Tobacco product menthol and flavour bans: their utility for LMIC and lessons from the EU ban

Abstract Background Flavoured tobacco products increase smoking uptake and create dependence. By June 2020 all cigarettes with a characterising flavour, including menthol were banned across the EU, UK and Moldova but many low and middle income countries (LMIC) are yet to develop and implement bans despite high smoking prevalence. This paper has two objectives: to establish whether (1) flavoured tobacco products are present and marketed in LMIC and (2) the experience of bans in Europe can guide development of legislation elsewhere. Methods Research involved analysis of menthol/flavour market data, review of academic and commercial literature and online media. Results The median menthol/capsule market share of the cigarette market grew significantly in middle income countries (p < 0.05) between 2005 and 2019, both in lower and upper middle-income countries [lower: 2.5% (IQR: 0.5-4.0) to 6.5% (IQR: 3.6-15.9); and upper: 4.0% (IQR: 0.8-9.8) to 12.3% (IQR: 3.5-24.3)]. No market data were available on low-income countries, but the academic literature suggested high prevalence of menthol use in Zambia. Tobacco industry strategies underpinning growth of menthol/flavoured tobacco use in LMICs included in-store marketing and display, colourful packs and non-conventional flavour names. Tobacco industry attempts to circumvent the EU ban included introducing new flavoured tobacco products and accessories not included in the ban and exploiting the ban on characterising flavour (as opposed to an ingredient ban) by introducing cigarettes with lower levels of menthol. Conclusions Banning flavoured and menthol cigarettes in LMIC would impact a growing proportion of smokers in these countries. From the European experience, menthol and flavour bans that include all tobacco products and accessories and ban flavour as an ingredient rather than a characterising flavour is recommended. Currently, lack of marketing bans and standardised packaging in LMICs exacerbate the impact of flavours. Key messages Flavoured and menthol tobacco products are a growing problem in LMICs. Bans should include all tobacco products and accessories and ban flavour as an ingredient.


Background:
A differentiated analysis of the structural relationships between social factors and health-related quality of life (HRQOL) in older German adults has not yet been conducted. In this analysis, we aimed to examine the relationships between sociodemographic, socioeconomic, psychosocial, and behavioural factors and both physical and mental HRQOL in older German adults.

Methods:
A community-based postal survey was used to collect crosssectional data from German adults aged 65 and older (n = 1687, 33% response proportion, 52% female). Physical and mental dimensions of HRQOL were assessed using Short Form 36, version 2. Multiple linear regression models were used to analyse the associations between social factors and both physical and mental HRQOL.

Results:
Health locus of control, physical activity, and income were positively associated with both physical HRQOL (Adj. R2 = 0.34, p < 0.001) and mental HRQOL (Adj. R2 = 0.22, p < 0.001), whereas age was negatively associated with both. Alcohol use was positively associated with physical HRQOL, and social support was positively associated with mental HRQOL.

Conclusions:
A differentiated understanding of the relationships between social factors and HRQOL assists in group-specific targeting of health interventions. Demand-oriented interventions should consider underlying social factors to reduce socially determined inequities in HRQOL among older German adults. Depending on the focus of the intervention, it may be helpful to take specific social conditions into account. The results may be transferable to municipalities in high-income European countries. Key messages: Sociodemographic, socioeconomic, psychosocial, and behavioural factors are associated with physical and mental health-related quality of life in older German adults. Social conditions should be considered when targeting group-specific interventions to reduce socially determined inequities in health-related quality of life among older adults.
Abstract citation ID: ckac130.034 Tobacco product menthol and flavour bans: their utility for LMIC and lessons from the EU ban

Background:
Flavoured tobacco products increase smoking uptake and create dependence. By June 2020 all cigarettes with a characterising flavour, including menthol were banned across the EU, UK and Moldova but many low and middle income countries (LMIC) are yet to develop and implement bans despite high smoking prevalence. This paper has two objectives: to establish whether (1) flavoured tobacco products are present and marketed in LMIC and (2) the experience of bans in Europe can guide development of legislation elsewhere.

Methods:
Research involved analysis of menthol/flavour market data, review of academic and commercial literature and online media.

Results:
The median menthol/capsule market share of the cigarette market grew significantly in middle income countries (p < 0.05) between 2005 and 2019, both in lower and upper middle-income countries [lower: 2.5% (IQR: 0.5-4.0) to 6.5% (IQR: 3.6-15.9); and upper: 4.0% (IQR: 0.8-9.8) to 12.3% (IQR: 3.5-24.3)]. No market data were available on lowincome countries, but the academic literature suggested high prevalence of menthol use in Zambia. Tobacco industry strategies underpinning growth of menthol/flavoured tobacco use in LMICs included in-store marketing and display, colourful packs and non-conventional flavour names. Tobacco industry attempts to circumvent the EU ban included introducing new flavoured tobacco products and accessories not included in the ban and exploiting the ban on characterising flavour (as opposed to an ingredient ban) by introducing cigarettes with lower levels of menthol.

Conclusions:
Banning flavoured and menthol cigarettes in LMIC would impact a growing proportion of smokers in these countries.
From the European experience, menthol and flavour bans that