Consistent with other epidemiology studies till date on flavoured cigarettes use, GATS displayed that female smokers tend to prefer flavoured cigarettes compared to male smokers [8, 22, 23]. The scientific literature is consistent with this finding for adult smokers [8, 24]. Unfortunately, we do not have any potential observation or previous data on flavoured cigarettes use in Poland to determine whether this proportion has changed or consistently remains the same. GATS also revealed that younger smokers until age 29 years use cigarettes with characterizing flavour far more likely than older smokers [25–27]. The lack of significant association with the age group 15-19 years could be explained by the small cell sizes for this youngest group of flavoured cigarettes smokers, but the positive direction of association remained. The proportion of menthol smokers among all cigarette smokers has been shown to be higher among adolescents than among adults in most, racial or ethnic groups with the exception of African American smokers .
The reasons for preferring flavoured cigarettes including menthol cigarettes among younger, novice smokers are many including tobacco industry aggressive advertisement or promotion tactics addressed to specific social and demographic groups, especially young people and women that may alter the attractiveness of the product . Packaging – colors, branding, shape of packs or additional descriptions (“delicious”, “super-slims”, “velvet mint”, “frissons”) also play an important role in creating false beliefs that these products are less harmful than others, less harassing and more pleasant in general [29–31]. Removing brand descriptors from packs significantly reduces measures of appeal and taste, particularly for brands with flavour descriptors, such as cherry and vanilla. Plain packs are significantly less likely to be associated with positive images, such as glamour, sophistication, and slimness .
On the other hand, some additives like menthol enhance the taste, reduce the harshness, and stimulate cold receptors, providing a sensation of coolness. Smokers find them tastier as well as easier to inhale especially for new smokers . Study by Hersey et al. based on data from the National Youth Tobacco Survey indicated that menthol cigarettes are a starter product that may be associated with smoking uptake by youth . Moreover menthol cigarettes seem to serve as a conditioned stimulus that reinforces the rewarding effects of smoking .
In GATS another important factor increasing use of cigarettes with aromatic additive is having a higher level of education. Factors that may potentially contribute to more common use of such products between respondents with higher levels of education may include general increased awareness on health, attitudes and social norms. People with higher levels of education may consider or be more aware of health risks of smoking and choose products advertised as less harmful or products that claim to increase mental or physical performance, unless based on misleading perceptions. In accordance with these outcomes, we noted that people aware of negative health consequences of smoking cigarettes are more likely to use flavoured brands. Similarly, there was an association between perceiving less harmful cigarettes with aromatized cigarettes. Several previous studies conducted with other populations have demonstrated comparable results .
In GATS we noted similar rates of respondents perceived some kinds of cigarettes less harmful than others (26.2%) compared to the results of the International Tobacco Control (ITC), where overall; 27.8% of current smokers believed that some cigarettes could be less harmful; with 22.4% of current smokers in the UK, and 24.3% in France endorsing beliefs that some brands might be less harmful . This proportion was higher only in Germany (36.7%). Compared to German smokers, Poles were less likely to hold beliefs that some brands might be less harmful. It should be stressed that across the countries, among those who believed that some cigarettes were less harmful than others; close to 50% thought taste was an indicator of harm . In addition, the most popular reasons participants gave for selecting the brands they usually smoked were taste and satisfaction which reached 72% among smokers. Despite this, over a fifth (21.8%) of participants overall gave health as reasons for selecting their brands which also contribute to justifying our results .
Living in a large city was another factor associated with use of flavoured cigarettes. Hypothetically it can be related to greater rates of people with higher education in large cities compared to rural settings. Another reason could be marketing strategies and more intensive targeting of this subgroup of population relative to the rural population. Unfortunately we lack data on tobacco industry campaigns. Nevertheless, due to a somewhat restrictive ban of tobacco advertisement, promotions including those in all mass media tobacco industries have to use more sophisticated, direct attitudes. It is also easier and more efficient to approach higher numbers of people in large cities, such as during mass events or in bars or discos. Another issue is lack of ban of displaying tobacco products at points of sale. Inhabitants of big cities due to more developed infrastructure and greater concentration of points of sales are more exposed on this type of marketing. On the other hand, the sociocultural aspect of menthol cigarette smoking among rural and urban respondents is a probable fundamental reason in explaining this issue.
