Transcript: Health Equity: The Impact of Racial Marketing with Georges C. Benjamin, MD & Keith Wailoo, PhD

We have Dr. Keith Wailoo, who is a professor of history and public affairs at Princeton University;

And we also have Dr. Georges Benjamin, who’s the Executive Director of the American Public Health Association.

Gentlemen, thanks to you both for being with us today.

DR. WAILOO: Hi, good afternoon.

MS. WINFIELD CUNNINGHAM: Let’s start by setting the stage, here. Dr. Benjamin, what is menthol, and why is it added to cigarettes?

DR. BENJAMIN: Well, it’s a cooling agent, and it just makes it more tolerable to take this very harsh substance, which has no medical value or health value, whatsoever, into your mouth and into your lungs. And as you can imagine, the tobacco industry has figured out that if you add this toxic substance, or this substance to their toxic product, then people are much more likely to use it.

MS. WINFIELD CUNNINGHAM: Well, thank you for that. And you know, we know, as the video that we just watched noted, we know Black Americans are much more likely to pick menthol cigarettes, to the point where more than 85 percent of African-Americans who smoke choose them.

Dr. Wailoo, can you walk us through why we’ve seen that trend and why that has increased so much in recent decades?

DR. WAILOO: Yeah, I mean, as your video says, that if you–in the 1950s, menthol and race was not connected. If you asked most tobacco executives in 1961 or ’62 whether there was a Black affinity for menthol smoking, they would look at you quizzically. They wouldn’t even maybe recognize the question, because as far as they were concerned, menthol smoking was taken up by people who were health anxious. Doctors–Dr. Benjamin just mentioned the kind of cooling agent. So, menthol doesn’t really cool but it gives you the sensation of coolness, and it was marketed as–for its health appeal. Early Kool ads said things like, you know, “When April showers make you cough like crazy, refreshing Kools taste fresh as a daisy.”

It was in the 1960s that the industry, when deprived of both this kind of explicit health marketing, but also during which a time when marketing to youth and campus marketing was closed off as a tactic, they pivoted aggressively to urban marketing in the 1960s. And it’s really starting in about 1964 that you begin to see a kind of deceptive, stunning precision of a new kind of aggressive marketing to urban Black smokers in the–in cities like St. Louis and Chicago and Cleveland and New York City and Philadelphia. And in some ways, it’s the shrewdness of this effort that has ended up building this menthol marketing in what the industry called poverty markets. Others called–they talked about a Kool inner city research project. And they used tactics like giving out free samples to people who were regarded as individuals of prestige in cities, like St. Louis, to hand out these products in a sort of secretive manner. And so, there are a wide range of tactics that were used to kind of build menthol as a consumer product, and of course also wrapping menthols in the veneer of Black pride and Black self-sufficiency was also a key tactic, as well.

MS. WINFIELD CUNNINGHAM: Well, and do you think that the misperception still exists, that this is a healthy, or at least less damaging, product than a regular cigarette?

DR. WAILOO: Absolutely it does.

DR. BENJAMIN: Oh, there’s no question. Yeah.

MS. WINFIELD CUNNINGHAM: Sorry, let’s go to Dr. Wailoo on that, first.

DR. WAILOO: Yeah, absolutely. I think that the long legacy–the belief that menthols are health-promoting, this led to the rapid increase in menthol smoking in the 1950s, precisely at the time that smoking was being linked to cancer.

And so, the industry has well understood the sort of therapeutic associations of mentholation on the throat and the nose and the mouth, and they have used that to very potent effect. It has become increasingly implicit in the marketing efforts, but it’s still there as a continuing feature of mentholated smoking’s appeal.

MS. WINFIELD CUNNINGHAM: And of course, we’re talking about this right now because the FDA has promised to release a more detailed menthol cigarette ban this spring and we’re waiting on that right now. I’d like to hear from each of you about this impending ban, what you’re hoping that it might look like.

Let’s start with you, Dr. Benjamin.

DR. BENJAMIN: Yeah, we’re obviously hoping that the FDA will just simply outlaw menthol completely. Again, other than the fact that it accelerates the use of this very toxic product, tobacco, it really doesn’t have any other value other than that, even in–you know, to health in any kind of way.

