Tobacco industry response to menthol cigarette bans in Alberta and Nova Scotia, Canada

PMI's IQOS and cigarette ads in Israeli media: a content analysis across regulatory periods and target population subgroups

BACKGROUND

IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes.

METHODS

Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test.

RESULTS

The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging.

CONCLUSIONS

IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.

A randomized controlled trial of potential tobacco policies prohibiting menthol flavor in cigarettes and e-cigarettes: a study protocol

BACKGROUND

Menthol cigarette use remains a large public health problem and disproportionately affects Black adults in the United States. The Food and Drug Administration has proposed prohibiting menthol flavor in cigarettes to protect public health. However, e-cigarettes are available in menthol flavor and are a popular alternative product adults might switch to if menthol is prohibited in cigarettes. Research is needed to understand how availability of menthol (vs. tobacco) flavored e-cigarettes could impact cigarette use among adults who smoke menthol cigarettes.

METHODS

We will recruit 150 adults who currently smoke menthol cigarettes and will randomize them to 1 of 3 conditions modeling different regulatory scenarios. We will recruit equal numbers of participants identifying as Black vs. non-Black and will stratify randomization by race. To promote standardization and adherence, cigarette and e-cigarette products will be provided for 8 weeks based on the assigned condition: (A) no menthol restriction (menthol cigarette and menthol flavored e-cigarette), (B) menthol prohibited in cigarettes only (non-menthol cigarette and menthol flavored e-cigarette), (C) menthol prohibited in both cigarettes and e-cigarettes (non-menthol cigarette and tobacco flavored e-cigarette). A follow-up visit will occur at week 12 to assess tobacco use status. The study aims are to (1) examine the impact of prohibiting menthol flavor in cigarettes and e-cigarettes on smoking behavior and (2) investigate whether outcomes differ by race to understand the impact of menthol policies on Black (vs. non-Black) individuals given high rates of menthol cigarette use in this population. The primary outcome will evaluate changes in the number of cigarettes smoked per day during the 8-week study period and will examine differences by regulatory scenario. Secondary outcomes will compare percent days smoke-free, changes in nicotine dependence, and motivation, confidence, and intentions to quit smoking by the regulatory scenarios. We will examine whether changes in the outcomes differ by Black vs. non-Black participants to compare the magnitude of the effect of the various menthol policy scenarios by race.

DISCUSSION

Results will contribute critical information regarding menthol in cigarettes and e-cigarettes to inform regulatory policies that maximize reductions in cigarette smoking and reduce tobacco-related health disparities.

TRIAL REGISTRATION

NCT05259566. Yale IRB protocol #2000032211, last approved 12/8/2023.

The Impact of Menthol Cigarette Bans: A Systematic Review and Meta-Analysis

INTRODUCTION

This review investigates the impacts of banning the sale of menthol cigarettes at stores.

METHODS

A systematic search of studies published in English up to November 2022 was conducted. The following databases were searched: PubMed/Medline, CINAHL, PsycINFO, Web of Science, and Embase, as well as a non-indexed journal. Studies evaluating either the impact of real-world or hypothesized menthol cigarette bans were included. Primary outcomes include tobacco use behaviors. Secondary outcomes include cigarette sales, retailer compliance, and the tobacco industry's response to a menthol ban. Data on tobacco use behavior after a menthol ban were pooled using random-effects models. Two pairs of reviewers independently extracted data and assessed study quality.

RESULTS

Of the 964 articles that were identified during the initial search, 78 were included in the review and 16 were included in the meta-analysis. Cessation rates among menthol cigarette smokers were high after a menthol ban. Pooled results show that 24% (95% confidence interval [95% CI]: 20%, 28%) of menthol cigarette smokers quit smoking after a menthol ban, 50% (95% CI: 31%, 68%) switched to non-menthol cigarettes, 12% (95% CI: 3%, 20%) switched to other flavored tobacco products, and 24% (95% CI: 17%, 31%) continued smoking menthol cigarettes. Hypothesized quitting and switching rates were fairly close to real-world rates. Studies found the tobacco industry attempts to undermine menthol bans. National menthol bans appear more effective than local or state menthol bans.

CONCLUSIONS

Menthol cigarette bans promote smoking cessation suggesting their potential to improve public health.

IMPLICATIONS

Findings from this review suggest that menthol cigarette bans promote smoking cessation among menthol cigarette smokers and have the potential to improve public health.

Reactions to using other nicotine and tobacco products instead of menthol cigarettes: A qualitative study of people who smoke menthol cigarettes in the United States

The US Food and Drug Administration is considering banning menthol cigarettes, which could result in some people who smoke menthol cigarettes switching to other tobacco products (OTPs). This qualitative study explored reactions to using OTPs instead of menthol cigarettes. People who smoke menthol cigarettes (N=40) completed a behavioral economic assessment of the effects of menthol cigarette price increases on OTP purchasing. At the highest price, most participants could not afford menthol cigarettes. Instead, they could purchase non-menthol cigarettes, little cigars/cigarillos (LCCs), e-cigarettes, smokeless tobacco, or medicinal nicotine, or they could abstain from tobacco use. Participants used the OTPs they purchased for three days. During follow-up sessions, participants (n=35) completed semi-structured interviews discussing their purchasing-decisions and experiences using OTPs instead of menthol cigarettes. Interviews were analyzed using reflexive thematic analysis methods. Factors influencing purchasing decisions included flavor, price, prior use of OTPs, interest in trying new OTPs, and perceived ability to satisfy nicotine cravings. Participants described positive experiences using e-cigarettes including the "refreshing" menthol flavor, ability to use in places where cigarettes are prohibited, and convenience of use relative to smoking. Among those using non-menthol cigarettes, many reported they were acceptable but less satisfying products compared to menthol cigarettes while others reported negative reactions to them such as tasting like "cardboard". Reactions to smoking LCCs were mostly unfavorable but participants said it gave them "something to light". Multiple considerations may affect switching to OTPs in light of pending menthol cigarette regulation including the availability of menthol-flavored alternatives and (dis)satisfaction with OTPs.

