Flavoured and Menthol Tobacco in LMICs

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Key Points

  • Menthol and flavoured cigarettes are widely available in low and middle-income countries (LMICs) many of which have high smoking rates
  • LMICs have young populations – flavours appeal to young people, who may not understand the harms of flavoured tobacco
  • Recently high-income countries have put bans in place; at the same time there has been marked growth of menthol market share in some LMICs
  • There is a lack of regulation to reduce the appeal of flavours e.g. plain packs and advertising bans at point-of-sale or near schools
  • Targets for new and improved bans include flavour capsules, and flavour references on packaging and cigarette sticks
  • A ban on all flavourings may be easier and more effective in preventing product substitution
  • A lack of data, especially in low-income countries, hinders the development of good regulation
  • Multinational tobacco companies can threaten income from tobacco exports if governments attempt to put tobacco controls in place

This page covers flavoured tobacco, including menthol cigarettes, in low and middle-income countries (LMICs).12

Background

Flavoured tobacco products are available in various forms around the world, including products previously only used in particular regions or countries. For example in Indonesia, the vast majority of smokers use kretek, clove-flavoured cigarettes,34 and they are now available in other countries.56

Flavoured tobacco is used in waterpipe, a device which originated in middle-eastern countries and is increasingly popular elsewhere, including among young people.7

Here we focus on what are often called ‘conventional’ products, like cigarettes and cigarillos, which are sold by large transnational tobacco companies (TTCs): Philip Morris International (PMI), British American Tobacco (BAT), Imperial Brands (IMB, previously Imperial Tobacco) and Japan Tobacco International (JTI) (JTI also owns Nakhla in Egypt, which produces flavoured waterpipe) We summarise findings from Tobacco Control Research Group (TCRG) research on the extent of flavoured and menthol cigarette use in LMICs and the development of the market for ‘capsule’ products (cigarettes with flavour capsules in the filter).

We describe specific challenges for LMICs, including flavour regulation and evidence gathering. We then summarise flavour market evidence and research, first relating to LMICs in general and then by World Health Organization (WHO) region and individual countries (where available).

  • For general background and evidence, including information on the global market, and details of specific bans and associated industry interference, see Flavoured and Menthol Tobacco.

For details of product regulation at country level, see the searchable database on the Tobacco Control Laws website, published by the Campaign for Tobacco Free Kids (CTFK). For countries that are parties to the WHO Framework Convention on Tobacco Control (FCTC) progress towards implementation of relevant articles, including newer products, is detailed in the FCTC implementation database

Specific challenges for LMICs

LMICs with no ban often have other major tobacco control policy gaps that are not necessarily menthol/flavour related but worsen the negative impact of menthol/flavours.8 One such policy is plain, or standardised, packaging,  which can include restrictions on flavour descriptors as well as colours on packaging which are known to signify flavour (e.g. green for menthol).9 However, plain packaging policies have yet to be implemented in many countries, including some high-income countries, so this would be a significant challenge in LMICs. Another relevant policy is the prohibition of marketing, especially near schools.10

Governments have more conflicts of interest in tobacco growing areas as they receive much needed foreign currency for tobacco exports,  and multinational companies can threaten this income stream if governments attempt to put tobacco controls in place.811  However, apart from rare exceptions the tobacco industry contributes little overall to the balance of payments.1213

Regulatory challenges

The WHO published brief guidance on the regulation of menthol and flavoured tobacco which summarised some regulatory options including restrictions on: the sale of menthol branded products,  the use of menthol at noticeable levels (giving a ‘characterising flavour’),  or banning any menthol ingredients.14  The report points to likely opposition from the tobacco industry in countries or regions with an established menthol market.14 This was the case with the European Union (EU) menthol ban which only came into full force in 2020, after the tobacco industry had successfully lobbied for a delay. Testing for characterising flavour is more difficult and expensive than a ban on ingredients; this makes banning menthol as an ingredient particularly efficient for LMICs.

