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In Canada, where bans on menthol have been implemented in the province of Ontario since January 2017 and across Canada since October 2017, products that can be used to add menthol flavour to non-mentholated tobacco such as flavour cards and menthol drops are available in stores, including the brand ‘Itsa’, which is distributed by a cigar company. These products can easily add menthol flavour by either placing the card or drops with the tobacco or in the package as a way of circumventing the ban. However, in Ontario, it appears that no major cigarette manufacturers had produced or advertised these flavour additives.1 The purpose of this letter is to examine the changes in use of after-market menthol additives after the menthol ban in Ontario.
Current (past month) cigarette smokers aged 16+ living in Ontario were surveyed pre-ban September to October 2016, then January 2017, January 2018 and January 2019. More details on the survey are available elsewhere.2 Questions about the use of additive cards, drops and oils to add menthol to tobacco were asked of menthol smokers (both daily menthol cigarette smokers and those who use menthol occasionally at least once in the past year) at all time points. The question was also asked of pre-ban non-menthol cigarette smokers in 2018 and 2019. A total of 1309 people responded to at least one of the additive questions.
Overall, 14.6% (95% CI: 11.0 to 19.2) of pre-menthol ban daily menthol cigarette smokers had reported using some sort of additive since the ban compared with 9.8% (95% CI: 7.8 to 12.2) of pre-menthol ban occasional menthol cigarette smokers (table 1). Before the menthol ban, 4.4% (95% CI: 2.6 to 7.8) of daily menthol smokers had previously tried flavour additives, rising to 5.1% (95% CI: 2.9 to 8.7) by January 2017, 12.5% (95% CI: 8.5 to 18.0) by 2018 and 9.5% (95% CI: 5.9 to 14.9) in 2019 (table 1). In 2018, 2.6% (95% CI: 1.3 to 5.1) of pre-ban non-menthol smokers had also tried the after-market additives, falling to 0.8% (95% CI: 0.2 to 3.0) in 2019. Flavour additive use was not significantly associated with making a quit attempt.
Despite a lack of promotion by major tobacco companies, flavour cards or additives were used by 14.6% of pre-menthol ban daily menthol smokers, a substantial minority, to substitute for the lack of availability of menthol cigarettes. The cards were also used by those who had not smoked menthol cigarettes before the ban. In December 2019, Imperial Tobacco in the United Kingdom announced a new line of ‘flavour cards’ as a way for retailers to ‘provide shoppers with options to help them stick with their flavour preference post ban and protect their sales as a result’.3 This suggests a change in industry practice to use flavour additives more prominently to circumvent the May 2020 menthol ban in the European Market. If these additive products are more available and promoted than they were in Canada, they may limit the effectiveness of the upcoming menthol restrictions in the Europe.
Contributors All authors contributed to editing and intellectual contributions to interpretation. MOC conceived the idea, conducted the analysis and drafted the letter. All authors contributed towards study design.
Funding This research was supported by the National Institute on Drug Abuse (NIDA) of the US National Institutes of Health (NIH) under Award Number P50DA036105 and the Center for Tobacco Products (CTP) of the US Food and Drug Administration (FDA) and the NIH Office of the Director under 1R21DA047358-01. The effort of TE, JEC and ES is also supported by NIDA and CTP/FDA under U54DA036105.
Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.
Competing interests TE is a paid consultant in litigation against the tobacco industry and is named on a patent application for a device that measures the puffing behaviour of electronic cigarette users.
Provenance and peer review Not commissioned; externally peer reviewed.