Documenting the Impact Potential of a Menthol Cigarette Ban at Point-of-Sale: A Photograph-Based Analysis of the Presence and Placement of Menthol Versus Regular Cigarette Packs on the Shelves of Tobacco Retail Outlets in New York City

INTRODUCTION

To investigate the absolute and proportionate number of menthol versus regular cigarette packs displayed on the shelves inside tobacco retail outlets (TROs) across New York City (NYC).

AIMS AND METHODS

Photographic surveillance methods were used to capture the presence and proportionate amount of all visible cigarette packs on the shelves inside N = 160 TROs. Statistical analyses examined the absolute and proportionate number of menthol packs in each TRO as a function of NYC borough, the local TRO environment, population smoking rates derived from the NYC Community Health Survey, and other demographic indicators from the American Community Survey.

RESULTS

The total number of cigarette packs on the shelves of each TRO and the proportion of menthol packs varied significantly across TROs, averaging about one-quarter of all packs displayed (M = 0.274; SD = .15). Modeling results indicate that the proportion of menthol packs displayed was significantly greater in areas with elevated population smoking rates (odds ratio [OR] = 1.03, CI: 1.01-1.06) and density of TROs per 1000 residents (OR = 1.23; CI: 1.01-1.49), although these associations varied in complex ways with the proportion living under the federal poverty level and the proportion under age 18 years residing within each zip-code.

CONCLUSIONS

Results of this study demonstrate the utility of photograph-based TRO audit methods for objective, reliable documentation of the presence and proportionate amount of menthol versus other cigarette pack types on TRO shelves and highlight the need to account for sources of variation between small areas when examining the TRO product landscape and evaluating the effectiveness of regulatory actions against menthol.

IMPLICATIONS

This study describes use of a "hands-free" surveillance technique that offers valuable advantages over traditional retailer surveillance techniques. Comprehensive photographic surveillance data collection allows for more objective measurements of, in this case, the retail outlet's tobacco power wall, as multiple coders can review the same images and interrater reliability can be empirically tested. The results of this analysis highlight the need to account for local variation between small areas when examining TRO product landscapes and the effects of policy changes at the retailer level.

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.

The Economics of Tobacco Regulation: A Comprehensive Review

Tobacco regulation has been a major component of health policy in the developed world since the UK Royal College of Physicians' and the US Surgeon General's reports in the 1960s. Such regulation, which has intensified in the past two decades, includes cigarette taxation, place-based smoking bans in areas ranging from bars and restaurants to workplaces, and regulations designed to make tobacco products less desirable. More recently, the availability of alternative products, most notably e-cigarettes, has increased dramatically, and these products are just starting to be regulated. Despite an extensive body of research on tobacco regulations, there remains substantial debate regarding their effectiveness, and ultimately, their impact on economic welfare. We provide the first comprehensive review of the state of research in the economics of tobacco regulation in two decades.

'Menthol-Plus': a major category of cigarette found among 'concept' descriptor cigarettes from Mexico

BACKGROUND

Tobacco companies are offering cigarettes with 'concept' descriptor names that suggest sensation and/or flavour properties (eg, Marlboro 'Velvet Fusion'). Little has been known about the identities and levels of flavour chemicals in such cigarettes.

METHODS

Thirty-three filter cigarette variants from 27 packs (including two sampler packs with four variations each) from Canada and Mexico were analysed (rod + filter) for 177 flavour chemicals plus triacetin, a filter plasticiser and possible flavourant. Five brands of US mentholated filter cigarettes were also analysed.

RESULTS

Twenty-seven of the 33 cigarettes (all were Mexican variants) were categorised as 'menthol-plus': significant menthol (3.0-11.9 mg/cigarette), plus varying amounts (0.32-3.4 mg/cigarette) of total other flavour chemicals (TOFCs) (excludes triacetin). For 10 of the 27, TOFCs >1.0 mg/cigarette. For 7 of the 27, the TOFCs profile was categorised as containing total fruit flavour compounds (TFFCs) >1.0 mg/cigarette. One Mexican variant was categorised as 'menthol-only' (TOFCs ≤0.15 mg/cigarette). All menthol-plus and menthol-only cigarettes contained one or two optional-crush capsules in their filters (crushed prior to analysis). All five Canadian brand variants were 'non-flavoured'. All five US brand variants were 'menthol-only'.

CONCLUSIONS

All but one of the 'concept' descriptor cigarettes from Mexico were 'menthol-plus'. While the Canadian cigarettes complied with Canada's flavour chemical ban, concept descriptors on the packs may increase appeal. Given the scale of the problem posed by menthol alone, health officials seeking to decrease the appeal of smoked tobacco should examine the extent to which 'concept descriptor' cigarettes using 'menthol-plus' flavour profiling together with artful descriptors are furthering the problem of smoked tobacco.

Prevalence of Menthol and Menthol Capsule Cigarette Use Among 11-16 Year Olds in Wales Prior to a Ban on Characterizing Flavors in Cigarettes: Findings From the 2019 Student Health and Wellbeing Survey

INTRODUCTION

The use of flavored cigarettes has increased in many countries because of the inclusion of one or more frangible flavor-changing capsules in the filter. Research suggests that these "capsule" cigarettes appeal most to youth, but little is known about how prevalent their use is among children.

METHODS

A cross-sectional school survey was conducted between September and December 2019 with 11-16 year-olds (N = 119 388) from 198 secondary schools across Wales; the sample represented approximately two-thirds of all 11-16 year-olds in the country. The sample was asked about smoking behavior, with a quarter (N = 26 950) also asked about awareness of menthol cigarettes, and use of menthol and menthol capsule cigarettes if a current smoker (N = 1447).