The WHO noted that:

“A ban on all flavour agents that increase tobacco product attractiveness, rather than focusing on menthol exclusively, can provide an alternate route to restricting menthol, and may prevent the unwanted introduction of menthol substitutes.”14

Research and data

As of 2021, when TCRG researchers conducted a review of evidence on menthol/flavour in LMICs,15 there were very few research papers from countries in Eastern Europe, the Eastern Mediterranean region, and Africa.

Lack of data means that it is hard to monitor markets and company shares in specific countries.  Market research service Euromonitor (which receives project funding from Philip Morris International) includes no low-income countries and is proprietary, making it expensive and hard to access even for the middle-income countries which are included.

More research is needed on menthol and flavour in LMICs to help governments monitor the tobacco industry and its products, as recommended by the WHO: “An evidence base using data collected from the region of interest can provide more direct support for regulation.”14

Market in LMICs

Evidence suggests menthol and flavoured tobacco products are widely used in LMICs.  Data from the International Tobacco Control (ITC) Policy Evaluation Project suggests that menthol is smoked by more than 20% of smokers in several middle-income countries. Although the dates vary (see the note above on data challenges) this research gives an indication of the scale of the problem. The highest rates were found in Zambia (42% in 2014) and Thailand (35% in 2012). Kenya and India also had over 20% menthol smokers, with China just under just under that level.16

A study from Johns Hopkins University, between 2015 and 2017, found a range of flavoured and capsule cigarettes on the market in those LMICs with the highest number of smokers: Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam.17

The main TTCs operating in these countries (PMI, JTI, and BAT) mostly sold menthol or mint flavours. China National Tobacco Corporation (CNTC) sold  a mix of flavours.17

There is also evidence from a number of studies that menthol and flavour tobacco use is rising, either as a proportion of the market or substantively.  Evidence from TCRG research shows that after the implementation of the European Union (EU) menthol ban in 2020, there was a marked increase in the share of menthol/flavoured products in some LMICs.15 A study of cigarette packs in Brazil, Indonesia, the Philippines, Russia, Thailand, and Vietnam, between 2013 and 2016, found that the number of flavour capsule variants on the market was growing.18 Most were mint and menthol flavour but with others the flavour was unclear from the product name.18

A number of studies have identified related marketing activities.  Marketing strategies for flavour capsules are likely driving their global growth particularly among young people in LMICs.19

TCRG’s review  of tobacco industry strategies underpinning the growth of menthol/flavoured tobacco use in LMICs  highlighted widespread marketing in stores (including retailers near schools), on billboards, on TV, online and via brand ambassadors. The packaging of flavoured and menthol products, legally displayed in stores, was  found to be colourful with non-conventional, appealing names for flavours.15

Tobacco companies also use symbols on cigarette sticks to indicate that they contain capsules.20 Researchers studying this form of marketing in LMICs have described the space on a cigarette as “valuable communicative real estate” for tobacco companies, which could be better used to display public health messages.20

 

Research and data from specific regions and countries is summarised below. We refer in many places to TCRG research based on 2019 cigarette market data from Euromonitor. In this data ‘high market share’ means 20% or more of the total cigarette market in that country in 2019. ‘High market share growth’ means that the share doubled between 2005-19 and was growing from 2017.15 We link to regional and country profile pages on TobaccoTactics, where available.

Africa

Nigeria has high menthol/flavour market share and high market share growth.15

Cameroon has high market share, the only other country in the region for which this data was available. (For Egypt see Eastern Mediterranean region below.)15

Tanzania

JTI sells a menthol cigarette called Sweet Menthol through its subsidiary in Tanzania. It describes this product as “the leading local mainstream menthol brand”.21

Zambia

JTI owned brand Sweet Menthol is the third most popular cigarette in Zambia.  It is cheap and is usually sold as single sticks.22  On its webpage for Zambia, JTI describes itself  as a leaf farming company, and does not mention that it sells cigarettes in the country. A locally owned company, Roland Imperial,  also sells menthol cigarette brands.23

