Menthol and flavored tobacco products in LMICs: A growing menace

INTRODUCTION: High income jurisdictions are banning menthol/flavored cigarettes and other tobacco products because they attract young people and create dependence. This study explores the importance of menthol and other flavored tobacco products for tobacco markets in low- and middle-income countries (LMICs), identifies countries where the menthol/flavor share is particularly high or rapidly growing, and identifies strategies tobacco companies are using to develop menthol/flavor markets. METHODS: Research involved analysis of menthol/flavor market data from 2005 to 2019, a systematic review of academic literature, and a scoping exercise with our advocate contacts in LMICs. RESULTS: The median menthol/capsule market share of the cigarette market grew significantly (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)]. Countries with both high market share and high market share growth were Russia, Guatemala, Peru and Nigeria. 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/flavored tobacco use in LMICs included in-store marketing and display, colorful packs and non-conventional flavor names. CONCLUSIONS: Menthol/flavor tobacco products are a growing problem in LMICs. In addition to menthol/flavor bans, we recommend marketing bans, point of sale display bans and standardized packaging.