And I think the other problem we have, of course, is that it doesn’t just extend it to cigarettes but it also extends to cigars and they even have it as part of other flavors as additive agents in e-cigarettes, as well.

MS. WINFIELD CUNNINGHAM: And Dr. Wailoo, what are your thoughts on that?

DR. WAILOO: Well, I think in some ways this ban is a long time coming. Back in 2009, when President Obama signed legislation that finally gave the FDA jurisdiction over tobacco products. Imagine that. Over the last–over the 20th century, there was no FDA jurisdiction over tobacco products at all.

So, that changed in 2009, and one of the things that that legislation did is it banned flavored cigarettes, characterizing flavors. No strawberry cigarettes, right? No other forms of flavoring, which is seen as an illegitimate enticement, particularly to initiators and youth. But menthols escaped that ban, and that has a lot to do with the way in which the industry provided support, sadly, to some Black lawmakers who were under the mistaken belief that mentholated smoking was a Black preference, and therefore to ban it would be discriminatory. And it’s because of that menthol exemption that FDA was handed authority to make the determination. So, you could say menthol escaped the ban in 2009. It escaped a couple of other actions by FDA. Scott Gottlieb, the FDA Commissioner under the form–in the former administration announced a ban and then left office thereafter.

So, easily you would say this is the third time that the FDA has moved or congressional figures have moved against menthol. And the question is, is the third time going to be the charm, and I’m guessing yes, based on just reading the events in the FDA, moving the proposed rulemaking to the Office of Management and Budget recently.

MS. WINFIELD CUNNINGHAM: Well, and I want to ask Dr. Benjamin about that, because, as you know, menthol has kind of slipped under the radar in some sense over the past decade.

Dr. Benjamin, are you concerned that we’re going to see OMB watering down the regulations?

DR. BENJAMIN: Well, OMB should not water down the regulations. It makes no sense.

And let me just remind everyone that tobacco, of course, is a leading cause of preventable death for public health, but for those people who think this is kind of an adult choice, recognizing that almost all people who smoke begin to use this addictive substance in their youth. So, they’re really, in many ways, targeting to youth. And it is cause of heart disease and more lung disease and more kidney disease. It is a factor–heart–you know, tobacco is a factor in infant mortality. So, we ultimately want to make sure that the Office of Management and Budget understands that they’re not just making a simple policy decision here, but they’re making a decision which impacts a whole range of chronic diseases, again, responsible for over 45,000 preventable deaths. And almost the last 40 years, if you add that up, that’s almost, you know, 380,000 premature deaths. Also, look at what–what COVID–we just went through COVID and the people that will most likely be impacted by COVID were people with chronic diseases. That included people that smoked. And so that, again, the utilization of menthol, indirectly exacerbates these chronic diseases. And so, when OMB is thinking about this even from a fiscal perspective, this will ultimately save lives but will also save money, and it will ultimately save government money–government money for taxpayers.

MS. WINFIELD CUNNINGHAM: Dr. Benjamin, I also want to ask you, though, about the FDA Commissioner. And as you know, Robert Califf, who was just recently confirmed, was also FDA Commissioner during this time that, as we already noted, menthol sort of slipped under the radar and was unregulated and it seemed as though the agency gave into a lot of the demands of the tobacco industry. Do you have confidence now that Robert Califf is going to push back against that this time around?

DR. BENJAMIN: Dr. Califf has a free hand. His expertise is cardiology. He clearly understands the critical linkage between tobacco and heart disease. And if anyone, he would be in the driver’s seat to make this happen. And I fully expect Dr. Califf to be strongly in support of banning menthol.

MS. WINFIELD CUNNINGHAM: Okay. I’ve got an audience question now that I’d like to send to Dr. Wailoo, and it’s this: Leonard Glantz in Massachusetts asks, “Why did cigarette companies choose to market menthol cigarettes to Black communities? Wouldn’t the companies make more money if they got people of all races to smoke their products?”

DR. WAILOO: Yeah, so, the answer is that they did market to a wide range of consumer groups. So, it’s by no means the case that menthols were exclusively advertised to African-Americans.

But in the 1960s, because African-American fashion, African-American culture, Africa-American music was widely emulated by White youth, the growth market was incredibly appealing. You adorn your product with Black motifs, and what the industry realized is that you could actually win over both Black smokers, but also young, White–White youth smokers.

