Removing the marketing power of cigarettes: A multi-method study aimed at protecting the health of adolescents in Latin America

Tobacco companies use flavours in cigarettes to make them taste better. These flavours may encourage young people to try smoking, start to smoke or continue to smoke. Flavoured cigarettes are sold across most of the world, but are very popular in Latin America. The popularity of flavoured cigarettes in many Latin American countries is due to a tobacco industry innovation. Tobacco companies introduced cigarettes that have capsules in the filter that can be burst, by squeezing the filter, to release a liquid that changes the flavour. Some cigarette sticks have as many as three different flavoured capsules in the filter, allowing several flavour options in a single cigarette. There has been little research on flavour 'capsule' cigarettes, even though they appear to appeal to young people and so are a potential route into starting smoking or continuing to smoke. They are a serious threat to adolescent health. The cigarette stick is an increasingly important way for tobacco companies to promote their products, including flavoured cigarettes. Therefore, researchers have recently started to explore ways of making the cigarette stick less appealing, for example by including health messaging on the stick, making it an unappealing colour, or a combination of both. These are called 'dissuasive' cigarettes.

Our project has two objectives. The first is to understand how tobacco companies market flavoured cigarettes in Latin America and the impact that flavoured cigarettes have on the smoking attitudes, intentions and behaviours of adolescents. The second is to understand whether dissuasive cigarettes may deter adolescents from smoking. We will conduct three studies in four countries in Latin America where flavoured cigarettes are extremely popular (Argentina, Guatemala, Mexico and Peru). Each study will be carried out in four different towns and cities in each country. For the first study we will visit retailers who sell tobacco to record if, and how, flavoured cigarettes are being promoted in retail outlets and via the cigarette pack and cigarette stick, and whether single cigarettes are sold. The second study will involve discussions with small groups of adolescent smokers and non-smokers to ask what they think about flavoured cigarettes and dissuasive cigarettes. We will show participants examples of the retail marketing and cigarette packs and sticks collected in the first study to help with the discussion. The third study will also explore how adolescents view flavoured cigarettes and dissuasive cigarettes, this time using questionnaires in schools that pupils will be asked to complete during class time. This study will be informed by what adolescents say about flavoured and dissuasive cigarettes in the second study, and also with input from adolescents to develop questions so that they are easy to understand and meaningful.

The research team has significant expertise on tobacco marketing and tobacco control policy, and considerable experience of working with policy makers. We will invite our project partners, including the Ministries of Health in each country and regional networks, to help us interpret the results, refine a communication plan and advise on how to make the results widely available. The findings will be communicated through research publications, presentations at conferences and to policy makers, and briefings for policy and advocacy organisations. We will hold stakeholder meetings in each country, and webinars, to present the findings to policy makers and the public. We will also have a website that focuses only on the project.

In terms of potential benefits of the research, the findings will allow policy makers and other stakeholders in each country, across Latin America, and globally, to understand how flavoured cigarettes are influencing adolescent smoking, and therefore the potential benefits of banning these, and whether dissuasive cigarettes could help put young people off smoking.

Flavoured cigarettes may encourage young people to try smoking, start to smoke or continue to smoke. Growing market share for flavoured cigarettes in many Latin American countries is due to 'capsule cigarettes', which have frangible capsules in the filter that can be burst to change the flavour. There is limited research on capsule cigarettes, even though they appeal to youth and are a potential route into starting or continuing to smoke. In response to the growing importance of the cigarette stick as a promotional tool for tobacco companies, researchers have begun to explore ways of making the cigarette stick 'dissuasive', for instance by including health messaging and/or making it an unappealing colour. Our objectives are to understand: 1) how tobacco companies' market flavoured cigarettes in Latin America and the impact these have on the adolescent smoking attitudes, intentions, and behaviours, and 2) whether dissuasive cigarettes may deter adolescents from smoking. Three interlinked studies will be conducted in four Latin American countries where flavoured cigarettes have high market share (Argentina, Guatemala, Mexico and Peru). Each study will be conducted in the same four urban and rural locations in each country. In Study 1, we will use a codebook to record how flavoured cigarettes are promoted in retail outlets and via the cigarette pack and stick, and whether single cigarettes are sold. Study 2 will involve focus groups with adolescent smokers and non-smokers to explore their thoughts on flavoured and dissuasive cigarettes. Study 3 will use school surveys with an embedded discrete choice experimental design to assess whether cigarette stick design can influence the desirability of, and interest in, smoking. We will engage with our project partners, which include regional networks and the Ministries of Health in each country, and other key stakeholders, to help us interpret the results, refine a communication plan, and ensure the results are widely shared.