ITC survey data showed a high prevalence of menthol smokers in Zambia, with 43% of smokers choosing the product.24 Menthol was most commonly used among younger smokers, those with a middle income, and those that don’t smoke every day. Over a third of smokers indicated that they thought menthol cigarettes were less harmful than non-menthol.24

Kenya

ITC survey data from Kenya also suggests a high prevalence of menthol smokers.2425 In 2018, 21% of smokers with a regular cigarette brand smoked menthol or sweet menthol (although Euromonitor estimates that only 7% of cigarette sales are menthol).15  More women smoke menthol than men in Kenya, and two thirds of smokers believed that menthol is less harmful than other cigarettes.2425

Ethiopia

In 2015, Ethiopia enacted a total flavour ban on all forms of tobacco.

This was a pre-emptive ban as flavour sales were low. However there has been a lack of enforcement at the retail level.8 Flavoured products are not made in Ethiopia and more collaboration with customs is needed to prevent illicit importation.8 There is also a lack of awareness that the ban includes waterpipe products.14

Since 2017, two years after the ban was enacted, JTI has owned 70%  the state owned tobacco company, NTE.26

Latin America

Menthol cigarettes are popular in Latin America, and increasingly so in some countries.15 Guatemala and Peru have high market share and high market share growth. There is high market share in Columbia and the Dominican Republic, and high market share growth in Argentina, Bolivia and Costa Rica.15

Use of flavour capsule cigarettes is particularly high in Chile and Mexico.27  According to BAT’s annual report in 2014,  sales of  flavour capsule cigarettes had increased in the region despite price rises, while overall cigarette sales were down.28

A study of over 1,000 retailers located close to schools in Latin American cities (Argentina, Bolivia, Brazil, Chile and Peru) found that the majority (85%) sold flavoured cigarettes, and most (71%) sold capsule versions.10 (Similar findings were reported in Uruguay, a high income country, immediately before the implementation of plain pack regulations in 2020.)29

These products were frequently displayed near the point of sale, or confectionary. Some stores also had advertisements and price promotions.10 Unconventional flavour descriptors such as “fusion blast” and “ruby ice” were very common.30

Brazil

Survey data from 2016-2017 among adult smokers in Brazil found that over 50% supported a ban on menthol and over 60% supported a ban on all additives.31 Support did not vary across sociodemographic groups. When menthol smokers were asked what they would do if menthol cigarettes were banned, a third reported they would quit, around 20% would reduce the amount they smoked and a similar number would switch to non-menthol cigarettes. Slightly fewer said they would still find a way to get menthol cigarettes.31

ITC survey data from the same period suggested that 8% of smokers with a regular cigarette brand smoked menthol.32 13% believed that menthol cigarettes were less harmful than non-menthol cigarettes, and over a third reported that they were smoother on the throat and chest.  Nearly two thirds  of surveyed smokers supported a complete ban on all cigarette additives, including flavourings.32

An online sample of women aged 16- 26 (smokers and non-smokers) preferred packs with flavour descriptors.33

Chile

In 2013, Chile sought to implement a law banning substances that cause higher levels of addiction, harm or risk, leading to tobacco industry resistance and interference.14

Mexico

Studies of retailers in Mexican cities, found that the majority sold menthol and flavoured products, and more than half of stores situated near schools sold flavour capsule cigarettes.3435 Many flavoured cigarettes have descriptors which suggest there is a flavour, but the type of flavour is unclear: chemical analysis of dual flavoured cigarettes suggested flavours were menthol and another flavour, for example fruit.36

A study in Mexico City found that colour and flavour descriptors on cigarette packs made the products more appealing, and some smokers believed they would taste better.37

Guatemala

A study of convenience store retailers in Guatemala found that all sold flavoured tobacco products.38

The majority (88%) of indoor tobacco advertisements in Guatemala were found to be for capsule cigarettes.38

South East Asia & Western Pacific

There is high market share of menthol/flavour in India, Malaysia, Philippines and Thailand, and high market share growth in Vietnam.15  A 2010 study noted that governments in the region had no legislation banning exotic flavours of cigarettes and cigarettes with new flavours had appeared in Cambodia, Indonesia, Malaysia and the Philippines.39

