Cessation behaviours among smokers of menthol and flavoured cigarettes following the implementation of the EU Tobacco Products Directive: findings from the EUREST-PLUS ITC Europe Surveys

Impact of the European Union's menthol cigarette ban on smoking cessation outcomes: longitudinal findings from the 2020-2021 ITC Netherlands Surveys

INTRODUCTION

To reduce the appeal of tobacco, the European Union (EU) banned menthol as a characterising flavour in cigarettes in May 2020. This pre/post-study evaluated the impact of the menthol ban on smoking cessation outcomes among a representative cohort of Dutch smokers.

METHODS

Adult (18+ years) smokers were recruited at wave 1 (pre-ban) of the International Tobacco Control Netherlands Surveys (February-March 2020) and followed post-ban at wave 2 (September-November 2020) and wave 3 (June-July 2021) (N=1326 participated in all three waves). Weighted bivariate, logistic regression and generalised estimating equation model analyses were conducted.

RESULTS

Usual menthol use decreased from pre-ban (7.8%) to post-ban (4.0% at wave 2 and 4.4% at wave 3) (p<0.001). Pre-ban menthol smokers had greater odds of making a post-ban quit attempt than non-menthol smokers (66.9% vs 49.6%, adjusted OR (aOR)=1.89, 95% CI: 1.13 to 3.16). Compared with pre-ban non-menthol smokers, a higher proportion of menthol smokers quit by wave 2 (17.8% vs 10.2%, p=0.025) and by wave 3 (26.1% vs 14.1%, p=0.002), although this was not significant after adjusting for other factors. Female pre-ban menthol smokers had greater odds of quitting by wave 3 than female non-menthol smokers (aOR=2.23, 95% CI: 1.10 to 4.51). Most pre-ban menthol smokers (n=99) switched to non-menthol cigarettes (40.0%) or reported that they continued to smoke menthol cigarettes (33.0%) at wave 3.

CONCLUSIONS

The EU menthol ban was effective in reducing menthol use and in increasing quit attempts and quitting among pre-ban menthol smokers. Impact could be maximised by closing gaps that allow post-ban menthol cigarette use.

An analysis of cigarette sales during Poland's menthol cigarette sales ban: small effects with large policy implications

BACKGROUND

In May 2020, the European Union Tobacco Products Directive mandated that EU member states, including Poland, ban the sale of menthol cigarettes. With menthol making up 28% of cigarette sales before the ban, Poland is the country with likely the largest menthol cigarette sales share in the world to ban their sale. We analyze how this ban changed the Polish tobacco market.

METHODS

We use monthly NielsenIQ data (May 2018-April 2021) on sales of cigarettes and roll-your-own tobacco by menthol and standard flavor in eight regions of Poland. We set up a bite-style regression model controlling for pre-ban menthol share, climate, border opening status, and Apple movement data to estimate the effect of the May 2020 menthol ban.

RESULTS

We find menthol cigarette sales fell at least 97% after the menthol cigarette ban across Poland and standard cigarette sales replaced them. Regression modeling indicates that total cigarette sales fell, after the ban, an average of 2.2 sticks per capita per month, equal to a 2.9% decline, however, results were not significant (P = 0.199). The bite component of our model reveals total cigarette sales did decline significantly in the regions with the highest pre-ban menthol sales shares. Roll-your-own tobacco sales increased by a statistically insignificant 0.03 stick-equivalents after the ban (P = 0.798). Product prices also fell in the wake of the menthol ban.

CONCLUSIONS

In Poland, the EU state with the one of the largest pre-ban menthol shares, we find mixed evidence that the ban is working as intended.

Menthol and flavored tobacco products in LMICs: A growing menace

INTRODUCTION

High income jurisdictions are banning menthol/flavored cigarettes and other tobacco products because they attract young people and create dependence. This study explores the importance of menthol and other flavored tobacco products for tobacco markets in low- and middle-income countries (LMICs), identifies countries where the menthol/flavor share is particularly high or rapidly growing, and identifies strategies tobacco companies are using to develop menthol/flavor markets.

