The use of flavour cards and other additives after a menthol ban in Canada

Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity

INTRODUCTION

This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017).

AIMS AND METHODS

Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol.

RESULTS

Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories.

CONCLUSIONS

After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity.

IMPLICATIONS

Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

An Estimation of the Prevalence of Smoking and e-Cigarette Use among U.S. Adults If Menthol Cigarettes and Flavored Cigars Are Banned

INTRODUCTION

People's reaction to the FDA's ban on flavored cigarettes and cigars may be modified by a concurrent ban on flavored e-cigarettes. We aim to estimate the prevalence of smoking and e-cigarette use among U.S. adults under various ban scenarios.

METHODS

We collected the reactions of people who used cigarettes, cigars, and e-cigarettes reactions to three hypothetical ban scenarios, (1) restricting menthol cigarettes and flavored cigars only, or (2) further restricting e-cigarettes with any flavors except menthol or tobacco, or (3) further restricting e-cigarettes with all flavors. The above data were analyzed to identify determinants of reactions and to estimate and calibrate the probabilities of quitting and switching to non-flavored cigarettes and cigars. Afterward, the probabilities were applied to 2018-2019 TUS-CPS respondents to estimate the prevalence of smoking and e-cigarette use.

RESULTS

Compared with the baseline, the prevalence of smoking decreased from 12.6% to 10.5%, and e-cigarette use increased from 2.6% to 3.8% in Scenario No.1. In Scenario No.2 and No.3, the prevalence of smoking was 10.5% and 10.7%, and the prevalence of e-cigarette use were 3.1% and 2.4%, respectively. For black people, the prevalence of smoking decreased from 14.2% in baseline to 8.1%-8.8% in three scenarios.

CONCLUSIONS

The result indicated that for a ban on menthol cigarettes and flavored cigars, a concurrent ban on flavored e-cigarettes with an exemption of menthol flavor could be more effective in encouraging people to quit smoking. Black people may see a disproportionate benefit from all ban scenarios compared with other race/ethics groups.

Across the world availability of flavour accessories for tobacco products

OBJECTIVE

This study aimed to provide an inventory of different types of flavour accessories for combustible tobacco products in eight countries varying in their approaches to flavour legislation and cultural aspects, including tobacco use.

METHODS

A standardised search protocol was developed and shared with local informants to acquire information on the availability and marketing of flavour accessories in web shops accessible from Brazil, India, Italy, Singapore, South Africa, Switzerland, the UK and the USA. Characteristics of the products and web shops were reported, and flavours were categorised in a flavour wheel.

RESULTS

Flavour accessories were available in all participating countries. Reported types are flavour capsules, cards, filter tips and tubes for make-your-own cigarettes, drops, sprays, rolling paper, aroma markers, a flavour stone and a flavour powder. In total, 118 unique flavours were reported, which were mostly fruity and sweet. Marketing of these products was often associated with (menthol) flavour bans.

CONCLUSIONS

The wide availability and variety of flavour accessories raise significant public health concerns, as they have attractive flavours, and thus hinder the regulatory aim of flavour bans. Flavour accessories are not tobacco products and thus not regulated as such. Therefore, it is recommended that policymakers include these products in comprehensive flavour bans, to close this loophole in existing tobacco control measures.

Illicit cigarette purchasing after implementation of menthol cigarette bans in Canada: findings from the 2016-2018 ITC Four Country Smoking and Vaping Surveys

OBJECTIVE

To examine the impact of menthol cigarette bans on use and purchasing of illicit cigarettes among menthol and non-menthol smokers in seven Canadian provinces.

METHODS

Data from 1098 non-menthol smokers and 138 menthol smokers in Canada who completed the ITC Four Country Smoking and Vaping Survey in 2016 (pre-ban) and 2018 (post-ban). Brand validation analysis was conducted to (1) compare self-reported use of menthols versus actual use of menthols as regular brand, and verify self-reported purchasing of menthols among pre-ban menthol smokers at post-ban; and (2) assess pre-post ban changes in purchasing of illicit cigarettes from First Nations reserves among non-menthol smokers and menthol smokers.