RESULTS

Current smoking prevalence was 5.7% among the entire sample and 5.9% among the analytical sample (those also asked about menthol and menthol capsule cigarettes). For the analytical sample, almost all current smokers (93.2%) were aware of menthol cigarettes, with three-fifths (60.5%) reporting having used menthol cigarettes in the past 30 days (42.3% capsule cigarettes, 18.2% noncapsule cigarettes). In comparison to nonmenthol smokers, those using menthol cigarettes (capsule and noncapsule) were more likely to be frequent smokers, with those using menthol capsule cigarettes more likely to have smoked for longer.

CONCLUSIONS

While past research suggests that flavored cigarettes appeal to youth, this study shows just how popular these products, and capsule cigarettes, in particular, were among young smokers in Wales. It also raises questions about why capsule cigarettes have received such limited public health attention.

IMPLICATIONS

That three in five 11-16 year-old smokers reported using menthol cigarettes in the past 30 days highlights how appealing these products are to young people, particularly capsule cigarettes, used by seventy percent of menthol smokers. Capsule cigarettes are one of the most successful tobacco product innovations in decades, even in countries with comprehensive bans on tobacco marketing and standardized packaging. The dearth of research on capsule cigarettes is a failure of global public health. Evaluation of the ban on characterizing flavors in the United Kingdom and across the European Union is critical.

Evaluating the impact of menthol cigarette bans on cessation and smoking behaviours in Canada: longitudinal findings from the Canadian arm of the 2016-2018 ITC Four Country Smoking and Vaping Surveys

OBJECTIVE

To evaluate the impact of menthol cigarette bans in seven Canadian provinces between 2016 and 2018.

METHODS

Longitudinal data from the Canadian arm of the 2016 and 2018 ITC Four Country Smoking and Vaping Survey. 1098 non-menthol and 138 menthol smokers were surveyed pre-menthol and post-menthol cigarette bans. Multivariate logistic regression models examined associations between pre-post ban changes in smoking behaviour, including differences between menthol and non-menthol smokers in quit attempts and quitting.

RESULTS

At follow-up, 59.1% of pre-ban menthol smokers switched to non-menthol cigarettes; 21.5% quit smoking and 19.5% still smoked menthols, primarily purchased from First Nations reserves. Menthol smokers were more likely than non-menthol smokers to make a quit attempt (adjusted OR (aOR)=1.61, 95% CI 1.03 to 2.51), and to remain quit (aOR=2.30, 95% CI 1.06 to 5.01). Menthol smokers did not differ significantly from non-menthol smokers in quit success (aOR=1.72, 95% CI 0.98 to 3.01); however, daily menthol smokers were more likely than daily non-menthol smokers to quit (aOR=2.21, 95% CI 1.15 to 4.24), and daily menthol smokers who quit before the ban were more likely than daily non-menthol smokers to remain quit (aOR=2.81, 95% CI 1.15 to 6.85).

CONCLUSIONS

Although menthol smokers were most likely to switch to non-menthol cigarettes, the menthol ban was also significantly associated with higher rates of quit attempts and quit success among menthol smokers compared with non-menthol smokers, and may have helped to prevent relapse among menthol smokers who had quit smoking before the ban. Results confirm and extend evaluation of Ontario's menthol ban across provinces covering 83% of the Canadian population.

Evaluating the Outcomes of the Menthol Cigarette Ban in England by Comparing Menthol Cigarette Smoking Among Youth in England, Canada, and the US, 2018-2020

Importance

Menthol cigarettes were prohibited in England in May 2020 and nationally in Canada in October 2017 but remain permitted in the US. Evidence on the outcomes of menthol cigarette bans among youth outside of Canada, and the characteristics of youth smokers, is lacking.

Objectives

To evaluate the outcomes of menthol cigarette bans on youth menthol cigarette smoking and to characterize youth menthol cigarette smokers in terms of demographics and cigarette consumption and dependence.

Design, Setting, and Participants

This survey study uses data from online repeat cross-sectional International Tobacco Control Youth Tobacco and Vaping Surveys conducted in 2018, 2019, February 2020, and August 2020. Participants included past 30-day smokers aged 16 to 19 years. Data analysis was performed from March 2021 to January 2022.

Main Outcomes and Measures

Usually smoke a brand of cigarettes that was menthol, including capsule.

Exposures

Menthol cigarette ban, comparing 3 countries over time: Canada, where a ban already existed, England, where a ban was implemented during the study, and the US, where no national ban was present. Age, sex, race, and consumption and dependence were also examined by menthol smoking in each country, and in England before vs after the ban.

Results

The analytical sample comprised 7067 participants aged 16 to 19 years, of whom 4129 were female and 5019 were White. In England, the weighted percentage of youth smokers who reported smoking a menthol or capsule cigarette brand was stable in the 3 survey waves before the menthol ban (2018 to February 2020, 9.4% vs 12.1%; adjusted odds ratio [AOR], 1.03; 95% CI, 0.99-1.06; P = .15) but decreased to 3.0% after the ban (February 2020 vs August 2020, AOR, 1.07; 95% CI, 1.04-1.10; P < .001). The decrease between February and August 2020 in England was similar across all demographic groups but was greater among youth who perceived themselves as addicted to cigarettes (AOR, 0.37; 95% CI, 0.41-0.97; P = .04). In the 2 comparison countries, menthol or capsule smoking was stable across all waves (2018 to August 2020: US, 33.6%-36.9%; Canada, 3.1%-2.3%) and was more prevalent in the US than in England (AOR, 5.58; 95% CI, 4.63-6.72; P < .001). Menthol or capsule smoking was also more prevalent among smokers in England who were female vs male (10.9% vs 7.2%; AOR, 1.04; 95% CI, 1.01-1.06; P = .002); among smokers in the US who identified as Black vs White (60.6% vs 31.9%; AOR, 1.33; 95% CI, 1.23-1.44; P < .001) or who were frequent smokers (AOR, 1.07; 95% CI, 1.01-1.13; P = .03), smoked more cigarettes per day (2-5 vs 1, AOR, 1.09; 95% CI, 1.02-1.15; P = .006; >5 vs 1, AOR, 1.10; 95% CI, 1.03-1.18; P = .007), or had urges to smoke every or most days (AOR, 1.08; 95% CI, 1.02-1.14; P = .006); and among smokers in Canada who perceived themselves as addicted to cigarettes (AOR, 1.02; 95% CI, 1.00-1.03; P = .01).

