More than a "characterizing flavor": Menthol at subliminal levels in tobacco products.

INTRODUCTION: In addition to imparting flavor, menthol in menthol-flavored cigarettes enhances nicotine addiction and increases experimentation, initiation, and progression to regular smoking. Menthol can be added to cigarettes at perceptible levels (so-called flavored cigarettes or characterized flavored cigarettes) or non-perceptible levels (subliminal). Our objective was to understand the reasons that tobacco companies use subliminal menthol. METHODS: We identified previously secret internal tobacco company documents dated 1955-2012 in the Truth Tobacco Industry Documents archive on menthol at subliminal levels. RESULTS: Beginning in at least the 1950s, tobacco companies used subliminal menthol to compensate the flavor loss caused by filters, reduce smoke harshness, reduce dryness, and increase smoke coolness. Varying menthol concentrations were considered to help convert people who smoke non-menthol to menthol brands, possibly because people who use menthol cigarettes have more harship quitting than people who use non-menthol cigarettes. CONCLUSIONS: Menthol is an important additive beyond its function as a "characterizing flavor." Tobacco companies use menthol in "non-menthol" cigarettes at subliminal (non-perceptible by the people who smoke cigarettes) levels to improve taste, make them easier to smoke and facilitate initiation, and possibly convert people who smoke non-menthol cigarettes to menthol cigarettes.

Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes.

BACKGROUND: E-cigarettes are promoted as less harmful than cigarettes. There has not been a direct comparison of health effects of e-cigarettes or dual use (concurrently using e-cigarettes and cigarettes) with those of cigarettes in the general population. METHODS: Studies in PubMed, EMBASE, Web of Science, and PsychINFO published through October 1, 2023, were pooled in a random-effects meta-analysis if five or more studies were identified with a disease outcome. We assessed risk of bias with Risk Of Bias In Non-randomized Studies of Exposure and certainty with Grading of Recommendations, Assessment, Development, and Evaluations. Outcomes with fewer studies were summarized but not pooled. RESULTS: We identified 124 odds ratios (94 cross-sectional and 30 longitudinal) from 107 studies. Pooled odds ratios for current e-cigarette versus cigarette use were not different for cardiovascular disease (odds ratio, 0.81; 95% confidence interval, 0.58 to 1.14), stroke (0.73; 0.47 to 1.13), or metabolic dysfunction (0.99; 0.91 to 1.09) but were lower for asthma (0.84; 0.74 to 0.95), chronic obstructive pulmonary disease (0.53; 0.38 to 0.74), and oral disease (0.87; 0.76 to 1.00). Pooled odds ratios for dual use versus cigarettes were increased for all outcomes (range, 1.20 to 1.41). Pooled odds ratios for e-cigarettes and dual use compared with nonuse of either product were increased (e-cigarette range, 1.24 to 1.47; dual use, 1.49 to 3.29). All included studies were assessed as having a low risk of bias. Results were generally not sensitive to study characteristics. Limited studies of other outcomes suggest that e-cigarette use is associated with additional diseases. CONCLUSIONS: There is a need to reassess the assumption that e-cigarette use provides substantial harm reduction across all cigarette-caused diseases, particularly accounting for dual use.

'If I hadn't seen this picture, I'd be smoking'-perceptions about innovations in health warnings for cigarette packages in Brazil: a focus group study.

OBJECTIVE: To investigate the perceptions of young people and adults, smokers and non-smokers about the current set of innovations introduced in 2018 into the Brazilian tobacco products' health warnings. METHODS: Twenty focus groups were conducted in five state capitals in Brazil. The participants (n=163) were segmented by smoking status, age (15-17 years, 18-55 years) and social grade (C, D-E classes) to examine cigarette packaging and explore the participants' perceptions of health warnings. RESULTS: Health warnings capture attention, eliciting apprehension, fear, disgust and concern about the negative consequences of cigarette consumption. The 2018 Brazil health warnings are spontaneously recalled by participants, even without the presence of cigarette packages. However, the analysis also reveals the challenges of overcoming communication barriers and distorted interpretations, especially among smokers. The inclusion of direct and provocative stimuli, such as the use of the word 'you', attracts attention and creates more proximity to the recipient of the message. The results also highlight the interest and fear elicited by warnings on toxic constituents and the importance of using contrasting colours in warnings, which differentiate them from the colours of cigarette packs. CONCLUSION: Introducing innovative components in health warnings can catch consumers' attention but considering that the interviewees encountered difficulties interpreting textual warnings about toxic constituents in cigarettes, the study reinforces the importance of adopting direct language and pictures, instead of text, which can visually transmit the warning messages and the use of specific wording that generates proximity between the emitter and receiver.

The taste of smoke: tobacco industry strategies to prevent the prohibition of additives in tobacco products in Brazil.

BACKGROUND: The tobacco industry (TI) uses several strategies to attract new consumers, including using additives in tobacco products, which makes tobacco especially attractive to youth. Based on scientific evidence and the principles of the WHO Framework Convention on Tobacco Control, the Brazilian Health Regulatory Agency (ANVISA, for the name in Portuguese), published the Collegiate Board Resolution (RDC, for the name in Portuguese) 14/2012 in 2012, prohibiting the addition of substances that enhance the flavour and taste of tobacco products in order to make them more attractive. In response, the TI used various strategies to prevent RDC 14/2012 from entering into force. At the time, the Brazilian additive ban was the most comprehensive in the world as it included a ban on menthol. OBJECTIVES: This paper analyses the arguments and strategies used by the TI to prevent the implementation of the additives ban. METHODS: Review of published articles, reports, legislation and legislative activity, internal TI documents, media stories and other documents to describe TI's reaction to the ban. RESULTS: The results show that the TI used some well-known strategies to delay or cancel the entering into force of the resolution. For example, the TI attempted political interference, used litigation and commissioned studies with findings that questioned the resolution's rationale. The TI strategies used in Brazil are similar to those used at the global level to oppose other tobacco control measures. CONCLUSIONS: TI successfully delayed the most comprehensive additive ban in the world using its usual tactics, despite the fact that none of the arguments presented by the TI had an acceptable scientific basis or evidence.

Comprehensive chemical characterization of Rapé tobacco products: Nicotine, un-ionized nicotine, tobacco-specific N'-nitrosamines, polycyclic aromatic hydrocarbons, and flavor constituents.

Rapé, a diverse group of smokeless tobacco products indigenous to South America, is generally used as a nasal snuff and contains substantial amount of plant material with or without tobacco. Previously uncharacterized, rapé contains addictive and harmful chemicals that may have public health implications for users. Here we report % moisture, pH, and the levels of total nicotine, un-ionized nicotine, flavor-related compounds, tobacco-specific N-nitrosamines (TSNAs) and polycyclic aromatic hydrocarbons (PAHs) for manufactured and hand-made rapé. Most rapé products were mildly acidic (pH 5.17-6.23) with total nicotine ranging from 6.32 to 47.6 milligram per gram of sample (mg/g). Calculated un-ionized nicotine ranged from 0.03 to 18.5 mg/g with the highest values associated with hand-made rapés (pH 9.75-10.2), which contain alkaline ashes. In tobacco-containing rapés, minor alkaloid levels and Fourier transform infrared spectra were used to confirm the presence of Nicotiana rustica, a high nicotine tobacco species. There was a wide concentration range of TSNAs and PAHs among the rapés analyzed. Several TSNAs and PAHs identified in the products are known or probable carcinogens according to the International Agency for Research on Cancer. Milligram quantities of some non-tobacco constituents, such as camphor, coumarin, and eugenol, warrant additional evaluation.