Article Text
PDF
Abstract
Introduction Flavour capsule cigarettes are a recent product worldwide, and little is known about the epidemiology of their use. We used data from a nationally representative survey to understand the sociodemographic characteristics of flavour capsule cigarette smokers and reasons for flavour capsule use.
Methods Data were from the nationally representative, U.S. Population Assessment of Tobacco and Health survey (2013–2014). Analyses included 7181 adults, aged 18–44 years, who were current or former established (≥100 lifetime cigarettes) cigarette smokers. Participants reported their usual brand of cigarettes which were classified as non-menthol, menthol or flavour capsule. Analyses assessed differences in participant demographics, smoking patterns and reasons for use by product type among those aged 18–24 years. Analyses were weighted to account for the survey design.
Results Flavour capsule cigarettes were the usual cigarettes among 9.4% of smokers aged 18–24 years and 6.0%, 3.7% and <1% of smokers aged 25–34, 35–44 and ≥45 years, respectively. Among smokers aged 18–24 year, a significantly higher percentage of Hispanic smokers (17.3%) usually used flavour capsule cigarettes versus non-Hispanic white (8.4%, P<0.05) and non-Hispanic black (3.2%, P<0.05) smokers. Flavour capsule use was associated with later onset of smoking and lower levels of nicotine dependency and flavour capsule users placed more emphasis on taste, lower price and pack design than menthol or non-menthol users.
Conclusions Flavour capsule cigarettes use is highest in young adults, particularly Hispanics. Young adult predominance, lower level of addiction symptoms and emphasis on pack design by flavour capsule users suggest that these products may be positioned as starter products.
- flavor capsules
- menthol cigarettes
- hispanic
Statistics from Altmetric.com
Introduction
Flavour capsule cigarettes feature a crushable capsule embedded in or near the filter of a combustible cigarette which releases concentrated flavouring when squeezed. Flavour capsule cigarettes were first introduced in Japan in 2007,1 although the development of such products dates back to a 1964 patent on a cigarette filter with a water-containing capsule to purify the smoke.2 In the past decade, a number of patents have been issued for flavour capsule filters.3–5 Sales of flavour capsule cigarettes have increased since their first introduction in 2007; as of 2011, these products were available in 40 countries worldwide, primarily in Europe and South America.1 Sales of flavour capsule cigarettes sold globally by British American Tobacco increased from 0.9 billion in 2007 to 4.4 billion in 2010. Between 2011 and 2014, market share for flavour capsule cigarettes rose from less than 5% to about 20% in Chile, Peru and Guatemala—the South American countries with highest prevalence of use of these products. While market share for flavour capsule cigarettes is lower in the USA, the exact value is unknown.6
Menthol is the most commonly employed flavour for capsule cigarettes.1 Menthol provides cooling, smoothing and anaesthetic effects on mucus membranes, allowing it to mask the irritating effects of cigarette smoke.7 Indeed, some studies have found the use of menthol cigarettes to be more common among new smokers and young adult smokers,8 9 who are most naïve to the harshness of cigarette smoke. Industry documents from major manufacturers as presented by Kahnert et al 1 suggest that young adult smokers are the primary target for flavour capsule cigarettes, with the smoker’s ability to control the menthol flavour provided via the crushable capsule as a marketing feature attractive to young adults. Patterns of marketing for flavour capsule products also support that these products are targeted to young adults and even adolescents.10 In the USA, only capsules flavoured with menthol are allowed as a result of the ban on characterising flavours stipulated by the 2009 Family Smoking Prevention and Tobacco Control Act. Some brands (eg, Camel Silver Menthol Kings) are a mentholated cigarette with a menthol flavour capsule, and other brands (eg, Camel Crush) are a non-mentholated cigarette that is converted to menthol when the flavour capsule is crushed.1
Given the widespread availability of flavour capsule cigarettes worldwide for more than 10 years, there is a noteworthy lack of data on the epidemiology of flavour capsule use. Using data from a 2014 online consumer marketing panel,11 Thrasher et al documented that 14% of established (≥100 lifetime cigarettes) current adult (aged 18–64 years) smokers in Australia preferred flavour capsule cigarettes, compared with 4% and 3% of such adult smokers in the USA and Mexico, respectively. Importantly, flavour capsule use was highest among young adult smokers in the USA and also high in Australian and Mexican young adult smokers. A better understanding for the sociodemographic characteristics of flavour capsule cigarette smokers and reasons for flavour capsule use are needed to understand if use is particularly prevalent among new and young adult smokers.