Our findings which show higher odds of using flavoured cigarettes among economically non active respondents is probably related to the characteristic of this group covering mostly young people; for example young women occupied with home and child care, pupils or students who as we previously indicated are more prone to use of flavoured cigarettes.
GATS data analysis revealed a lack of association between income and the use of flavoured cigarettes. A review of the evidence on this topic by Caraballo et al. showed that data on income and the use of menthol cigarettes is almost nonexistent in the literature . Figures from the US National Survey on Drug Use and Health (NSDUH) showed that adult smokers with family incomes of less than $50 000 were more likely to smoke menthol cigarettes than adult smokers with higher family incomes. Nonetheless, there is also no previous available statistics from Poland for comparison.
There was also no association between duration of smoking and number of cigarettes smoked per day with use of aromatized cigarettes. It might be expected that those who smoke less cigarettes and beginner smokers smoking for short period would prefer flavoured cigarettes and then due to rising dependency for example switch to traditional cigarettes. Although we found higher percentage of non-flavoured cigarettes users among female consuming twenty cigarettes per day or more this association was not confirmed in the multivariate analysis for entire population. In other studies results are inconsistent regarding the frequency and direction of switching between menthol and nonmenthol cigarettes . No studies were identified by Rising et al. in their review that directly addressed whether current smokers started smoking with menthol cigarettes and then switched to non-menthol cigarettes .
But it also may suggest that smokers at different stages or trajectories of cigarette smoking are susceptible to tobacco advertisement and promotion of flavoured brands regardless on the length of habit and the level of dependency.
As has been concluded based on analysis of documents derived from tobacco companies menthol is a prominent design feature used by cigarette manufacturers to attract and retain new smokers [13, 35, 36]. Marketing studies showed that the companies carefully research the menthol segment of the market in order to recruit smokers to their brands. The industry tracks menthol cigarette usage by age, gender and race to inform product development and marketing decisions. Furthermore, the tobacco industry knows consumers perceive menthol as healthier than non-menthol cigarettes, and this was the intent behind marketing [13, 28, 35].
However there are some promising observations from the study that explored how menthol smokers might react if menthol cigarettes were banned. O’Connor et al. noted that over 60% of menthol smokers in the United States might respond to a ban on menthol cigarettes reducing or quitting smoking (36.5% of current menthol cigarettes smokers would try to stop smoking, 27.1% would smoke less than now if such cigarettes were banned) . Finally 14.7% declared that would switch to another brand, 10.6% would add menthol on their own . There is no such studies regarding flavoured cigarettes use by Poles but increasing the information on determinants of smoking of flavoured cigarettes is fundamental for developing and implementing more effective tobacco control measures and enact legislation at the national and European levels.
GATS providing nationally representative figures on status of different tobacco products use based on a high number of respondents covering all 16 voivodeships of our country . However this study is not free of limitations . There are well-known potential limitations resulting from use of self-reports and cross-sectional design, but these issues were discussed in previous papers and should not significantly decrease the quality of the study [18, 19, 21]. It should be also mentioned that in relation to current analysis information on smoking initiation with particular type of cigarettes (regular or aromatized) and switching or not to different types of tobacco were missing. Although GATS questionnaire included questions on beliefs about harmfulness of regular and different cigarettes, important information about reasons for choosing brands, taste preferences or beliefs about indicators of less harmful cigarettes were missing. This missing information makes it unable for us to compare GATS data with other results and should be a subject of further, in-depth investigations.