Philippines

Menthol has been advertised to appeal to young women in the Philippines since the 1970s with menthol brands common for many decades.40 PMI, JTI, BAT and Korea Tobacco & Ginseng (KT&G) all sell flavoured capsule cigarettes in the Philippines.41

Menthol packs studied in the Philippines were harder than non-menthol (for capsule protection) giving a quality feel. Flavoured capsule brands had a greater technological appeal,41 and packs were rated as more attractive by young adults.42

Blue and white packs were perceived to be less harmful than other colours, as were the descriptors ‘light’ and ‘cool’, whereas the term ‘strong’ was perceived as more harmful.42  Researchers called for greater action and support for banning flavour additives.

Malaysia

In Malaysia, menthol cigarette marketing has been aimed at young people and women.  In the 1980s Brown and Williamson’s Newport menthol cigarettes were marketed in Malaysia with youthful American images and were sold at a cheap price point.43 An internal document from 1993 reveals how the company was developing sweet and fruit flavours for the Malaysian market. 4344 A 2003 study noted that the menthol variant of Cartier Vendome (a BAT brand at the time) was described as ‘pearl tipped’ so likely to appeal to women.45

In 2013, vanilla, mint and fruit flavoured cigarettes were on sale, and strawberry cigarette packs with pink packaging were documented.46

China

In China ‘flavour capsule’ was found to be one of the most common cigarette terms used in online tobacco marketing.  One website explicitly linked flavour capsules with female smokers.47

Indonesia

In Indonesia the dominant cigarettes are kreteks which are flavoured with cloves.  Industry attempts to introduce their own cloved flavoured products had failed at least to 2004.48  In 2009 PMI and BAT acquired two domestic manufacturers which allowed them access to the kretek market.49 In 2009 PMI launched the first super slims kretek for women and Marlboro black menthol for young men.  By 2012 BAT had launched several kretek brands. Both companies were aware that kreteks  are particularly carcinogenic due to the presence of toxic chemical compounds: Anethole, Coumarin and Eugenol.49

In Indonesia the flip lid of the cigarette packet was used by Esse (owned by Korean Tobacco & Ginseng, KT&G) to promote the brand with phrases evoking flavour, like “sweet surprise” and “its honey”.  Research found seven cigarette brands with capsules.  Flavours included mint, menthol, berry and honey.50

Eastern Mediterranean

There is high market share growth in in Pakistan and Egypt .15

  • See also Waterpipe for information on the role of flavours in promoting these products.

Eastern Europe

Data shows that in Russia menthol/flavour has both a high market share and high market share growth.15

Other LMICs in the region with high market share growth are Ukraine, Bosnia Herzegovina, Belarus, Azerbaijan, Kazakhstan and Uzbekistan.15

Relevant Links

WHO Advisory note: banning menthol in tobacco products (2016)

WHO Case studies for regulatory approaches to tobacco products: menthol in tobacco products (2018)

WHO FCTC decision on banning waterpipe flavour (2016)

A global map of menthol bans is available on Tobacco Atlas: Product Sales

TobaccoTactics Resources

TCRG Research

A growing menace: menthol and flavoured tobacco products in LMIC, M. Zatonski, K. Silver, S. Plummer, R. Hiscock, Tobacco Induced Diseases, 2022;20(April):39, doi:10.18332/tid/146366
STOP research summary (May 2022)

Marketing of flavour capsule cigarettes: a systematic review, C. Kyriakos, M. Zatonski, F. Filippidis, Tobacco Control, Published Online First: 18 January 2022, doi: 10.1136/tobaccocontrol-2021-057082[/ref]

Flavour capsule cigarette use and perceptions: a systematic review, C.N. Kyriakos, M.Z. Zatoński, F.T. Filippidis, Tobacco Control, Published Online First: 04 October 2021, doi: 10.1136/tobaccocontrol-2021-056837

For a comprehensive list of all TCRG publications, including research that evaluates the impact of public health policy, go to TCRG publications.

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