Conclusions and Relevance

In this survey study, the proportion of youth smokers who smoke menthol (including capsule) cigarettes decreased substantially after the menthol ban in England. This association was consistent across all demographic groups. Perceived addiction among menthol smokers was also lower where menthol cigarettes were banned.

Taking global leadership in banning menthol and other flavours in tobacco: Canada's experience

Measures to ban or restrict menthol and other flavours in tobacco products are under consideration or newly implemented in an increasing number of jurisdictions across the world. As one of the world leaders, Canada's experience in successfully developing and implementing such measures can be instructive for other jurisdictions. This paper explores the history of how Canada was able to implement tobacco flavour bans including menthol, examines some of the challenges and presents lessons learnt for other jurisdictions. The crucial motivation for these bans emerged from surveillance data showing high rates of flavoured tobacco use by youth, including menthol cigarette smoking, that was publicised by non-governmental organisations. Further data showed that early legislation in 2009 contained loopholes (cigar size exemptions and menthol exemptions) that limited the benefits of the legislation. Leadership by the provinces created an environment in which the federal ban on menthol ingredients in 2017 was a clear and obvious step to ensure implementation across the country. The Canadian measures have been successful at reducing the use of flavoured tobacco including menthol cigarettes and facilitating smoking cessation. Lessons learnt include the downsides of exemptions, the lack of a contraband issue (despite an existing supply in Canada), the benefits of availability of youth flavour prevalence data and the success of subnational regulations to advance national regulation.

Menthol cigarette use in substance use disorder treatment before and after implementation of a county-wide flavoured tobacco ban

INTRODUCTION

This study examined the impact of a San Francisco City and County ban on all flavoured tobacco products, including menthol cigarettes, among clients in residential substance use disorder (SUD) treatment.

METHODS

We conducted cross-sectional surveys of clients at two residential SUD programmes before the County began enforcing the ban (n=160) and twice after enforcement began (n=102, n=120). The samples were compared on demographic characteristics, smoking status, smoking behaviours and the proportion reporting menthol as their usual cigarette. Menthol smokers were asked whether they smoked only menthol cigarettes, mostly menthol, both menthol and non-menthol or mostly non-menthol. Post-ban samples were asked about awareness of the ban and access to menthol cigarettes.

RESULTS

In multivariate analyses, we found no evidence that the ban was associated with decreased number of cigarettes per day or increased readiness to quit among current smokers. However, odds were lower post-ban for reporting menthol as the usual cigarette (OR=0.80, 95% CI 0.72 to 0.90), and for smoking only menthol cigarettes (OR=0.19, 95% CI 0.18 to 0.19). Perhaps most importantly, and with the ability to influence all other findings, 50% of self-identified menthol smokers reported purchasing menthol cigarettes in San Francisco nearly 1 year after the ban was implemented.

CONCLUSION

In subgroups where smoking has remained elevated, like those receiving SUD treatment, local menthol bans may have only modest impacts on smoking behaviour. Broader regional, state or national bans, that effectively restrict access to menthol products, may be needed to show stronger effects on smoking behaviour.

A Comprehensive Qualitative Review of Studies Evaluating the Impact of Local US Laws Restricting the Sale of Flavored and Menthol Tobacco Products

Objectives

To assess the quality of evidence on the effectiveness of local US laws restricting the sale of flavored tobacco products.

Methods

We conducted a systematic search and qualitative scoping review of English-language papers published through May 2020 that evaluated flavored tobacco sales policies implemented by US jurisdictions during 2010–2019. We constructed a conceptual model for flavored and menthol tobacco sales restriction outcomes, assigned GRADE quality of evidence ratings to policy outcomes evaluated through the included studies, and summarized factors that might explain weak or inconsistent findings.

Results

We found moderate to high quality of evidence associating policy implementation with reduced availability, marketing, and sales of policy-restricted products, and decreased youth and adult tobacco use of these products; however, policy exclusions and exemptions, implementation challenges, tobacco industry actions (e.g., marketing of concept-named flavored products; exploiting policy exemptions for certain store types), and consumer responses (e.g., cross-border or illicit purchasing) might undermine or mitigate intended policy effects.

Conclusions

Flavored and menthol tobacco product sales restrictions implemented and evaluated in US jurisdictions appear to have achieved some of their intended outcomes; however, deficiencies in study designs, methods, and metrics could contribute to equivocal findings on quality of evidence associating policy implementation and outcomes. Gaps in the evidence are beginning to be filled with research using more rigorous study designs, improved measurement and analytic methods, and longer-term follow-up.

Implications

In the absence of comprehensive federal action, US jurisdictions have the obligation to restrict flavored and menthol product sales to protect vulnerable populations from tobacco-related harms. The considerable expenditure of financial resources, political will, and time dedicated to policy adoption and implementation argue for evaluation studies designed to maximize the quality of evidence. This review offers generalizable insights into evaluation findings that can inform efforts to enhance tobacco control policy implementation and impact in the US and globally.