Here, we expand on the previous consumer marketing panel study9 by examining the characteristics of flavour capsule smokers using data from the nationally representative Population Assessment for Tobacco and Health (PATH) Study.12 We further assess whether smoking histories, measures of nicotine dependence and reasons for product selection differ among flavour capsule cigarette smokers compared with mentholated and non-mentholated cigarette smokers among those with the highest prevalence of flavour capsule use: smokers aged 18–24 years.
Methods
We analysed data from the public use file for wave 1 of the PATH Study, a national household survey conducted September 2013 and December 2014. The National Institutes of Health, through the National Institute on Drug Abuse, has partnered with the Food and Drug Administration’s (FDA) Center for Tobacco Products to conduct the PATH Study. The PATH Study used audio-computer assisted self-interviews available in English and Spanish to conduct surveys on tobacco use and associated health behaviours among youth and adults in the USA. Recruitment used an address-based, area-probability sampling and an in-person household screener to select potential participants. Adult tobacco users, young adults ages 18 to 24 years and African Americans were oversampled relative to population proportions. The data file provided weights for adjusting for oversampling and nonresponse; combined with the use of a probability sample, the weighted data allow the estimates produced by the PATH Study to be representative of the non-institutionalised, civilian US population. The weighted response rate for the household screener was 54.0%. Missing data on age, gender, race and Hispanic ethnicity were logically assigned from household screener data, as described in the PATH Restricted Use File User’s Guide.13 Further details regarding the PATH Study design and methods are published elsewhere14 and on the PATH Study’s website (www.pathstudyinfo.nih.gov). Data were analysed in 2016–2017.
Sample
The current study focused on adult current established smokers and adult former established smokers. Established smokers were defined as having smoked at least 100 cigarettes in their lifetime. Former established smokers were defined as established smokers who had quit within the past 12 months and were no longer smoking at the time of the interview. This group was included to provide the broadest estimate of recent flavour capsule cigarette use.
Demographics
Participant demographics included age (18–24, 25–34, 35–44, ≥44 years), education, gender, race/ethnicity, education level and US Census region; demographics were assessed for the sample overall and stratified by usual product.
Usual product used and reasons for use
Respondents selected their usual or last-smoked cigarette product from a series of dropdown menus that included colour photographs of cigarette brands and products within brands. That dropdown list included four variants of flavour capsule cigarettes available at that time: Camel Crush, Camel Crush Bold, Camel Silver Menthol Kings and Marlboro NXT.
We collapsed participant responses into non-mentholated, mentholated and flavour capsule cigarettes based on the product chosen. Participants were also asked about eight a priori reasons for choosing their usual product related to taste, satisfaction, cost, use by people important to them, tar and nicotine levels, quitting aid, lower health risks and pack design, as well as about perceptions of harm compared with other cigarette brands.
Smoking history, frequency, time of first cigarette and polytobacco use
Participants reported the age they first smoked a cigarette and the age they first became established smokers; responses were precoded into age groups (eg, <18 years, 18–24 years, 25–34 years, and so on) in the PATH public access data file. Current established smokers who smoked every day (vs some days) were also asked to report the time to their first cigarette of the day after waking (which we classified as within 1 hour or more than 1 hour) and the number of cigarettes smoked per day. Participants who also reported using one of the following products ‘fairly regularly’ on ‘some days’ or ‘every day’ were defined as polytobacco users: e-cigarettes, traditional cigars, cigarillos, filtered cigars, hookah, pipe tobacco, smokeless tobacco, snus pouches or dissolvable tobacco.
Statistical analyses
Prevalence of usual product use (non-menthol, menthol, flavour capsule) was assessed stratified by age group among all current or former established smokers aged 18–44 years. Because of the lower prevalence of flavour capsule use among older adults, additional analyses were completed only among young adults (aged 18–24 years). Specifically, rates of usual product use were presented by race/ethnicity among all current or former smokers aged 18–24 years, and measures of smoking history, nicotine dependency and reasons for product use were further compared by usual product use among current smokers 18–24 years.