METHODS

Research involved analysis of menthol/flavor market data from 2005 to 2019, a systematic review of academic literature, and a scoping exercise with our advocate contacts in LMICs.

RESULTS

The median menthol/capsule market share of the cigarette market grew significantly (p<0.05) between 2005 and 2019, both in lower and upper middle-income countries [lower: 2.5% (IQR: 0.5-4.0) to 6.5% (IQR: 3.6-15.9); and upper: 4.0% (IQR: 0.8-9.8) to 12.3% (IQR: 3.5-24.3)]. Countries with both high market share and high market share growth were Russia, Guatemala, Peru and Nigeria. No market data were available on low-income countries, but the academic literature suggested high prevalence of menthol use in Zambia. Tobacco industry strategies underpinning growth of menthol/flavored tobacco use in LMICs included in-store marketing and display, colorful packs and non-conventional flavor names.

CONCLUSIONS

Menthol/flavor tobacco products are a growing problem in LMICs. In addition to menthol/flavor bans, we recommend marketing bans, point of sale display bans and standardized packaging.

Evaluating the public health impact of partial and full tobacco flavour bans: A simulation study

Background

Methods

Findings

Interpretations

Funding

European Tobacco Products Directive (TPD): current impact and future steps

Efforts to reduce the toll of tobacco-related morbidity and mortality in the European Union are spearheaded by the Tobacco Products Directive (TPD), a legal act implemented during 2016-2021, with the overall aim to reduce tobacco consumption by 2% in Europe. Within this time frame, several core tobacco control measures were implemented, the impact of which is outlined within this manuscript. Key successful legislative actions implemented in this time frame led to greater availability of information and further regulation of additives, the banning of mentholated cigarettes, enhanced pictorial package warnings and a regulatory framework for e-cigarettes. While repeated cross-sectional data indicated a 12.5% relative reduction in smoking prevalence after implementation of the TPD, the differential regulation of cigarettes and roll-your-own tobacco compared with other products, such as cigarillos, e-cigarettes and heated tobacco products, may have also led to product displacement. Moreover, as the TPD could not keep up with the ever-changing nicotine product landscape, further adaptations may be needed.

Cross-sectional survey of flavored cigarette use among adult smokers in Singapore

INTRODUCTION

Singapore, a city-state with a multi-ethnic Asian population, has one of the world's largest market shares for cigarettes with added flavors, such as menthol and fruit, which increase the appeal of smoking. Little is known on the sociodemographic or smoking-related traits associated with flavored cigarette use in the Asian context.

METHODS

A cross-sectional survey was conducted in January-March 2020 of 1123 Singaporean adult (aged 21-69 years) current smokers using a self-completed online or postal questionnaire. We used descriptive statistics and bivariate analyses to compare the answers of flavored and non-flavored cigarette users and fitted a multivariate logistic regression model to identify correlates of flavored cigarette use.

RESULTS

Of the respondents, 85.2% reported ever use and 52.7% of respondents with a regular brand reported current use of flavored cigarettes. Older age 40-49 years (AOR= 0.63) age ≥50 years (AOR=0.60), Indian ethnicity (AOR=0.39), and a moderate (AOR=0.57) or high (AOR=0.34) dependence level were correlated with non-flavored cigarette use, while female gender (AOR=2.53) and a later initiation age (16-20 years: AOR=1.72; age ≥21 years: AOR=2.19) were correlated with flavored cigarette use.

CONCLUSIONS

Consistent with findings from other countries, flavored cigarette use in Singapore is associated with being younger in age, female, of a certain ethnicity (Malay or Chinese), and having a lower nicotine dependence level.

Perceptions, Predictors of and Motivation for Quitting among Smokers from Six European Countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n = 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking-related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasise these factors through health warnings and/or campaigns and other policies.