Health warnings first appeared on cigarette packaging 60 years ago. Researchers and health professional have described tobacco as addictive since the 1970s.
Yet nearly 50 million people in the United States — 1 in 5 adults — still report using tobacco, according to the Centers for Disease Control and Prevention.
Scientists and regulators work on ways to discourage tobacco use while the tobacco industry continues to make products more appealing and accessible.
"It's a patchwork approach to regulation," said Roberta Freitas-Lemos , assistant professor and a tobacco researcher at Virginia Tech's Fralin Biomedical Research Institute at VTC . "But what's the best patchwork? We need to experimentally test tools and policies that may help improve health outcomes."
Some efforts limit tobacco flavorings, like menthol. Others use increased taxation to deter cigarette purchases.
Freitas-Lemos recently published the results of three studies as a series in the journal Tobacco Control examining regulation efforts and the industry's response. One examines how marketing language tries to sidestep limitations on menthol restrictions. Another explores how limiting flavorings affects tobacco use. And a third investigates how four different taxation approaches impact consumers.
Marketing menthol replacement products
In one study , Freitas-Lemos and Ana Carolina de Lima Bovo, a postdoctoral researcher at the institute, found distinct differences in how tobacco menthol accessories are marketed in the U.S. compared with Europe. The products, which can be used to add menthol to unflavored cigarettes, became a concern in jurisdictions that restrict menthol in cigarettes, as they may reduce the effectiveness of such restrictions.
European Union countries, the United Kingdom, Massachusetts, and California had all banned menthol flavoring in cigarettes by 2022. Researchers noted the subsequent introduction of external menthol flavoring methods into the market. These include aroma cards, filters, capsules and sprays, which are also banned by laws in Massachusetts and California, but not the United Kingdom and European Union.
"We're trying to monitor the industry and understand what's the industry response to these bans," said Freitas-Lemos, who also holds a faculty appointment in the Department of Psychology in Virginia Tech's College of Science .
When first buying menthol accessories for use in research, Freitas-Lemos and her lab team noticed that the advertising language described them for use with cigarettes. When they went back later to buy more, cigarettes weren't mentioned.
Using Amazon online shopping sites for different countries, the researchers examined the product marketing and found that in Europe, where they are not banned, they're described as accessories to add menthol flavor to cigarettes. In the United States, they're advertised as "air refreshers" to be used in medical masks or for "air filtering purposes."
"We are interested in these accessories and how they are marketed, because they can basically undermine the public health impact by circumventing regulations intended to discourage smoking," Freitas-Lemos said.
Menthol cigarette and flavored vaping bans
In a second study , Freitas-Lemos used the Experimental Tobacco Marketplace, a simulated online store designed by researchers at the Fralin Biomedical Research Institute, to explore how menthol bans impact users' decisions on whether to continue smoking or choose less harmful alternatives.
Twenty-five people who smoke menthol cigarettes were exposed to four flavor restriction scenarios involving cigarettes and e-cigarettes. Nicotine replacement therapy products, such as gums and lozenges, were also available.
"We are trying to understand if banning just menthol cigarettes or banning flavoring in e-cigarettes as well would transition individuals who smoke away from the combustible cigarettes," Freitas-Lemos said.
The study found that restricting menthol in cigarettes reduced cigarette purchases and increased substitution with e-cigarettes. Flavor restrictions in e-cigarettes were associated with increased purchases of nicotine replacement products.
"These flavor ban policies are out there," Freitas-Lemos said. "They're banning cigarette flavors, they're banning e-cigarette flavors. We need to understand how they interact."
Testing tobacco taxes
A third study used the Experimental Tobacco Marketplace to examine how four tax policies affected tobacco purchases.
About 400 study participants were exposed to the four tax policies on tobacco products:
- Lower taxes on tobacco products certified to have modified health risk
- Lower taxes on products with less nicotine
- Lower taxes for reduced harm
- All products taxed the same, but no tax on nicotine replacement products
"These approaches represent ways different advocacy groups think are the best to promote cessation," Freitas-Lemos said.
While higher taxes consistently reduced spending, the tax based on nicotine content led to the largest reduction in spending and the greatest shift toward untaxed nicotine replacement products.
The policies were similarly effective across all socioeconomic groups, which is important because tobacco use disproportionately impacts people with less education and lower household income.
"These finding show that strategic taxation is a robust and adaptable tool for shifting how people spend money on tobacco and can be effective at reducing use of the highest risk products," Freitas-Lemos said.
Funding for all three studies came from the National Institutes of Health and the Fralin Biomedical Research Institute. The first study was also supported by a Lyerly Postdoctoral Excellence Award, and the study on tax policies received support from the Red Gates Foundation.