Salem cigarettes were predominantly–or at least there was a prevalence for young women smoking Salems, and Kool cigarettes tilted towards African-Americans. So, the industry was very savvy about what you might call segmented marketing and understanding the different kinds of ways you pitch a particular product like menthol to different groups. I mean, still, today, you know, people have the sense that 85 percent of African-American smokers preferring menthol brands means that it’s a Black-exclusive product. Well, 30 percent of White smokers smoke menthol brand. So, what you find today is there is just a disproportionate tilt towards African-American smokers who prefer and smoke mentholated cigarettes, and that’s a byproduct of this aggressive, intensive marketing strategy over the course of decades, but it’s by no means exclusive.

MS. WINFIELD CUNNINGHAM: And Dr. Wailoo, you’ve written a book on this topic, of course, called “Pushing Kool.” And in it, you describe a sort of perverse alliance between some different players. Can you tell us more about who these players were and what the nature was of this arrangement?

DR. WAILOO: Yeah, I think that–what’s important to understand is that the history of rolling back the reach of cigarette into different vulnerable communities has been very strong over the course of history. Banning television and radio ads, banning pitches on college campuses, banning pitches to children, and banning flavored cigarettes. But along the way, cigarette companies have had ardent defenders.

So, for instance, when RJ Reynolds came out with a brand called Uptown in 1990 announced that it would be marketed only to Black people, the HHS, the Health and Human Services Secretary, a Black physician named Louis Sullivan in a Republican administration called out this tactic as slick and sinister and promoting a culture of cancer. But surprisingly perhaps to many, the industry’s right to market to Blacks was defended by the Executive Director of the NAACP, Benjamin Hooks. And this highlights the way in which the industry has been able to secure its place in Black communities by garnering support among African-American influencers, leaders, largely because they are also being supported by industry dollars.

So, the Uptown campaign was greeted enthusiastically by Benjamin Hooks while it was lashed by Louis Sullivan. And the Black media in Philadelphia which depended on advertising revenue from the industry remained largely silent. This is just an indication of the kinds of webs, the webs that have helped to keep menthol smoking in place.

Now, of course, what’s wonderful about that story is that Louis Sullivan’s assault on–criticism of, calling out of RJ Reynolds for this tactic ultimately led to the quick demise of Uptown cigarettes, and in some ways helped to generate the local activism that resulted helped to sort of generate the skepticism and the local criticisms of these tactics that promise to come to fruition this year with the ban of mentholated cigarettes.

So, the tactics that the industry has used have been highly effective at, in some ways, planting the seeds of skepticism in the Black community itself. Any time there’s a sense that their interests are being undermined, they will find individuals like Benjamin Hooks and others to speak on their behalf.

MS. WINFIELD CUNNINGHAM: Well, and all of this is so interesting to understand these industry pressures and tactics as we think about where we are at, now.

Dr. Benjamin, how do you view all of this now in terms of the influence that the industry is trying to exert over Black lawmakers and Black policymakers?

DR. BENJAMIN: I think it’s going to be very important that we continue to reach out to African-American and other–and Hispanic and other lawmakers and policymakers so they understand the real tradeoff, here.

And the fact that the industry, quite frankly, has profiled us in very negative ways because they know that they can sell their toxic product, and this is a very, very toxic product, again, with no particular redeemable value whatsoever, to our communities. And it is exactly the same tactics that other drug users–drug pushers use in communities: They give away free product; they market it; they subsegment the market very well; and then, this was an addictive drug. And we should think of this as a terribly addictive drug which kills people prematurely and those lawmakers need to really understand that.

MS. WINFIELD CUNNINGHAM: And Dr. Benjamin, on the flip side of that, who have been the loudest voices on the other side of trying to urge more regulation and just less use of menthol cigarettes?

DR. BENJAMIN: Well, my colleague here, Keith, has obviously written a great book, and we should promote that. But Campaign for Tobacco-Free Kids, excellent example. My organization, American Public Health Association; the Truth Initiative, which is a cam–which is a foundation that was set up under the Master Settlement Agreement, have been groups that have been very active, particularly with youth activity, to try to do a better job educating people about the harms of tobacco. The American Heart Association, the American Lung Association, all those groups have been working lockstep at the hip to try to make sure that tobacco is not used effectively in this country.

