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Impact of Non-Menthol Flavours in Tobacco Products on Perceptions and Use Among Youth, Young Adults and Adults: a Systematic

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Impact of Non-Menthol Flavours in Tobacco Products on Perceptions and Use Among Youth, Young Adults and Adults: a Systematic Tob Control: first published as 10.1136/tobaccocontrol-2016-053196 on 21 November 2016. Downloaded from Review Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review Li-Ling Huang,1 Hannah M Baker,2 Clare Meernik,2 Leah M Ranney,1,2 Amanda Richardson,1 Adam O Goldstein1,2 ► Additional material is ABSTRACT Prevention and Tobacco Control Act (FSPTCA) published online only. To view Objective This systematic review examines the impact banned cigarettes containing non-menthol flavour- please visit the journal online fl 2 (http:// dx. doi. org/ 10. 1136/ of non-menthol avours in tobacco products on tobacco ings, a step that other global entities, including the tobaccocontrol- 2016- 053196). use perceptions and behaviours among youth, young European Union (EU), Australia and France, have adults and adults. also taken. Other countries, such as Canada and 1Lineberger Comprehensive Data sources English-language peer-reviewed Brazil, have extended, or are in the process of Cancer Center, University of publications indexed in 4 databases were searched extending, flavour bans to include other tobacco North Carolina, Chapel Hill, fl 3 North Carolina, USA through April 2016. products and even menthol avour. 2Department of Family Medicine, Study selection A search strategy was developed The passage of the FSPTCA was influenced by Tobacco Prevention and related to tobacco products and flavours. Of 1688 data showing that candy-flavoured and fruit- Evaluation Program, School of articles identified, we excluded articles that were not flavoured cigarettes may be marketed to selectively Medicine, University of North 4–6 Carolina, Chapel Hill, North English-language, were not peer-reviewed, were appeal to and attract younger consumers. An Carolina, USA qualitative, assessed menthol-flavoured tobacco products examination of tobacco industry documents outlines only and did not contain original data on outcomes that perceived benefits of flavoured products to consu- Correspondence to assessed the impact of flavours in tobacco products on mers, including pleasing aromas and aftertaste, Dr Li-Ling Huang, Lineberger perceptions and use behaviour. increased excitement about the flavours and smoking Comprehensive Cancer Center, Data extraction Outcome measures were identified enjoyment and a ‘high curiosity to try factor’.4 University of North Carolina, Chapel Hill, Chapel Hill, NC and tabulated. 2 researchers extracted the data Flavouring was determined as one of the key factors independently and used a validated quality assessment underlying the growth in smokeless tobacco sales 27599, USA; copyright. huangl@ email. unc. edu tool to assess study quality. from 2005 to 2011, accounting for 59.4% of the Data synthesis 40 studies met the inclusion criteria. total growth in moist snuff sales alone.7 Owing to Received 24 May 2016 Data showed that tobacco product packaging with the reported rapid rise of novel tobacco products Revised 14 October 2016 fl Accepted 26 October 2016 avour descriptors tended to be rated as more appealing and the concern over their effects on public health, Published Online First and as less harmful by tobacco users and non-users. the US Food and Drug Administration (FDA) fina- 21 November 2016 Many tobacco product users, especially adolescents, lised a rule in May 2016 to extend its authority over reported experimenting, initiating and continuing to use all tobacco products (also known as the ‘deeming fl ’ 8 fl avoured products because of the taste and variety of rule ). FDA cited the high prevalence of avoured http://tobaccocontrol.bmj.com/ the flavours. Users of many flavoured tobacco products tobacco use among youth and young adults as a also showed decreased likelihood of intentions to quit reason for extending their authority over other compared with non-flavoured tobacco product users. tobacco products.8 However, FDA has not banned Conclusions Flavours in most tobacco products appear flavours in non-cigarette tobacco products in the to play a key role in how users and non-users, especially final deeming rule but intends to issue a proposed youth, perceive, initiate, progress and continue using product standard for prohibiting flavoured cigars, tobacco products. Banning non-menthol flavours from including cigarillos and little cigars.9 tobacco products may ultimately protect public health by Despite recent bans on flavoured cigarettes in reducing tobacco use, particularly among youth. some countries, the marketing and sale of flavoured cigarettes still occurs in many countries. Further, fl the marketing and sale of exempted avoured on September 29, 2021 by