All analyses were weighted to account for the complex sampling design and non-response; variance estimates were computed using Fay’s balanced repeated replication (rho=0.3) using replicate weights provided in the data file. Proportions and weighted 95% CI were computed for population-level rates; estimates were considered to be statistically unreliable if the denominator sample size was <50 or if the coefficient of variation of the estimate or its complement (for percentages) was larger than 30%. Weighted means and 95% CIs were computed for continuous measures. Statistical significance among point estimates was determined with weighted χ2 tests to compare proportions or weighted linear regression models to compare means; P<0.05 was considered statistically significant. All analyses were conducted with the R statistical programming language, V.3.2.0, using the survey package.15
Results
Of the 32 320 adults in the PATH survey, 12 493 were current or former established smokers, of whom 10 322 reported a usual or last cigarette product. Less than 1% of adult smokers over age 44 years used flavour capsule products, so we restricted the analysis to adults between 18 and 44 years, resulting in a final, unweighted sample size of 7181 participants (2659, 2645 and 1877 ages 18–24, 25–34 and 35–44 years, respectively). Overall, 57.6% of the sample was male; 67.2% identified as non-Hispanic white, 11.5% as non-Hispanic black, 14.3% as Hispanic and 6.9% identified another race; 88.0% of participants were current smokers and 12.0% were former (12 month) smokers. All participants usually purchased manufactured cigarettes, and 5.4% also reported they usually purchased roll-your-own tobacco,
Among all established current or former US adult smokers, usual products were non-menthol cigarettes for 62.0%, menthol cigarettes for 33.7% and flavour capsule for 4.3% of smokers. Rates of usual use for flavour capsule cigarettes were greatest among young adults (9.4%; 95% CI 8.2% to 10.8%) and decreased with increasing age (6.0% (95% CI 5.1% to 7.0%) and 3.7% (95% CI 2.9% to 4.7%) for ages 25–34 and 35–44 years, respectively; χ2 P<0.001). Among those aged 45 years or older, only 0.9% (95% CI 0.6% to 1.0%) usually used flavour capsule cigarettes. The remainder of the analysis focuses on the adults aged 18–24 years, the highest prevalence group.
As shown in figure 1, usual use of flavour capsule products among former or current smokers aged 18–24 years was lowest among young adult non-Hispanic blacks (3.2%; 95% CI 1.1% to 8.8%), higher among non-Hispanic whites (8.4%; 95% CI 7.0% to 10.1%) and was the usual product for almost 17.3% of Hispanic young adults (95% CI 13.1% to 22.4%) (χ2 P<0.001). Non-menthol cigarettes were used by the majority of non-Hispanic white and Hispanic young adults. Menthol cigarette use predominated among non-Hispanic blacks. There were no significant differences in the prevalence of flavour capsule use by gender, education level or region of the country (data not shown), and current and former (12 month) smokers did not differ in their use of non-menthol, menthol or flavour capsule cigarettes (data not shown). Rates of polytobacco use among current or established smokers aged 18–24 years were lowest among those who usually smoked menthol cigarettes (35.7%; 95% CI 32.6% to 38.9%) compared with non-menthol (41.2%; 95% CI 38.6% to 43.9%) or flavour capsule products (40.9%; 95% CI 34.4% to 47.7%; χ2 P=0.02).
Usual product use by race and ethnicity, ages 18–24 years. Current and former (who quit within past 12 months) smokers, limited to those aged 18–24 years (n=2659). Percentages are weighted to account for the complex survey design. P value from weighted χ2 test comparing race/ethnicity by usual product use. *Estimate should be interpreted with caution because it is statistically unreliable. It is based on a denominator sample size of <50, or the coefficient of variation of the estimate or its complement is larger than 30%. †Rate of flavour capsule use was statistically greater among Hispanic smokers than non-Hispanic white or black smokers; P<0.05; rates were not statistically different among Hispanic smokers and smokers of other race/ethnicities.
Among current smokers aged 18–24 years, those who usually used flavour capsule cigarettes smoked less often than those who did not. Specifically, 46.3% (95% CI 39.6% to 53.1%) of flavour capsule users smoked on some days (vs every day) compared with 32.5% (95% CI 29.6% to 35.5%) and 24.9% (95% CI 21.8% to 28.3%) of non-menthol and menthol cigarette users, respectively (χ2 P<0.001; figure 2). Among those who did smoke every day (figure 2), those who used flavour capsule cigarettes started smoking later in life and were less likely to smoke within an hour of waking than their peers who used non-menthol or menthol cigarettes. The mean cigarettes smoked per day was lowest among those who usually used flavour capsule cigarettes at 10.7 cigarettes per day (95% CI 9.1 to 12.3) compared with 13.1 (95% CI 11.6 to 14.6) and 14.3 (95% CI 13.0 to 15.6) cigarettes per day among menthol and non-menthol cigarette users, respectively; weighted linear regression demonstrated that the group mean was lower among flavour capsule users versus non-menthol (P<0.001) and menthol (P=0.03) users.