Local sales restrictions significantly reduce the availability of menthol tobacco: findings from four Minnesota cities

BACKGROUND

In 2017 and 2018, Minneapolis, St. Paul, Duluth and Falcon Heights, Minnesota were among the first US cities to restrict the sale of menthol tobacco to adult-only stores. The study examined changes in the availability and marketing of these products following policy implementation.

METHODS

Retail store audits were conducted approximately 2 months pre-policy and post-policy implementation. Tobacco retail stores (n=299) were sampled from tobacco licensing lists in Minneapolis, St. Paul, Duluth and Falcon Heights, as well as six comparison cities without menthol policies. The presence of menthol tobacco was assessed, along with the number of interior and exterior tobacco ads and promotions at each store.

RESULTS

The majority of policy intervention stores (grocery, convenience stores and pharmacies) were compliant (Minneapolis, 84.4%; Duluth, 97.5%; and St. Paul and Falcon Heights, 100.0%) and did not sell menthol tobacco. In contrast, menthol tobacco was available in all comparison city stores, and most (96.0%) exempted tobacco shops and liquor stores post-policy implementation. Two Minneapolis convenience stores added interior tobacco shops, allowing them to continue selling menthol tobacco. Significant decreases in menthol tobacco marketing post-policy were observed in the stores' interior in Minneapolis, St. Paul and Duluth (p<0.001) and on the stores' exterior in Duluth (p=0.023).

CONCLUSIONS

Findings demonstrate high rates of compliance, indicating that sales restrictions can significantly reduce the availability of menthol tobacco. However, challenges to policy adherence underscore the need for continued monitoring and enforcement action.

Changes in retail sales of tobacco products in Ontario after a menthol sales restriction

BACKGROUND

Ontario, Canada prohibited menthol tobacco product sales beginning 1 January 2017. We measured retail sales of menthol cigarettes and possible substitute products before and after policy implementation in Ontario.

METHODS

We licensed retail scanner data for tobacco product sales in Ontario and British Columbia (BC), a comparison province without a menthol tobacco policy at that time. We assessed changes in per capita unit sales (per 1000 people) from pre-policy (January-June 2016) to post-policy (January-June 2017) periods. Classification of cigarettes as menthol or non-menthol, or having menthol-suggestive descriptors ('green', 'blue', 'silver' and 'fresh'), was based on scanner data.

RESULTS

Ontario menthol cigarette sales decreased 93%, from 596 to 40 packs per capita compared with a 2% decrease (696 to 679 packs per capita) in BC. Menthol capsule cigarette sales remained low in Ontario (<1% of total cigarette sales) but rose sixfold in BC. Although cigar sales data were unavailable, substitution appeared minimal; sales of non-menthol cigarettes increased 0.4% in Ontario (11 470 to 11 519 packs per capita) while vaping product sales decreased. Ontario had a larger increase in sales of cigarettes with menthol-suggestive descriptors (11% increase) than BC (3% increase). In Ontario, nearly all (>99%) pre-policy sales of cigarettes with 'green' menthol-suggestive descriptors were menthol cigarettes, but post-policy, 94% of 'green' cigarettes sold were non-menthol.

CONCLUSIONS

Ontario's menthol policy was associated with a decrease in retail sales of cigarettes classified as menthol, with little evidence of product substitution. Understanding changes in sales of cigarettes with menthol-suggestive descriptors would be informative.

Prior Daily Menthol Smokers More Likely to Quit 2 Years After a Menthol Ban Than Non-menthol Smokers: A Population Cohort Study

BACKGROUND AND AIMS

The province of Ontario, Canada, banned the use of menthol-flavored tobacco products as of January 1, 2017. This study aims to assess the longer-term impact of a menthol ban on smoking behavior at 2 years, which is unknown.

METHODS

Population cohort study with baseline survey (n = 1821) conducted September-December 2016 and follow-up survey January-August 2019 among current smokers in Ontario (16+) prior to the menthol ban. Poisson regression was used to assess the probability of quitting smoking by pre-ban menthol status, controlling for differences in smoking and demographic characteristics, with multiple imputations used to address missing data.

FINDINGS

Menthol smokers were more likely to report having quit smoking (12% [daily menthol] and 10% [occasional menthol] vs. 3% [non-menthol]; p < .001) than non-menthol smokers in the 2 years after a menthol ban. After adjustment for smoking and demographic characteristics, daily menthol smokers had higher likelihood of quitting smoking (adjusted relative risk [ARR] 2.08; 95% confidence interval [CI] 1.20-3.61) and reported more quit attempts (ARR 1.45; 95% CI 1.15-1.82). Among those who attempted to quit, menthol smoking was not associated with relapse (daily ARR = 0.96; 95% CI: 0.86, 1.07; occasional ARR = 0.99; 95% CI: 0.90, 1.08). However, there was a statistically significant interaction among menthol users who reported using other flavored tobacco products 1 year after the ban (ARR = 0.26 [95% CI: 0.08, 0.90]).

CONCLUSIONS

The study found increased probability of quitting among daily menthol smokers and more quit attempts among daily and occasional menthol smokers compared with non-menthol smokers in Ontario 2 years after the implementation of a menthol ban.

IMPLICATIONS

This study examines quitting behavior 2 years after a menthol ban in Ontario, Canada. Those who were daily menthol smokers prior to the ban were more likely to quit smoking and make more quit attempts in the 2 years after the ban. While there was no difference in the likelihood of relapse between menthol and non-menthol smokers among those who attempt to quit, there were indications that pre-ban daily menthol smokers who used other tobacco products after the ban were likely to quit.

Evaluating a Real World Ban on Menthol Cigarettes: An Interrupted Time-Series Analysis of Sales

Background

Menthol in cigarettes has been shown to increase regular cigarette smoking and nicotine dependence, and decrease success in smoking cessation. Owing to these reasons, in May 2015, the province of Ontario introduced a menthol ban on tobacco products that came into effect in January 2017 prior to a Federal Canadian Ban in October 2017. The objective of this article was to assess the effect of a provincial menthol ban on cigarette wholesale sales in Ontario.