MS. WINFIELD CUNNINGHAM: So, we’ve been talking a lot about, you know, the positive side or why we should be regulating menthol cigarettes more, banning them, but I want to throw some questions that–at you–that onlookers have raised about the potential downsides.

And one is that, as you know, if menthol cigarettes were federally banned, their sale and distribution would be punishable as a felony, and some civil rights groups have raised concerns that this could actually worsen incarceration among Black Americans.

Dr. Benjamin, what do you make of that argument?

DR. BENJAMIN: Yeah, well, the FDA is going after the industry, not individuals. And so, we need to make sure the regulations target the industry and not individual smokers.

You know, the Garner story in New York, because of the single sales is fresh on many people’s minds, but that is not what is supposed to happen here. And we need to make sure that both the law and the regulations come out to focus on the companies, not individuals. And we hope that the enforcement authorities would also understand that this is basically a big industry that’s targeting individuals, and that we should not treat the victims of that targeting.

MS. WINFIELD CUNNINGHAM: Well, and as you note, you’re correct that the FDA has said it won’t go after any individuals for using menthol cigarettes, only manufacturers and retailers.

Dr. Wailoo, what do you make of that promise from the FDA?

DR. WAILOO: I applaud that promise, but I also think that what’s very important to realize here is that those who say that a ban will lead to more people like George Floyd or Eric Garner being murdered, as young Black men are subject to policing for smoking what would be bootleg menthols. I think that they are using a legitimate civil rights issue, a legitimate set of concerns about discrimination and racism, but they also have the story wrong in many ways. They are using these acts of discrimination to help support the industry’s right to sell and continue to exploit Black lives.

So, sadly, this is actually part of the familiar playbook of the industry, that is, to say this is part of what has allowed the industry to keep menthol present in cities. They have it wrong for one particular reason. You know, the murder of Eric Garner while selling loose cigarettes gave rise to the familiar cry, “I can’t breathe,” and it’s echoed tragically by Mr. Floyd. But menthols are intimately part of the history of “I can’t breathe.” They’re part of the history of predation and inequity. They’re part of the history of the devastating effect that this product has on Black people’s ability to breathe, many people’s ability to breathe, ending often in premature, tragic death.

So, the people–the difference is that the people responsible for this targeted phenomenon aren’t on a video. They work very quietly in boardrooms and in social science settings, in psychology, but their work solely extracts life and breath from Black people. It happens very quietly, and it’s also attracting wealth from Black communities. And so, in some ways, while I understand the concerns about civil rights and the possibilities of targeting, the problem is that the true story of what menthol ban is intended to stop is not these kinds of imagined deaths from Black–from police killings, which remain a deep civil rights concern that we should mitigate going forward, but the thousands and thousands of previous unseen and future deaths that happen off camera also ending in the plea, “I can’t breathe.”

MS. WINFIELD CUNNINGHAM: Well, and you wonder if this also is–there’s a misperception, perhaps, that as we know, Black people are using menthols more, but it’s not because they inherently love menthol cigarettes more; it’s because of this targeted marketing, as you say, for decades upon decades that has led to this situation.

I know that we do have some test cases when we look at the states. At least two, Massachusetts and California, have actually banned menthol cigarettes entirely. Dr. Benjamin, do you have a sense of how those bans are working out in those places?

DR. BENJAMIN: Reasonably well, but I think that it’s early. And I think the hope is that the states should continue, not really wait for the federal government. I mean, the federal government, even once OMB rules, it will take time to get that in place. So, I would encourage other states to put bans in place and then, again, not allow, as Keith pointed out, us to make a false choice, because people will die prematurely from heart disease, lung disease, and cancer, because of the use of tobacco, you know, accelerated by the use of menthol.

MS. WINFIELD CUNNINGHAM: Dr. Wailoo, what about you? Have you taken a look at the state level, what states are doing there, and do you think that’s a sort of second, alternate pathway, I suppose, if we don’t end up with the federal ban that’s been promised?

DR. WAILOO: It certainly is. And cities and in states and entire countries outside of the U.S. have banned menthol products. I think it is early days to figure out what the implications will be because, in many ways, these bans on sale have been–are just only now being implemented. So, it is rather early.

