Tobacco Additives

7. Do additives make tobacco more attractive?

• 7.1 How do additives affect the attractiveness of tobacco products?
• 7.2 What does the evidence say about specific additives?
• 7.3 What are the current trends in tobacco use?

7.1 How do additives affect the attractiveness of tobacco products?

The SCENIHR opinion states:

A number of additives increase the attractiveness of tobacco products. This may be attained by creating a better experience of the product (e.g. appearance of the product, white and full smoke) or by making it easier to start smoking (e.g. by means of a cool, sweet and mild smoke, as well as causing less irritation in the lungs).

For many additives, attractiveness depends on multiple functions which may be difficult to distinguish clearly. One of the reasons to use additives is to attract the smoker to a specific product and to promote/encourage (young) people to start using the product. Other reasons for using additives are to produce a unique product, typical in taste and markedly different from competitor products, and to maintain the stability of the taste of the product.

Better experience of the product

Preservation of humidity of the tobacco product

Humectants are added to tobacco products to retain the water, i.e. to prevent them from drying out, and consequently increase the shelf life of the products.

Examples of additives

Examples of additives include: glycerol, propylene glycol and sorbitol.

Appearance, smell and irritation of tobacco smoke

In order to make the smoke more attractive to the smoker, but also to other people in the proximity of the smoker, it is important that the smoke is appealing and not annoying. This may be attained with additives which make the smoke whiter and more attractive to people seeing the smoke. The smell of the smoke may be also changed so that it is also more attractive and less irritating (Connolly et al. 2000, Ling and Glantz 2005).

Connolly et al. (2000) examined tobacco industry patents covering the function of environmental tobacco smoke masking. These strategies include reducing smoke odour, and reducing side-stream smoke visibility and emissions.

Methods to neutralize or reduce lingering smoke odour include addition of acetylpyrazine, anethole and limonene to modify the side-stream odour. These compounds have rather low odour thresholds, and are subsequently easily picked up, while they elicit no trigeminal nerve response. Aroma precursors, e.g. polyanethole provided a noticeable fresher, cleaner and less irritating cigarette side-stream aroma, while others (e.g. cinnamic aldehyde, pinanediol acetal) produce slightly sweet, spicy, clean, fresh, and less cigarette-like aroma. Also, more “classic” additives (e.g. vanillin, benzaldehyde, bergamot oil, cinnamon/cinnamon extract, coffee extract and nutmeg oil) modify side-stream odour.

Reduced visibility of side-stream smoke is accomplished by the addition of magnesium oxide, magnesium carbonate, sodium acetate, sodium citrate and calcium carbonate to the wrapper (cigarette paper). This has an effect on particle size; particles become smaller and therefore do not easily scatter light and become less visible. Reducing side-stream emissions is based on encapsulating the smoke in an impermeable cone using different types of additives such as potassium succinate, potassium citrate and magnesium carbonate.

By combining the use of additives and the look of the tobacco product, greater acceptance of the smoke may be created. Less resistance may be encountered from persons that do not smoke, and at the same time greater pleasure for the smoker may be created. The same agents may also be used to target the individual product at certain target groups (Carpenter et al. 2005a, Connolly 2004).

Taste and experience of the smoke

Cis-3-hexenol is added to increase the organoleptic characteristics of tobacco and it has a characteristic smell of newly mown grass (Alford and Johnson 1970). Cis-3-hexenol adds a green, foliaceous taste and a smell of chlorophyll to the tobacco smoke (Leffingwell et al. 1972). Apart from adding a taste and flavour of fresh tobacco to the tobacco smoke, the substance has another important characteristic: cis-3-hexenol reduces irritation (Alford and Johnson 1969).

The American tobacco company Brown & Williamson has tested the effect on the characteristics of the smoke when adding cis-3-hexenol to cigarettes (Alford and Johnson 1969, Alford and Johnson 1970). Cigarettes with added cis-3-hexenol in concentrations of 0.05, 0.10 and 0.15 mg per cigarette were tested against control cigarettes without added cis-3-hexenol by having an expert panel smoke the various cigarettes. All cigarettes with cis-3-hexenol were preferred to the control cigarettes (Alford and Johnson 1969, Alford and Johnson 1970). The effect of cis-3-hexenol was ”A dramatic increase in smoke freshness and acceptability. Irritation is also markedly reduced.”