Methods

Wholesale data submitted by tobacco manufacturers to Health Canada pursuant to the federal Tobacco Reporting Regulations from October 2012 to September 2017 were analyzed using interrupted time-series analysis. Changes in sales of cigarettes with and without menthol were estimated, using the province of British Columbia as a comparison. Analyses were seasonally adjusted.

Results

Sales of menthol and nonmenthol cigarettes increased from 2013 until the implementation of the 2017 provincial ban. Subsequently, a sharp decline of 55 million menthol cigarettes and 128 million total cigarettes was observed in Ontario. As a comparison, no significant changes were observed in British Columbia.

Conclusion

This study supports the conclusion that implementation of a menthol ban in Ontario was associated with significant reduction of menthol cigarette sales and total cigarettes sales, compared to British Columbia where there was no provincial menthol ban. This suggests that menthol regulations in jurisdictions with a larger percentage of menthol smokers are likely to be highly effective.

Implications

The 2017 menthol ban was associated with significant reduction of menthol cigarette sales and total cigarette sales suggesting that menthol regulations will have important effects on cigarette consumption.

The actual and anticipated effects of a menthol cigarette ban: a scoping review

Background

The United States (US) Food and Drug Administration (FDA), under the 2009 Family Smoking Prevention and Tobacco Control Act, banned characterizing flavors in cigarettes; however, mentholated tobacco products were exempt. Since 2009, over 20 US jurisdictions and numerous countries around the world have extended this restriction to menthol. Currently, the FDA is reconsidering its position on a nation-wide menthol cigarette ban. However, the effects of such a ban remain unclear. We conducted a scoping review to explore the impact of a menthol cigarette ban on individual behaviors (initiation, cessation, and product switching), sales, and compliance.

Methods

We conducted a search of the international literature using PubMed, EBSCO, and Web of Science (to November 25, 2019). We retrieved articles relevant to the impacts of an implemented or hypothetical menthol ban. We also included studies of flavored tobacco product bans due to their potential relevance in gauging compliance and product substitutability.

Results

The search identified 493 articles, of which 24 were included. Studies examined the effects of implemented menthol bans (n = 6), hypothetical menthol bans (n = 12) and implemented flavor bans that exclude menthol (n = 6). Menthol bans were found to reduce sales and increase smoking cessation with only partial substitution for non-menthol cigarettes. US smokers’ reactions to a hypothetical ban indicate that about 25–64% would attempt to quit smoking and 11–46% would consider switching to other tobacco products, including 15–30% to e-cigarettes. Flavor ban studies indicate reductions in initiation of 6%. Ban compliance was high, but studies indicate that the tobacco industry and retailers have attempted to circumvent their impact via packaging changes and online sales.

Conclusion

Our review finds that extending the US cigarette flavor ban to menthol products would promote smoking cessation and reduce initiation. This evidence supports further action by the FDA towards mentholated tobacco products. However, few studies have been conducted in the vaping era.

'It has candy. You need to press on it': young adults' perceptions of flavoured cigarettes in the Philippines

BACKGROUND

The Philippines has a high smoking prevalence and one of the largest tobacco menthol market shares in the world. Flavour capsule cigarettes were introduced to the Philippines in 2013, most of which are menthol flavoured, and their market share is increasing. We explored perceptions of flavoured cigarette packaging among young adult Filipinos.

METHODS

We conducted eight focus groups with 63 young adults ages 18-24 years in Manila in 2019, stratified by gender and smoking status. We conducted a thematic analysis of the transcripts.

RESULTS

Most participants assessed relative harm of cigarettes based on strength, mainly determined by colour of the packaging. Menthol cigarettes with primarily blue packaging were considered less harmful than menthol cigarettes with primarily green packaging. Many participants considered flavour capsule packs most attractive, compared with non-flavoured and traditional menthol cigarettes, due to the colouring of the packs and expectations regarding taste. Some participants likened the capsules and the taste of flavour capsule cigarettes to candy, and many participants thought flavour capsule cigarettes would most likely be smoked by teenagers or young adults.

CONCLUSIONS

Young adult Filipinos believe that some menthol-flavoured cigarettes are less harmful than other flavoured cigarettes and non-flavoured cigarettes and find flavour capsule cigarettes attractive. A tobacco flavour ban and implementation of plain packaging might help reduce misperceptions of risk and make cigarettes less appealing.

Product Substitution After A Real-World Menthol Ban: A Cohort Study

Objectives

The province of Ontario, Canada banned menthol in cigarettes and other tobacco products effective January 1^st, 2017 adding to an existing flavour ban. However, all flavoured e-cigarettes, flavoured cigars larger than 6g, and alcohol flavoured cigars without filters over 1.4g were exempted. This paper examines the association between use of flavoured non-cigarette products and self-reported cigarette smoking cessation after the ban.

Methods

Current past-30 day cigarette smokers (N=913) who were 16 years or older, living in Ontario were recruited between September-December 2016 and re-contacted January-August 2018.

Results

Both daily and occasional pre-ban menthol cigarette smokers were more likely to use flavoured cigar products (adjusted relative rate, RR=1.53, 95% confidence interval, CI=1.01, 2.31; adjusted RR=1.57, 95% CI=1.06, 2.30) after the ban, while occasional pre-ban menthol cigarette smokers were more likely to use other tobacco products (adjusted RR=1.25, 95% CI=1.02, 1.53) or flavoured other tobacco products (adjusted RR=1.56, 95% CI=1.09, 2.24), conditional on prior use.

Conclusions

Menthol smokers prior to the ban were more likely to use other tobacco products, or flavoured tobacco products, after the ban. These results suggest that comprehensive menthol bans could be more effective without the option of using flavoured tobacco or nicotine products as substitutes.

