposure is not as harmful as smoking,” Shastri says. “Secondhand smoke exposure is equally harmful, particularly for young children whose respiratory systems are not as developed and for women who are pregnant.”

According to the Surgeon General, 2.5 million non-smokers have died due to secondhand smoke exposure since 1964. Secondhand smoke exposure can cause heart disease, stroke and sudden infant death syndrome. More than 7,300 nonsmokers die each year from lung cancer caused by exposure to secondhand smoke.

Disparities in secondhand smoke exposure

“The science shows that the health effects from secondhand smoke exposure are long-lasting,” Shastri says. “Although we’ve made progress in the US in reducing secondhand smoke exposure, that progress has stalled over the last decade, and disparities persist.”

From 1988 to 2012, secondhand smoke exposure among non-smokers declined from 87.5% to 25.3%. The latest available data shows the rates have barely decreased since then, to 24.6% in 2018. Shastri and Sanjay Shete, Ph.D., recently published a study in JAMA Internal Medicine that analyzed data on secondhand smoke from 2011-2018 to determine how common the problem is currently.

“We found very clear disparities in terms of who is exposed to secondhand smoke,” Shastri says. “There are significantly higher rates of secondhand smoke exposure in children ages 3 to 11, non-Hispanic Black individuals, and people living below the poverty line, in rental housing or without a high school education.”

Strategies to reduce secondhand smoke exposure

After beginning his career in internal medicine, Shastri was recruited to establish and lead the Preventive Oncology department at one of India’s largest cancer hospitals. In this role, he created the Smokefree Mumbai Campaign and implemented tobacco cessation clinics at cancer centers throughout the country. He’s continued to work on tobacco control projects since joining MD Anderson’s Health Disparities Research team in 2018. 

Shastri’s team is currently working on a pilot project to address secondhand smoke exposure among public housing residents in Houston. The project will begin with a blood test to measure the baseline secondhand smoke exposure levels among non-smoking residents, followed by a series of interventions to identify and fill gaps in existing resources designed to help residents and property managers comply with the 2017 Smoke-Free Public Housing Rule. The project will also offer free, onsite tobacco cessation therapy to residents who smoke. After one year, the team will measure secondhand smoke exposure levels among non-smoking residents again to see if the interventions made a difference.

“It’s critical that we prioritize strategies to reduce secondhand smoke exposure among the groups who are disproportionally affected and may have long-term health issues as a result,” Shastri says. “I can’t think of a more powerful motivation to quit smoking than the health of your loved ones.”

MD Anderson offers resources for individuals who want to quit smoking, including smoking cessation studies for Texas residents and Tobacco Treatment Program for MD Anderson patients and employees. Anyone can call 1-800-QUIT-NOW or visit smokefree.gov to be connected to free quitting resources in their state.

Cigarette smoking has been on the decline for years. But menthol cigarettes are one segment of the tobacco market that has remained strong.

The Food and Drug Administration (FDA) proposed new rules today to prohibit these products and flavored cigars. These proposed rules are in response to public health concerns about the dangers of menthol cigarettes and their huge popularity among young people and Black, Hispanic and Asian American smokers.

We spoke with Jennifer Cofer, director of the EndTobacco® Program at MD Anderson, about the harms posed by menthol cigarettes and why the FDA's decision matters.

What is menthol, and why do manufacturers add it to cigarettes?

Menthol is a flavor additive with a minty taste and smell. In addition to tasting good, it has a cooling and painkilling effect. Cigarette manufacturers add it to cigarette filters to cover up the unpleasant taste of tobacco and make cigarettes more appealing.

What does the FDA decision on menthol cigarettes mean?

The FDA has the authority to regulate ingredients, marketing and new products. It banned flavored cigarettes in 2009, but made an exception for menthols. The FDA is essentially catching up by including menthol as a banned flavor now. Last year, the FDA announced that a plan was in the works to catch up, essentially, by including menthol as a banned flavor.

Now, the public will have the opportunity to comment on the proposed rules this summer before the product standards are finalized. It could be several months before menthols and cigars disappear from shelves.

Who smokes menthol cigarettes?

About 18.5 million people in the United States are regular menthol smokers. That’s 37% of the cigarette market. Here’s a breakdown of their use by race in the United States:

• 85% of Black smokers smoke menthols
• 46% of Hispanic smokers smoke menthols
• 39% of Asian American smokers smoke menthols

Why is race important? Because people who smoke menthols tend to inhale more deeply and have a harder time quitting smoking. That means that the health effects of smoking have a disproportionate impact on those communities with a higher rate of menthol use. 

Menthols and mint are also extremely popular among teenage smokers. More than half of cigarette smokers ages 12 to 17 use menthol cigarettes.

The hope is that, once finalized, the rules will help reduce the number of new, young adult nonsmokers and improve the health of people who currently use menthol cigarettes.

What does the research say about the dangers of menthol cigarettes?

Because menthol flavoring masks the harsh taste of cigarette smoke, menthol smokers engage in more intense smoking behaviors than smokers of regular cigarettes. As a result, they suffer greater damage to their health. Here are three reasons menthols are so dangerous:

• People who smoke menthols smoke more. The minty coolness of the menthol covers up the harshness of the cigarette, so smoking is easier to tolerate. As a result, menthol smokers inhale more deeply and they smoke more cigarettes. That means over their smoking lifetime, they take in more of toxic chemicals and tar from cigarettes.
• Menthols are harder to quit. Research by both the FDA and the Tobacco Products Scientific Advisory Committee shows that those who smoke menthol cigarettes are more likely to be dependent and have more trouble quitting. So, while Black smokers are more likely to try to quit smoking than white smokers, they’re less likely to be successful. That’s because of a higher nicotine dependence related to smoking menthol cigarettes. One result: Black men and women have a higher rate of lung cancer than any other race.
• Menthols appeal to young smokers. Studies show that young people who start smoking menthol cigarettes are more likely to become addicted and become long-term daily smokers.

What are the health risks of flavored cigars?

Flavored cigars, or cigarillos, come in flavors like cherry, grape and vanilla. They are typically available at convenience stores and gas stations for a very low price.

Like menthol cigarettes, flavored cigars were not covered by the 2009 flavor ban. Cigars are not regulated in the same way as cigarettes.

Removing these products would be an important step in reducing the overall impact of tobacco on public health, especially in communities where they are popular.

Is there anything else should we know about menthol cigarettes?

There is no safe tobacco product. If you are a smoker or vaper, one of the best things you can do to protect your health and reduce your risk of cancer is to quit. The best way to do that is through a comprehensive program that includes a combination of medications and counseling. MD Anderson offers free research studies for adults in Texas at any stage of smoking cessation. Learn more at SmokeFreeStudy.org.

Youth and young adults who want to quit using tobacco products can text VAPEFREETX to 88709. Parents can text QUIT to 202-899-7550 to get tips and advice for helping their teens and young adults quit using tobacco or vape products.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.