RESULTS

Among the subset of 138 pre-ban menthol smokers, 36 (19.5%) reported smoking menthols at post-ban. Brand validation analyses showed that 19 (9.0%) were actually using a non-menthol brand; of the 17 (10.5%) who were actually using a menthol brand, 13 (7.9%) bought a menthol brand at last purchase, and 4 (2.6%) bought a non-menthol brand. Among the full sample of smokers who purchased cigarettes from First Nations reserves at both pre-ban and post-ban, there was no change in purchasing of menthols (n=9 menthol smokers; 51.2% vs 51.2%, p=1.00), non-menthols (n=1024 non-menthol smokers; 9.1% vs 8.7%, p=0.69) or all cigarettes (menthol+non-menthol) (n=1086 smokers; 9.7% vs 9.2%, p=0.56).

CONCLUSIONS

Actual rates of brand-verified menthol smoking were substantially lower than self-reported rates at post-ban. After Canada's menthol ban, there was no increase in illicit purchasing of menthol or non-menthol cigarettes from First Nations reserves.

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.

Prevalence, perceptions and factors associated with menthol cigarette smoking: findings from the ITC Kenya and Zambia Surveys

BACKGROUND

Menthol masks the harshness of cigarette smoke, promotes youth smoking and encourages health-concerned smokers who incorrectly believe that menthols are less harmful to smoke menthols. This study of smokers in Kenya and Zambia is the first study in Africa to examine menthol use, smokers' beliefs about its harmfulness and the factors associated with menthols.

METHODS

Data were from the International Tobacco Control (ITC) Kenya Wave 2 (2018) and Zambia Wave 2 Survey (2014), involving nationally representative samples of smokers. This study focuses on 1246 adult smokers (644 in Kenya, 602 in Zambia) who reported smoking a usual brand of cigarettes (menthol or non-menthol).

RESULTS

Overall, menthol use was significantly higher among smokers in Zambia than in Kenya (48.0% vs 19.0%), females (45.6% vs 31.2% males), non-daily smokers (43.8% vs 30.0% daily) and those who exclusively smoked factory-made (FM) cigarettes (43.0% vs 15.2%). The erroneous belief that menthols are less harmful was more likely among smokers in Zambia than in Kenya (53.4% vs 29.3%) and among female smokers (38.5% vs 28.2%). In Kenya, menthol smoking was associated with being female (adjusted odds ratios (AOR)=3.07; p=0.03), worrying about future health (AOR=2.28; p=0.02) and disagreeing with the statement that smoking was calming (AOR=2.05; p=0.04). In Zambia, menthol use was associated with being female (AOR=3.91; p=0.002), completing primary school (AOR=2.14; p=0.03), being a non-daily smoker (AOR=2.29; p=0.03), exclusively using FM cigarettes (AOR=14.7; p<0.001), having a past quit attempt (AOR=1.54; p=0.02), believing that menthols are less harmful (AOR=3.80; p<0.001) and choosing menthols because they believed it was less harmful (AOR=3.52; p<0.001).

CONCLUSIONS

Menthols are highly prevalent among females in both countries. There is a need in African countries to combat the myth that menthols are less harmful and to ban menthol and other flavourings.

Illicit purchasing and use of flavour accessories after the European Union menthol cigarette ban: findings from the 2020-21 ITC Netherlands Surveys

BACKGROUND

The 2020 European Union (EU) menthol cigarette ban increased quitting among pre-ban menthol smokers in the Netherlands, but some reported continuing to smoke menthol cigarettes. This study examined three possible explanations for post-ban menthol use-(i) illicit purchasing, (ii) use of flavour accessories and (iii) use of non-menthol replacement brands marketed for menthol smokers.

METHODS

Data were from the ITC Netherlands Cohort Surveys among adult smokers before the menthol ban (Wave 1: February-March 2020, N = 2067) and after the ban (Wave 2: September-November 2020, N = 1752; Wave 3: June-July 2021, N = 1721). Bivariate, logistic regression and generalized estimating equation model analyses were conducted on weighted data.

RESULTS

Illicit purchasing remained low from pre-ban (2.4%, 95% CI: 1.8-3.2, Wave 1) to post-ban (1.7%, 1.2-2.5%, Wave 3), with no difference between menthol and non-menthol smokers from Wave 1 to Wave 3. About 4.4% of post-ban menthol smokers last purchased their usual brand outside of the EU and 3.6% from the internet; 42.5% of post-ban menthol smokers and 4.4% of smokers overall reported using flavour accessories, with greater odds among those aged 25-39 years vs. 55+ (aOR = 3.16, P = 0.002). Approximately 70% of post-ban smokers who reported using a menthol brand were actually using a non-menthol replacement brand.

CONCLUSIONS

There was no increase in illicit purchasing or of smuggling outside the EU among menthol and non-menthol smokers in the Netherlands 1 year after the EU menthol cigarette ban. Use of flavour accessories and non-menthol replacement brands best explain post-ban menthol use, suggesting the need to ban accessories and ensure industry compliance.

