The use of flavour cards and other additives after a menthol ban in Canada

Introduction:

In Canada, where bans on menthol have been implemented in the province of Ontario since January 2017, and across Canada since October 2017, products that can be used to add menthol flavour to non-mentholated tobacco such as flavour cards and menthol drops are available in stores, including the brand “Itsa” which is distributed by a cigar company. These products can easily add menthol flavour by either placing the card or drops with the tobacco or in the package as a way of circumventing the ban. However, in Ontario it appear that no major cigarette manufacturers had produced or advertised these flavour additives. The purpose of this letter is to examine the changes in use of after-market menthol additives after the menthol ban in Ontario.

Methods:

Current (past month) cigarette smokers aged 16+ living in Ontario were surveyed pre-ban September to October 2016, then January 2017, January 2018, and January 2019. More details on the survey are available elsewhere (2). Questions about use of additive cards, drops, and oils to add menthol to tobacco were asked of menthol smokers (both daily menthol cigarette smokers, and those who use menthol occasionally at least once in the past year) at all time points. The question was also asked of pre-ban non-menthol cigarette smokers in 2018 and 2019. A total of 1309 people responded to at least one of the additive questions.

Results:

Overall, 14.6% (95% CI: 11.0, 19.2) of pre-menthol ban daily menthol cigarette smokers had reported using some sort of additive since the ban compared to 9.8% (95% CI:7.8, 12.2) of pre-menthol ban occasional menthol cigarette smokers (Table 1). Before the menthol ban, 4.4% (95% CI: 2.6, 7.8) of daily menthol smokers had previously tried flavour additives, rising to 5.1% (95% CI: 2.9, 8.7) by January 2017, 12.5% (95% CI: 8.5, 18.0) by 2018 and 9.5% (95% CI: 5.9, 14.9) in 2019 (Table 1). In 2018, 2.6% (95% CI: 1.3, 5.1) of pre-ban non-menthol smokers had also tried the after-market additives, falling to 0.8% (95% CI: 0.2, 3.0) in 2019. Flavor additive use was not significantly associated with making a quit attempt.

Table 1.

Percentage reporting use of flavour cards, drops, oils or other additives to add menthol to tobacco in Ontario, Canada 2016–2019 (n=1309).

		Percent reporting use of flavour additive
	N	%	95 % CI	p value
Gender
Female	747	8.4	[6.6,10.7]	p<0.001
Male	550	9.5	[7.3,12.2]
Other	10	50.0	[22.4,77.6]
Total	1,307	9.2	[7.7,10.9]
Age				p=0.002
16–29	210	14.8	[10.6,20.2]
30+	1,099	8.1	[6.6,9.9]
Total	1,309	9.2	[7.7,10.9]
Education				p=0.021
High School or Less	395	6.3	[4.3,9.2]
More than High School	898	10.4	[8.5,12.5]
Total	1,293	9.1	[7.7,10.8]
Race				p=0.239
Non-White	234	11.1	[7.7,15.8]
White	1,073	8.7	[7.1,10.5]
	1,307	9.1	[7.7,10.8]
Frequency of Smoking				p=0.003
Daily	1,172	8.4	[6.9,10.1]
Occasional	137	16.1	[10.8,23.2]
Total	1,309	9.2	[7.7,10.9]
Baseline ever use of non-cigarette flavoured tobacco products (e-cigarettes, hookah, smokeless, bidi, kreteks)				p<0.001
No	649	4.8	[3.4,6.7]
Yes	660	13.5	[11.1,16.3]
Total	1,309	9.2	[7.7,10.9]
Made a quit attempt since the menthol ban				p=0.271
No	221	8.1	[5.2,12.6]
Yes	672	10.7	[8.6,13.3]
Total	893	10.1	[8.3,12.2]
Baseline Menthol Smoking Status				p<0.001
Non-Menthol	313	2.6	[1.3,5.1]
Occasional Menthol	702	9.8	[7.8,12.3]
Daily Menthol	294	14.6	[11.0,19.2]
Total	1,309	9.2	[7.8,10.9]

Percent not reporting flavour additive usage not reported. Characteristics reported at baseline except for having made a quit attempt since the ban.

Conclusion:

Despite a lack of promotion by major tobacco companies, flavour cards or additives were used by 14.6% of pre-menthol ban daily menthol smokers, a substantial minority, to substitute for the lack of availability of menthol cigarettes. The cards were also used by those who had not smoked menthol cigarettes before the ban. In December 2019, Imperial Tobacco in the United Kingdom announced a new line of ‘flavour cards’ as a way for retailers to “provide shoppers with options to help them stick with their flavour preference post ban and protect their sales as a result.”(3) This suggests a change in industry practice to use flavour additives more prominently to circumvent the May 2020 menthol ban in the European Market. If these additive products are more available and promoted than they were in Canada, they may limit the effectiveness of the upcoming menthol restrictions in the Europe.