Menthol and flavor capsule cigarettes in the Philippines: A comparison of pack design

INTRODUCTION

Tobacco use is a major public health problem in the Philippines. Menthol flavored and flavor capsule cigarettes are independently associated with increased smoking initiation and appeal to youth and young adults. Packaging is an important tobacco marketing tool. We describe cigarette packs sold in the Philippines market and describe products’ flavor and capsule inclusion.

METHODS

Tobacco packs were systematically collected in the Philippines in 2016 and categorized as non-flavored non-capsule, menthol non-capsule, menthol capsule, and non-menthol capsule. Structural elements (e.g. pack type, shape) and graphic components (e.g. imagery, descriptors, color) of the packs were compared.

RESULTS

Menthol capsule packs were significantly more likely to be hard packs than menthol non-capsule. Menthol packs were more likely to be colored green than non-flavored packs. Non-menthol capsule packs were more likely to display the term ‘fresh’ than non-capsule packs. Capsule packs were more likely to display technological appeals than non-capsule packs.

CONCLUSIONS

Menthol and flavor capsule cigarettes are packaged differently (most notably, in terms of color and technological appeals) than non-menthol and non-capsule packs. Packaging and labeling policy should take this into consideration.

Ban on menthol-flavoured tobacco products predicts cigarette cessation at 1 year: a population cohort study

OBJECTIVES

The province of Ontario, Canada, banned the use of menthol-flavoured tobacco products as of 1 January 2017. The long-term impact of a menthol ban on smoking behaviour has not been previously evaluated.

METHODS

Population cohort study with baseline survey conducted September-December 2016 and follow-up January-August 2018 among residents of Ontario, Canada, 16 years old and over who reported current smoking (past 30 days) at baseline survey and completed follow-up (n=913) including 187 reporting smoking menthol cigarettes daily, 420 reported smoking menthol cigarettes occasionally, and 306 were non-menthol cigarette smokers. Relative rates of making a quit attempt and being a non-smoker at follow-up were estimated with Poisson regression controlling for smoking and demographic characteristics at baseline.

RESULTS

At follow-up, 63% of daily menthol smokers reported making a quit attempt since the ban compared with 62% of occasional menthol smokers and 43% of non-menthol smokers (adjusted relative rate (ARR) for daily menthol smokers compared with non-menthol smokers: 1.25; 95% CI 1.03 to 1.50). At follow-up, 24% of daily menthol smokers reported making a quit since the ban compared with 20% of occasional menthol smokers and 14% of non-menthol smokers (ARR for daily menthol smokers compared with non-menthol smokers: 1.62; 95% CI 1.08 to 2.42).

CONCLUSIONS

The study found higher rates of quitting among daily and occasional menthol smokers in Ontario 1 year after the implementation of a menthol ban compared with non-menthol smokers. Our findings suggest that restrictions on menthol may lead to substantial improvements in public health.

Opening windows and closing gaps: a case analysis of Canada's 2009 tobacco additives ban and its policy lessons

BACKGROUND

In 2009, Canada adopted legislation (Bill C-32) restricting the sale of flavoured tobacco products, one of the first in the world. This study examines the agenda-setting process leading to the adoption of Bill C-32.

METHODS

This research was conducted using a case study design informed by Kingdon's Multiple Streams framework and Heclo's policy learning approach. In-depth interviews were conducted with key informants from government, health-based non-governmental organizations (NGOs), trade associations and the cigar manufacturing sector (n = 11). Public documents produced by media (n = 19), government (n = 11), NGOs (n = 15), as well as technical reports (n = 8) and formal stakeholder submissions (n = 137) were included for analysis. Data were coded with the objective of understanding key events or moments in the lead up to the adoption of Bill C-32 and the actors and arguments in support of and opposition to Bill C-32.

RESULTS

The findings point to the importance of a small but active group of NGOs who worked to publicize the issue and eventually take advantage of an open policy window. Our analysis also illustrates that even though consensus was developed about the policy problem and civil society was able to garner political support to address the problem, disagreement and dissent pertaining to the technical dimensions of the policy solution created loopholes for the tobacco industry to exploit.

CONCLUSIONS

NGOs remain a critical factor in efforts to strengthen tobacco control policy. These organizations were able to mobilize support for the tobacco flavouring ban adopted at the Federal level in Canada, and although the initial Bill had major limitations to achieving the health objectives, the persistence of these NGOs resulted in amendments to close these loopholes.

Is blue the new green? Repackaging menthol cigarettes in response to a flavour ban in Ontario, Canada

Background

As of 1 January 2017, the Canadian province of Ontario banned the distribution and sale of menthol tobacco products. There is limited knowledge about how tobacco companies will adapt their packaging in response to a menthol ban.

Methods

We conducted a content analysis of preban traditional menthol (no capsule) and menthol capsule cigarette packs and their postban replacements. Preban and postban packs were matched using tobacco company descriptions of replacement brands in business-to-business marketing materials, advertising on cigarette pack cellophane and a tobacco company website.

Results

A total of 63 menthol (n=30) and ‘non-menthol alternative’ (n=33) cigarette packs were included in the analysis. Approximately half of the preban packs were menthol capsule cigarettes and half traditional menthol cigarettes. While some postban brands continued to convey menthol-like qualities via the colour and/or brand descriptor ‘green’, ’blue' was the most common colour and brand descriptor postban. Packs shifted from using ‘menthol’ and/or ‘fresh’ as taste descriptor preban to using ‘smooth’ postban; some postban packs had ‘non-menthol alternative’ or ‘without menthol/capsules’ written on their cellophane. The presence of innovative filter technologies continued in the postban samples.

