Background: Flavours, particularly menthol, increase the appeal and palatability of tobacco use. This mixed methods study examined global trends of flavoured cigarette use and implementation and impact of national menthol cigarette bans.
Methods: Systematic reviews were conducted on use and perceptions and marketing of flavour capsule cigarettes (FCCs). The International Tobacco Control (ITC) Surveys were used to assess use of FCCs and behavioural impact of menthol bans. Key informant interviews were conducted to examine factors influencing implementation of menthol bans in low- and middle-income countries (LMICs).
Results: FCC use was prevalent among adults who smoked in most countries examined (50.3% in Mexico, 31.8% in Republic of Korea, 26.5% in Malaysia, and 21.6% in Japan in 2020/2021), and most popular among young people. Marketing strategies of FCCs included use of packaging and advertising at the point-of-sale. Factors perceived to influence implementation of menthol bans in LMICs included social climate, institutional capacity, and tobacco industry interference. A menthol ban in the Netherlands was associated with reduced prevalence of menthol use (7.8% pre-ban to 4.4% post-ban, p<0.001) and increased post-ban quit attempts among adults who smoked menthol vs non-menthol at pre-ban (66.9% vs 49.6%, aOR=1.89, 95%CI: 1.13-3.16). Post-ban quitting was also higher among adults who smoked menthol vs non-menthol (26.1% vs 14.1%, p=0.002), but after adjusting for other factors was only significant among females (aOR=2.23, 95%CI: 1.10-4.51). There was no evidence that menthol bans led to increased illicit purchasing. Use of menthol accessories, which circumvent the bans, were popular among youth who smoked in England (24.2%) and Canada (15.6%).
Conclusions: FCC use is high in many countries globally. Findings indicate that menthol cigarette bans resulted in reduced menthol use, increased quit outcomes, while not increasing illicit purchasing. The experiences of countries in implementing flavour bans may support other countries in their efforts.