Smoking history and nicotine dependency by usual product use among adult current smokers aged 18–24 years. P value from weighted χ2 tests comparing the rate of each outcome by usual product use. *Denominator sample sizes for current smokers: flavour capsule 211, menthol 992 and non-menthol 1173. †Denominator sample sizes for current and every day smokers: flavour capsule 113, menthol 748 and non-menthol 808.
Table 1 lists reasons why respondents chose their usual brand of cigarettes among current, every day smokers aged 18–24 years. Among all of those smokers, the most common reasons were taste, satisfaction and cost. Almost all of flavour capsule users reported that choosing their brand for taste, a rate that was statistically greater than for users of non-mentholated products (P<0.001). Flavour capsule users also more commonly reported ‘less expensive’ as a reason for choosing their brand as compared with users of other products (P=0.003), although that difference was significant only when compared with users of menthol cigarettes. Finally, the design of the pack was selected as a reason for choosing the product more often among users of flavour capsule cigarettes (P=0.02), although that difference was, again, significant only when compared with users of menthol cigarettes. Menthol cigarette users were more than twice as likely to perceive their product as more harmful than other products compared with non-menthol users (P<0.001). The differences in reasons for product use and perceptions of harm across usual cigarette type were similar when stratified by ethnicity (data not shown); however, several point estimates in that stratified analysis were considered unreliable due to the small sample sizes.
Reasons for product use and perceptions of harm among current, every day smokers aged18–24 years
Discussion
This research in a recent, large, nationally representative sample of US smokers indicates that flavour capsule cigarettes have become well established since their introduction in 2007, with their use being most common among young adults. Flavour capsule product preference among adults overall and by age group was similar to the rate reported from a 2012–2014 survey using an online consumer panel, which also showed highest prevalence among young adults. That study indicated rates among Hispanics that were no higher than other groups. In contrast, this study found rates for flavour capsule use for Hispanic young adults that were about double the rate among white non-Hispanics and over five times larger compared with non-Hispanic blacks. The high rate of use among Hispanic smokers is not surprising given the popularity of these products in Latin American countries. In 2014, the market share for flavour capsule cigarettes based on global marketing data was the greatest in Chile (25.5%), Peru (22.5%), Guatemala (19.1%), Mexico (11.9%) and Argentina (9.6%).6 It is possible that the preference for flavour capsule products among Latin Americans is carrying over to Latinos in the USA.
In addition to the higher prevalence in young adults, several findings suggest that these products may be marketed as a starter product. Smokers indicated that pack design and lower price were common reasons to use the product. Thus, marketing strategies, including appealing packaging and price discounts, may be playing a significant role in use of these menthol flavour capsule cigarettes in the USA. Pack design may be important in other countries as well, as another study of high school students in Mexico, where flavour capsules are popular, found that adolescents perceived packaging for these products as more attractive compared with regular cigarettes.16 Tobacco companies have long used price discounts to engage smokers in use of their products, and discounts in targeted neighbourhoods can be used to engage particular populations into smoking.1 17
Another suggestion of starter product status for flavour capsule cigarettes is that these users started smoking later and tended to smoke less in amount and frequency than users of the other two product categories. Another interpretation of the cross-sectional findings could be that flavour capsules are less addicting products. Whether flavour capsules will serve primarily as a novel starter product only or will be associated with later transitions to regular or menthol cigarettes, or whether flavour capsule smokers will develop a long term following of their own, is not yet clear and can only be settled by longitudinal research.
The primary flavour in capsules worldwide is menthol. Menthol is an additive associated with chemosensory properties that include cooling and anaesthetic effects, reducing the harshness of smoke and the irritation caused by nicotine, and making it easier to inhale smoke.18 19 Industry documents indicate that menthol cigarette marketing has attempted to position these products as a reduced harm product.20 Industry marketing materials, use of blue and green in packaging, and words emphasising coolness and mildness could lead consumers to believe that mentholated cigarettes are reduced harm products. However, as recently as the 2011 FDA Tobacco Products Scientific Advisory Committee review,18 there were no data that compared menthol users’ perceptions of harm for menthol versus non-menthol cigarettes. This study clearly demonstrates that young adult menthol cigarette users perceive their products as more harmful than other cigarette brands, a belief that flavour capsule users do not seem to share.