But I do think it’s important to be watchful, because when tobacco advertising on television and radio was banned and the industry was deprived of the mechanism of mass marketing, this is one of the catalysts in 1970 for increasingly intensive urban-focused marketing, in order to make up for lost markets. So, one of the things we always have to be watchful for in this industry is that one ban, whether it’s a ban on college advertising, whether it’s a ban on advertising to kids, whether it’s a ban on television and radio, whether it’s a ban on billboards which came out of the Master Settlement in the late 1990s, all of them have led to other strategies that also fly under the radar of regulation. And so, this is what I would be watchful for, in knowing and having studied the industry through this book.

MS. WINFIELD CUNNINGHAM: And Dr. Wailoo, you alluded to the situation in other countries. What do we see when we look elsewhere in terms of how they regulate menthol products?

DR. WAILOO: Well, I mean, the difference in other countries like the UK or Canada is that menthols have never been as widely used. And so, the impact on the market has not necessarily been as significant, nor has it been the regulatory debate. I mean, it was just widely understood that flavored cigarettes are initiator products, as the industry itself described it–they’re starter products that draw especially young smokers into smoking, in a more pleasurable way, as the industry describes it, and that leads to lifelong smoking.

And so, most of the other countries have really seen this as the primary problem, that is to say, a device for initiating use into a highly addictive substance that has short- and long-term devastating health implications.

MS. WINFIELD CUNNINGHAM: I’ve got another audience question that I want to send to Dr. Benjamin.

Margaret Hoggie in Australia asks, “Statistics seem to indicate that raising the price of tobacco has been the most effective way to help smokers to quit? Is this the case in the United States, and what is the next most effective method?” Dr. Benjamin, what would you say to that?

DR. BENJAMIN: There’s no question about that. Raising tobacco taxes has been an extraordinarily effective mechanism to utilize–to reduce utilization, and particularly for children. Children are very, very price sensitive. I think the other thing of course has been the efforts to limit children’s accessibility to tobacco. So, this is putting the sales behind counters. This is making sure that you raise the age of tobacco, the ability to purchase tobacco. Those kinds of things are extraordinarily effective here in the United States.

MS. WINFIELD CUNNINGHAM: And Dr. Wailoo, another question to you about just this marketing question. I find this so interesting. You know, there’s been a lot of talk in recent years about e-cigarettes and how they’re targeting kids. Do you see any parallels between that marketing campaign and then the marketing campaign around menthol cigarettes in the 1970s?

DR. WAILOO: Yeah. There are a number of parallels. One is that I would say that, shockingly and surprisingly, the menthol cigarette came onto the market in the 1920s and ’30s as the answer to harsh smoking in other brands. So, mentholated smoking emerged as the kind of–you know, the way to soothe your throat, what was called smoker’s throat, with this, quote, “medicated” cigarette.

Interestingly enough, the e-cigarette emerged, at least, for some, as the answer to tobacco smoking, that is to say as a smoking cessation product. But the parallel also continues in which you might say the menthol smoking market expanded with this deceitful product and there was always kind of implicit luring of youth smokers. And this is also the story, in a shorter period of time, with e-cigarette, the idea that a product that came onto the market promising to be the solution to the problem of smoking now becomes a problem in itself, especially because young people take it up so avidly.

So, you know, they have similar pathways that they follow. But the other issue that I would raise with e-cigarettes is that, you know, e-cigarettes are–well, let me just stop there. I would say that therein lies the kind of dilemma. The other thing I would say the FDA confronts is the idea that, if e-cigarettes really were a smoking cessation product, then you could actually see the Food and Drug Administration embracing it a little bit more, even if it has within it nicotine that is addictive, in the same way that Nicorette gum or the nicotine patch is embraced as a better product, an improvement over tobacco smoking. So, I think the FDA has the dilemma that it’s confronting which is, you know, whether to try to encourage the e-cigarette to be all that it promised to be in its early stages, which is not a route into smoking because of nicotine dependence, but a pathway out of tobacco smoking.

MS. WINFIELD CUNNINGHAM: Well, we’re going to have to leave it there, but Dr. Wailoo, Dr. Benjamin, thank you so much for joining us today on Washington Post Live.

MS. WINFIELD CUNNINGHAM: And thanks to all of you for joining us, today. To check out what interviews we have coming up, please head to WashingtonPostLive.com to register and find more information about all of our upcoming programs.

I’m Paige Winfield Cunningham, thanks so much for watching.

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