Closing the loopholes on a flavored cigar ban: Anticipated challenges and solutions

For the first time since Congress authorized the U.S. Food and Drug Administration (FDA) to regulate tobacco in 2009, FDA proposed two tobacco product standards on May 4, 2022. After a period of public comment and agency review, if the product standards are finalized in their current form, they will ban menthol cigarettes (U.S. Food and Drug Administration, 2022b), which comprised 37% of the U.S. cigarette market in 2019 and 2020 (Federal Trade Commission, 2021), and flavored cigars (U.S. Food and Drug Administration, 2022a), which have exceeded 50% of cigar sales since 2012 (Delnevo et al., 2021b). This commentary examines potential challenges to banning flavored cigars and highlights issues FDA and Congress should consider.

Electronic cigarette users' reactions and responses to a hypothetical ban of flavoured electronic cigarette liquids

Regulations have been proposed to limit e-cigarette flavours, but limited research has examined potential impacts of such policies. This study examined adult e-cigarette users’ reactions to a hypothetical e-cigarette flavour ban.

How Smokers of Menthol Cigarettes and Flavored Cigars Might Respond to FDA's Proposed Bans

INTRODUCTION

A ban on menthol cigarettes and flavored cigars may reduce smoking and tobacco-related disparities.

AIMS AND METHODS

We aimed to examine the response of current smokers to a hypothetical ban on menthol cigarettes and flavored cigars. Current smokers were recruited online and reported the alternative products that they may switch to under a hypothetical ban, if they would try to obtain the banned products from illicit channels, and their support to the ban.

RESULTS

51% of current smokers would use nonflavored cigarettes and cigars as alternatives, 45% would switch to flavored heated tobacco products or e-cigarettes or quit smoking. 17% would try to obtain the banned flavored products from illicit markets. A majority of menthol only smokers opposed the ban. Daily smokers would be more likely to switch to nonflavored smoking, to try illicit market products, and were less supportive of the ban. Black smokers would be less likely to switch to nonflavored smoking and were more supportive of the ban. Smokers who used menthol cigarettes only would be more likely to switch to nonflavored smoking, less likely to try illicit market sellers, and were the least supportive of the ban.

CONCLUSIONS

In response to a ban of all added flavors for cigarettes or cigars, nearly half of the current smokers would quit smoking, largely by switching to nonsmoking products. However, smokers with more chronic use and those who used only menthol cigarettes would be more likely to switch to nonflavored smoking, diminishing the harm reduction potential. The ban may decrease the relatively higher prevalence of menthol cigarette smoking among Blacks compared with other groups.

IMPLICATIONS

A ban on the sale of menthol cigarettes and flavored cigars may decrease the prevalence of smoking because some current smokers may quit smoking and switch to nonsmoking products. However, smokers with more chronic use and those who used menthol cigarettes only were more likely to switch to nonflavored cigarettes or cigars, diminishing the harm reduction potential of the ban. Black smokers would be more likely to switch to products other than cigarettes and cigars thus decreasing their relatively higher prevalence of smoking compared with other groups.

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.

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.

Moving targets: how the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges

Tobacco, nicotine and related products have and continue to change rapidly, creating new challenges for policies regulating their advertising, promotion, sponsorship and sales. This paper reviews recent commercial product offerings and the regulatory challenges associated with them. This includes electronic nicotine delivery systems, electronic non-nicotine delivery systems, personal vaporisers, heated tobacco products, nicotine salts, tobacco-free nicotine products, other nicotine products resembling nicotine replacement therapies, and various vitamin and cannabis products that share delivery devices or marketing channels with tobacco products. There is substantial variation in the availability of these tobacco, nicotine, vaporised, and related products globally, and policies regulating these products also vary substantially between countries. Many of these products avoid regulation by exploiting loopholes in the definition of tobacco or nicotine products, or by occupying a regulatory grey area where authority is unclear. These challenges will increase as the tobacco industry continues to diversify its product portfolio, and weaponises 'tobacco harm reduction' rhetoric to undermine policies limiting marketing, promotion and taxation of tobacco, nicotine and related products. Tobacco control policy often lags behind the evolution of the industry, which may continue to sell these products for years while regulations are established, refined or enforced. Policies that anticipate commercial tobacco, nicotine and related product and marketing changes and that are broad enough to cover these product developments are needed.

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.