ThruLines is a DC Health data brief series designed to inform the public about ongoing public health challenges.
The series aims to take insights gleaned from analysis of local data to inspire evidence-based policies and programs that improve health in the District.

Menthol Tobacco Smoking in the District of Columbia

Smoking is responsible for an estimated one in six deaths in the District of Columbia.¹ Tobacco companies have long used flavorings in their products to attract new users.^{2, 3, 4}  Menthol is a particularly dangerous flavoring because it makes smoking easier to start and harder to quit.^{5, 6} For decades, the tobacco industry has aggressively marketed menthol products especially to non-Hispanic Black communities.^{7, 8} 

In 2021, the D.C. Council passed legislation to prohibit the sale or distribution of tobacco products containing flavorings. The law took effect on October 1, 2022.⁹

This ThruLines examines data from the 2022 Adult Tobacco Survey (ATS) to: (1) estimate flavored tobacco use among District adults; (2) understand how residents may respond once the law is fully enforced.

Most District residents who smoke use menthol

One in nine District adults (11.2%) reported smoking combustible products (i.e., cigarettes, cigars, cigarillos, or little filtered cigars). Of those residents who smoked any combustible product, 64% smoked menthol products. Those who smoked cigarettes were particularly likely to smoke menthol flavored cigarettes.

There are stark differences in menthol smoking among subgroups of District residents

Compared to the District overall, smoking rates were significantly higher among residents who lived in Ward 7, were non-Hispanic Black, had lower incomes, or had a high school education or less. Across these communities, 1 in 5 individuals smoked - almost double the citywide average of 1 in 9 - with menthol products making up most of that use. In contrast, among other demographic groups, only 1 in about 15 residents smoked, and fewer than half of those smokers reported using menthol products.

Most DC residents who smoke menthol want to quit and roughly half support a gradual ban on cigarettes

The majority of menthol smokers stated that they were ready to quit and many said they would not have started smoking if given a second chance.

Even smokers who felt “very addicted” to tobacco responded that they were thinking of quitting (data not shown). Moreover, nearly half of menthol smokers supported a gradual ban on cigarettes. Similar patterns of support were seen among groups with higher tobacco use, including non-Hispanic Black residents, individuals who reported lower incomes, older adults, single people, and men. Research suggests that people with lower levels of nicotine dependence are more likely to succeed in quitting.¹⁰ In the District, one third of residents that smoked menthol cigarettes reported having low or no nicotine dependence¹¹.

In 2022—the same year the flavored tobacco prohibition took effect—about two thirds of menthol smokers reported that they typically purchased tobacco products in the District, primarily from corner stores, convenience shops, grocery stores, or pharmacies.

The Takeaway

In other jurisdictions, evidence suggests that prohibitions on the sale of flavored tobacco products nudge smoking residents to quit and others not to start. These data suggest that this policy will be particularly helpful in the District as a large fraction of smokers use menthol products, most want to quit, many purchase products in DC, and a sizeable proportion have low levels of dependence on nicotine. Furthermore, most menthol smokers support stronger enforcement.

A 2024 survey of retail stores—conducted two years after the flavored tobacco prohibition took effect—revealed that approximately 1 in 10 licensed District stores were still illegally selling menthol products, and about 1 in 3 continued to sell other flavored tobacco products unlawfully (data not shown). These findings underscore the need for the District to fully enforce the ban on flavored tobacco sales and to evaluate its impact on purchasing behaviors and tobacco use.

WHAT CAN BE DONE:

DC Health will:

• Work with other District agencies to enforce restrictions on the sale of tobacco products, especially the sales of flavored products and sales to people under the age of 21.
• Help health care providers automate systems to screen patients for tobacco use and refer users to  resources that help them quit, including DCQuitNow.
• Build referral pathways with community organizations to DCQuitNow (1-800-QUIT-NOW or dcquitnow.org)
• Disseminate health communication campaigns to promote DCQuitNow and encourage quitting.

Policymakers should:

• Ensure strong enforcement of the flavored tobacco prohibition, Tobacco 21, smoke-free workplace laws, and comprehensive state tobacco control programs through tobacco taxes, settlement payments, and licensing fees, and increased penalty fees.
• Support ongoing surveys to monitor tobacco smoking, selling and purchasing.Increase tobacco retail licensing fees.
• Prohibit the discounting of tobacco products and require point-of-sale warnings at retail establishments to dissuade customers from purchasing tobacco products.
• Require insurance coverage for all FDA-approved smoking cessation treatments.
• Expand smoke-free protections to multi-unit housing.

Healthcare systems and providers should:

• Integrate and standardize tobacco screening and treatment processes, including direct referral to DCQuitNow.
• Measure quality indicators for tobacco screening and treatment and establish continuous quality improvement processes to improve system performance.
• Standardize screening for health-related social needs and referral to resources that address factors influencing smoking, such as access to healthy foods, housing, stress, and social isolation.

Health plans should:

• Reimburse for all FDA-approved tobacco cessation treatments.
• Provide financial incentives, such as value-based payments for high performance by providers on smoking cessation counseling.
• Reimburse DCQuitNow for cessation services provided to beneficiaries.

Employers should:

• Offer comprehensive cessation therapies through employee health insurance plans.
• Implement and enforce 100% tobacco-free facilities.
• Promote and refer employees to preventive services such as smoking cessation counseling.

Retailers should:

• Become familiar with and comply with DC tobacco regulations: Prohibition Against Selling Tobacco Products to Individuals Under 21 Amendment Act of 2016 (“Tobacco 21” or “T21) and Flavored Tobacco Product Prohibition Amendment Act of 2021 (the “flavors law”).
• Ensure all employees check identification for any person buying tobacco products.

Community-based organizations can:

• Support residents by promoting and providing smoking cessation resources, including DCQuitNow.
• Sponsor quitting support groups.
• Adopt 100% smoke-free facilities.

Residents can:

• If you don’t smoke, don’t start. If you do smoke, talk with your healthcare provider about cessation therapies that are right for you. Call 1-800-QUIT NOW or visit www.dcquitnow.org for cessation support and nicotine replacement therapy available at no cost to DC residents.
• Encourage and support friends and families who use tobacco to quit.
• Become a member of the DC Tobacco Free Coalition (www.dctfc.org) to lend your voice toward a tobacco-free DC.

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