Conclusion

Results suggest that tobacco companies attempted to maintain menthol smokers in Ontario by aggressive preban promotion of menthol capsule cigarettes, continued promotion of innovative filter technologies and by directing smokers to non-menthol alternatives whose packaging both in text and in colour connoted menthol-like qualities (eg, green) and reduced harshness or harm (eg, blue, white, silver, smooth taste).

No surge in illicit cigarettes after implementation of menthol ban in Nova Scotia

Background

In May 2015, the Canadian province of Nova Scotia became the first jurisdiction in the world to ban menthol cigarettes specifically. The tobacco industry warned that ‘the primary effect of this law will be to increase the illegal tobacco market in Nova Scotia’. This is the first attempt to examine the impact of the menthol ban on trends in illicit cigarettes.

Data and methods

Data on the number of illicit cigarettes seized in Nova Scotia covering the period from 2007/2008 to 2017/2018 was obtained from the Provincial Tax Commission. Data from before and after the ban are compared.

Results

According to the local authorities, while the enforcement efforts in Nova Scotia have not declined, the number of seized illicit cigarettes declined significantly, from >60 000 cartons in 2007/2008 to <10 000 cartons in 2017/2018. Since the menthol ban, the seizure volume remained stable, with no statistically significant difference in the number of cigarettes seized before and after the menthol ban (t=−0.71, p=0.55). There were only a few small seizures of menthol cigarettes in the year following the ban, after which there have been no further seizures of menthol cigarettes.

Discussion

Contrary to the tobacco industry’s assertions, there was no surge in illicit cigarettes after the 2015 ban on menthol cigarette sales in Nova Scotia. Credible, industry-independent evidence on illicit cigarette trade is desperately needed to support the implementation of tobacco control policies.

Compliance with the City of Chicago's partial ban on menthol cigarette sales

INTRODUCTION

In the USA, menthol cigarettes are associated with smoking initiation and decreased likelihood of cessation, particularly for low-income and non-White populations. Local ordinances to restrict menthol cigarette sales are an emergent policy option. In July 2016, Chicago, Illinois became the first major US city to ban menthol cigarette sales within 500 feet of schools. This study assessed ban compliance in June 2017.

METHODS

We randomly selected 100 of 154 stores within 500 feet of a high school. Ninety stores were included in the analysis, excluding permanently closed stores or stores that did not sell tobacco prior to the ban. Compliance was determined by whether a menthol cigarette pack was purchased. We also assessed presence of menthol cigarette replacement packs. Multivariable logistic regression modelled compliance by store type, school (distance to high school, school type) and neighbourhood-level factors (poverty level, proportion of non-White residents).

RESULTS

Compliance rate was 57% (weighted, n=53) and no replacement packs were observed. Non-compliant stores were more likely to advertise menthol cigarettes, but ads were present in eight compliant stores. Gas stations had 81% lower odds (OR=0.19, 95% CI 0.06 to 0.58) of complying with the menthol cigarette ban compared with larger/chain stores. School-level and neighbourhood factors were not associated with compliance.

DISCUSSION

The poor compliance observed with Chicago's partial menthol cigarette ban highlights the need for comprehensive efforts. Optimising local resources to target enforcement efforts in gas stations could improve compliance. Ordinances that also restrict advertising could potentially enhance ban impact by reducing exposure to product and promotions.

Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International

OBJECTIVE

Describe the process of enacting and defending strong tobacco packaging and labelling regulations in Uruguay amid Philip Morris International's (PMI) legal threats and challenges.

METHODS

Triangulated government legislation, news sources and interviews with policy-makers and health advocates in Uruguay.

RESULTS

In 2008 and 2009, the Uruguayan government enacted at the time the world's largest pictorial health warning labels (80% of front and back of package) and prohibited different packaging or presentations for cigarettes sold under a given brand. PMI threatened to sue Uruguay in international courts if these policies were implemented. The Vazquez administration maintained the regulations, but a week prior to President Vazquez's successor, President Mujica, took office on 1 March 2010 PMI announced its intention to file an investment arbitration dispute against Uruguay in the International Centre for the Settlement of Investment Disputes. Initially, the Mujica administration announced it would weaken the regulations to avoid litigation. In response, local public health groups in Uruguay enlisted former President Vazquez and international health groups and served as brokers to develop a collaboration with the Mujica administration to defend the regulations. This united front between the Uruguayan government and the transnational tobacco control network paid off when Uruguay defeated PMI's investment dispute in July 2016.

CONCLUSION

To replicate Uruguay's success, other countries need to recognise that strong political support, an actively engaged local civil society and financial and technical support are important factors in overcoming tobacco industry's legal threats to defend strong public health regulations.

Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review

Objective

This systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults.

Data sources

English-language peer-reviewed publications indexed in 4 databases were searched through April 2016.

Study selection

A search strategy was developed related to tobacco products and flavours. Of 1688 articles identified, we excluded articles that were not English-language, were not peer-reviewed, were qualitative, assessed menthol-flavoured tobacco products only and did not contain original data on outcomes that assessed the impact of flavours in tobacco products on perceptions and use behaviour.

Data extraction

Outcome measures were identified and tabulated. 2 researchers extracted the data independently and used a validated quality assessment tool to assess study quality.

Data synthesis

40 studies met the inclusion criteria. Data showed that tobacco product packaging with flavour descriptors tended to be rated as more appealing and as less harmful by tobacco users and non-users. Many tobacco product users, especially adolescents, reported experimenting, initiating and continuing to use flavoured products because of the taste and variety of the flavours. Users of many flavoured tobacco products also showed decreased likelihood of intentions to quit compared with non-flavoured tobacco product users.

Conclusions

Flavours in most tobacco products appear to play a key role in how users and non-users, especially youth, perceive, initiate, progress and continue using tobacco products. Banning non-menthol flavours from tobacco products may ultimately protect public health by reducing tobacco use, particularly among youth.