guest. Protected INTRODUCTION non-cigarette tobacco products is still broadly In 2010, WHO Framework Convention on allowed, and the tobacco industry continues to Tobacco Control guidelines recommended restric- introduce new flavours in non-cigarette products tions or bans on flavours in tobacco products and into the market.10 The use of flavoured non- recognised that ‘masking tobacco smoke harshness cigarette tobacco products remains high. For with flavours contributes to promoting and sustain- example, in 2014, ∼12% of US middle and high ing tobacco use’ and that ‘there is no justification school students used flavoured tobacco products in for permitting the use of ingredients, such as fla- the past 30 days,11 and a 2012 study found that vouring agents, which help make tobacco products 19% of US young adults reported past 30-day use attractive’.1 Jurisdictions (including cities, states/ of flavoured tobacco products.12 The prevalence of provinces and countries) around the world have flavoured tobacco product use in the last 30 days fl To cite: Huang L-L, taken legislative measures to regulate avours in among Canadian students in grades 9 through 12 is 13 Baker HM, Meernik C, et al. tobacco products with different levels of restrictions also high, at 10% in 2013. Tob Control to reduce tobacco product attractiveness, especially Understanding the impact of flavouring on 2017;26:709–719. among youth. The 2009 US Family Smoking tobacco use is a research priority outlined by FDA Huang L-L, et al. Tob Control 2017;26:709–719. doi:10.1136/tobaccocontrol-2016-053196 709 Tob Control: first published as 10.1136/tobaccocontrol-2016-053196 on 21 November 2016. Downloaded from Review Figure 1 PRISMA flow diagram of article identification, screening and selection. *Checking reference lists of included articles. Center for Tobacco Products,14 and it is an area of interest for Type of outcome measures and intervention tobacco researchers and government bodies worldwide.15 Our outcome measures included reasons for using flavoured While FDA and its affiliated Tobacco Products Scientific tobacco products; perceptions about product taste, appeal and Advisory Committee have investigated the effect of menthol health risks; expectancies and beliefs; intention to try; intention copyright. flavouring on public health,16 17 more limited work has investi- to quit; use behaviours, including experimentation, initiation, gated the impact of non-menthol flavouring on youth and preference and progression to regular use, dual or poly tobacco adult perceptions, initiation, use and cessation of diverse use, and cessation. tobacco products. A recent systematic review examined the use of and attitudes Data sources and study selection fl 18 towards non-menthol avoured tobacco products, but its One author (HMB) conducted searches of PubMed, Embase, scope was limited to US studies only, and only studies prior to PsycINFO and CINAHL during March 2015. A general search 18 http://tobaccocontrol.bmj.com/ September 2013 were included. While this review did strategy was developed using Boolean language to connect var- fl examine the prevalence of avoured tobacco use and the rela- iants of words related to tobacco products and use and flavour fl i tionships between avoured tobacco use and age, it did not crit- for PubMed, which was translated to match the search string fl ically examine the role that non-menthol avouring plays in requirements for other databases. To supplement the database tobacco use behaviours, such as initiation and cessation, and search, two authors (CM and HMB) conducted a manual search fl fi whether the avouring in tobacco products speci cally affects of the reference lists in each of the included articles. In these relationships. Given the rapid pace at which the market- September 2015, authors conducted a second search using the fl place and research on avoured tobacco products are evolving, same search strings and databases to include articles published and the interest of the topic to domestic and international pol- and indexed after the initial search. A total of 2013 articles icymakers, we conducted a systematic review of articles pub- resulted from searching the 4 databases during the initial search lished through April 2016 to investigate the role of non-menthol flavoured tobacco products in attitudes, percep- on September 29, 2021 by guest. Protected tions, intentions, use and cessation of tobacco products in the iFinal PubMed search string: (electronic cigarettes[mesh] OR tobacco USA and globally. products[mesh] OR smoking[mesh]) AND flavoring agents[mesh] OR (((smoke OR smoker OR smokers OR smokes OR smokings OR smoking OR cigarette OR cigarettes OR cigar OR cigars OR cigarillos OR cigarillo METHODS OR hookahs OR hookah OR waterpipe OR waterpipes OR narghile OR Eligibility criteria narghiles OR argila OR argiles OR tobacco OR tobaccos OR cigar* OR Eligibility criteria
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