Harshness

According to the tobacco industry definition, harshness is a chemically induced physical effect associated with a roughness, rawness experience generally localised in the mouth and to a lesser degree in the upper reaches of the throat and the trachea due to inhalation of tobacco smoke. Harshness can also cause a drying, rasping, coarse, astringent sensation usually associated with the smoke flavour of Virginia or air-cured type tobaccos.

Harshness is classically measured in four degrees: (i) Free – an absence of harshness; (ii) Touching – a slight awareness of a sensation; (iii) Scratchy – some discomfort, a stinging effect; and (iv) Harsh – rough, raw, raspy, coarse, astringent, painful inhalation.

Reducing the harshness of the smoke makes it possible to inhale deeper and increase the number of puffs, as more physical barriers will be reduced (Wayne and Henningfield 2008b).

The ratio between nicotine and tar is an important parameter in relation to the smoker’s experience of the cigarette. If the concentration of nicotine in relation to tar is too high, the harshness of the smoke will be much higher (Hurt and Robertson 1998). Nicotine is irritating in high doses compared to other substances in the smoke (Baker 1990).

The irritating effect of nicotine on the lungs and the bad experience at too large amounts of nicotine in relation to the amount of tar may be remedied by additives that may drown or reduce the harshness of the smoke. This may also be achieved by adding nicotine salts that do not cause the same irritation, but are still delivering nicotine or keeping the nicotine effect by means of a quicker absorption by ensuring larger amounts of free nicotine (Bates et al. 1999, Keithly et al. 2005).

Smoothness

Tar provides a strong flavour and mouth sensation, masking the harsher, bitter taste of nicotine which may be unpalatable to new smokers and uncomfortable to established smokers. Certain highly flavoured additives may also have the same properties to “smoothen” or reduce the harsh irritation of nicotine in tobacco smoke.

A central feature of tobacco marketing strategy has been to promote the perception that some cigarettes are less hazardous than others, so that smokers worried about their health are encouraged to switch brands rather than quit. Products bearing the word “smooth” or using lighter coloured branding mislead people into thinking that these products are less harmful to their health. Adults and children are significantly more likely to rate packs with the terms “light”, “smooth”, “silver” and “gold” as lower tar, lower health risk and either easier to quit (adults) or their choice of pack if trying smoking (children). For example, more than 50% of adults and youth reported that brands labelled as “smooth” were less harmful than the “regular” variety. The colour of packs was also associated with perceptions or risk and brand appeal. For example, compared to Marlboro packs with a red logo, cigarettes in packs with a gold logo were rated as lower health risk by 53% and easier to quit by 31% of adult smokers.

Plain packs significantly reduced false beliefs about health risk and ease of quitting and were rated by the children as less attractive and appealing (Hammond et al. 2009a).

Examples:

Propylene glycol

The addition of propylene glycol (1,2-dihydroxypropane) to tobacco results in a milder smoke (Danker 1958). It was found that propylene glycol reduces the delivery of nicotine, while the formation of tar is increased (Shepperd and Bevan 1994b). In another study, also by the Brown & Williamson Tobacco Company, a reduction of nose irritation was observed and a reduced delivery of nicotine was confirmed (Shepperd 1994a). It was suggested that the sensation of reduced effect and irritation in cigarettes with added propylene glycol is caused by reduced liberation of nicotine, since the tar/nicotine ratio is of importance to the sharpness of the smoke (Danker 1958, Shepperd and Bevan 1994b).

Levulinic acid and levulinates

Based on the information submitted by the tobacco industry to the competent authorities of the EU Member States, these two substances have in many cases not been included in the reports, but have been used and mentioned several times in the internal documents of the tobacco industry.

These organic salts would also be able to reduce the harshness of nicotine, as the salts do not cause the harshness that otherwise characterises high levels of nicotine (Bates et al. 1999). In a study of the published literature up until 2004, Keithly has also shown that the primary purpose of levulinic acid as an additive in tobacco is to make the smoke sweeter and softer and at the same time increase the nicotine absorption and the effect of nicotine in the brain. Keithly also describes the use of nicotine levulinate and levulinic acid to cause less harshness (Keithly et al. 2005).

Easier to start smoking

Tobacco products may also be designed in such a way that they are easier to start smoking with. This may be attained by making it easier to inhale the smoke in the lungs and by creating a sweeter, milder or “colder” smoke. By reducing and changing the harshness of the smoke, special target groups may be reached (Carpenter et al. 2005a, Carpenter et al. 2005b, Cummings et al. 2002, Klein et al. 2008, Wayne and Connolly 2002).