Menthol cigarettes were extensively marketed to African Americans beginning in the 1950s and have continued to be the dominant product used by this group, as confirmed by this study. Menthol cigarette use is now growing in all groups, but particularly among white and Hispanic young adults,9 and our study demonstrates that flavour capsule products are being disproportionately used by those very groups for whom menthol use is expanding. Studies are needed to understand if the introduction of flavour capsule cigarettes may in part be responsible for the growth in the menthol market. Additionally, in some countries, flavours have extended beyond menthol to fruit and other flavours, and cigarettes with multiple capsules have been introduced. Such trends raise the question of how flavour capsule products can be regulated to minimise potential harm.
By requiring demonstration of substantial equivalence, the US FDAFDA has limited the introduction of new flavours and additives that go beyond the few products that were already on the market when the agency started regulating tobacco. Those actions, which included a 2015 order for R. J. Reynolds to end the distribution of Camel Bold flavour capsule cigarettes,21 may have limited the expansion of the flavour capsule market in the USA. Our study demonstrates that flavour capsule users in the USA tended to emphasise pack design and lower price of their products as reasons for choosing them, which suggests that the marketing of these products has been effective. In addition to monitoring product harm, the FDA has also the regulatory authority to limit flavour capsule marketing, which major public health organisations have criticised as overly appealing to youth.10 The agency cannot regulate how cigarette companies price their products but could limit promotional two-for-one marketing campaigns that effectively lower the price of these products.
Several limitations of this research require attention. We assessed only the usual product used among adult cigarette smokers. We did not assess whether these smokers initiated their tobacco use with flavour capsule products, or the role of advertisements may have played in their decision making. Finally, this study, being cross-sectional, cannot answer whether flavour capsule users report lower levels of usage and addiction because they are earlier in the course of their smoking uptake, or because of the abuse liability of the product, although we have no reason to believe that these products are any different from other cigarettes with respect to abuse liability.
In conclusion, the patterns of flavour capsule cigarette use in this nationally representative sample suggest that these products may be positioned as starter products. The growing use of these products among young adults deserves attention. Given that menthol flavouring aids tobacco smoking initiation and persistence, heavy marketing of menthol flavour capsule products could increase the overall rate of smoking or prevent its decline in the USA. This is particularly important among Hispanics, as Hispanics currently have one of the lowest rates of smoking compared with white and black non-Hispanic Americans,22 yet Hispanics had the greatest prevalence of flavour capsule product use. Thus, monitoring the effects of flavour capsule use on smoking rates among US Hispanic young adults deserves special attention. Future studies should examine whether flavour capsule cigarettes are used to initiate smoking, the role of advertisements and promotions in their uptake and use, and the relationship between use and acculturation among Hispanic smokers in USA.
What this paper adds
Flavour capsule cigarettes contain a capsule of concentrated flavour in the filter that bursts when squeezed. Industry documents suggest that flavour capsule cigarettes are targeted to young adults.
As a relatively new product, little is known about the epidemiology of flavour capsule cigarette use.
In this nationally representative survey, flavour capsule cigarettes were the usual product for 9.4% of young adult smokers overall, but was 17.3% among Hispanics and only 3.2% of blacks. Flavour capsule use was associated with a later onset of smoking and lower mean daily consumption. They placed more emphasis on taste, lower price and pack design compared with users of other types of cigarettes.
The current profile of use is consistent with marketing that suggests tobacco companies are positioning flavour capsule cigarettes as a starter product.
Acknowledgments
We thank the participants of the PATH study.
Footnotes
Contributors JDS conceived the research question, wrote and revised the manuscript and oversaw data analysis; JAE wrote the manuscript and completed the analyses; SS and MFB contributed to data interpretation and manuscript revision. All authors approved of the final version.
Funding This research was funded in part by the National Institutes of Health, R01CA077026 and P30 CA023108. The funders had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the views of the sponsor.
Ethics approval The institutional review board at the contracting research organisation for PATH approved the study design and protocol, and the Office of Management and Budget approved the data collection instrument.
Provenance and peer review Not commissioned; internally peer reviewed.