In a number of countries, sweet and tasteful tobacco products are the most preferred tobacco products among children and adolescents as well as experimenting smokers (Ashare et al. 2007, Giovino et al. 2005, Klein et al. 2008).

How to make inhalation of smoke less aversive

Liquorice

Glycyrrhizin is the active substance of liquorice i.e. the root extract of Glycyrrhiza glabra and has a sweet taste (Hodge and Shelar 1979). Apart from glycyrrhizin, liquorice also contains sugar substances, cellulose fibres and essential oils (Covington & Burling 1987b).

The taste and flavour of tobacco with liquorice/liquorice root added are described as sweet, woody and round (Leffingwell et al. 1972), but adding liquorice/liquorice root also has the objective of camouflaging the unpleasant taste of tobacco (Covington & Burling 1987b).

The use of adding liquorice/liquorice root to tobacco has the following advantages (Vora 1983); it reduces the harshness of tobacco smoke, the dryness in the mouth and throat, and it provides a pleasant sweet undertone to the smoke.

Menthol

The additive menthol is relevant for how a smoker experiences the smoke in the lungs and the concentration of menthol may be an important issue for the group that the cigarette brand is targeted at. This is described further in section 3.8.3.1, which broadly outlines the potency of menthol to inhale smoke more easily and deeply.

Cooler and milder smoke

Certain substances make the smoke milder and cooler, e.g. menthol (see section 3.8.3.1), liquorice and propylene glycol. However, many more additives probably have these effects on the smoker’s lungs, but they have not yet been evaluated, or have not been described in the literature.

Sweeter taste

The presence of sugars in cigarettes is associated with a more favourable taste. The experience of the smoke is less negative and the irritability is somewhat masked. The tobacco producers have used additives that create sweetness and taste in the smoke to make it easier for new smokers to start smoking, since these tobacco products do not have the same harshness and bad experience at the first inhalations (Cummings et al. 2002, Wayne and Connolly 2002).

Conclusions on how certain additives can increase the attractiveness of tobacco products

The attractiveness of tobacco products may be increased by a number of additives. An attractive effect may be obtained in a number of ways, such as changing the appearance of the product and the smoke, decreasing the harshness of the smoke, and inducing a pleasant experience of smoking. The harshness depends partly on the tar/nicotine ratio, but may also be decreased by certain additives such as propylene glycol or levulinates. Various sugars constitute a large proportion of additives, and the sweetness of the smoke is an important characteristic.

Many different additives are used to create a specific taste/flavour in order to attract certain target groups. In order to make the smoke less aversive and permit deeper inhalation, additives such as liquorice and menthol are used. Finally, in order to make smoking more acceptable to people around, some additives have the function of reducing lingering odour or side-stream smoke visibility.

7.2 What does the evidence say about specific additives?

Menthol

Menthol is an important tobacco additive and it is the only additive explicitly declared to the consumer. For more than 40 years, scientific discussions have covered the health effects of the addition of menthol to tobacco. Menthol is a monocyclic terpene alcohol. It is a naturally occurring compound of plant origin which gives plants of the Mentha species the typical minty smell and flavour (Eccles 1994). Mentholated cigarettes have a major share of the market in the USA. However, in most European countries, the market shares for mentholated cigarettes range between 1 and 5% (Giovino et al. 2004). The menthol content has been investigated in the USA in 48 commercially available mentholated cigarette sub brands. Menthol content per g tobacco was reported to range between 2.88 and 5.75 mg menthol (Celebucki et al. 2005). In Germany, the menthol content was analyzed in non-mentholated cigarettes as well as in raw tobacco. Menthol content in raw tobacco and home grown tobacco was in the range 0.02-0.18 µg menthol/g tobacco. Menthol content per g tobacco in non-mentholated cigarettes ranged between 0.019 and 13.3 µg menthol (Merckel et al. 2006). These data clearly prove three points: firstly, menthol occurs naturally in very small amounts in tobacco; secondly, some brands contain no added menthol at all and in some brands, microgram amounts of menthol have been added; and finally, mentholated brands contain milligram amounts of menthol per g tobacco. The tobacco industry advertises menthol as a substance which alleviates harshness and enhances taste and smoothness, but menthol may also facilitate nicotine delivery and increase the sensory impact of cigarettes.

Menthol can be applied to cigarettes in a number of ways; it can be applied directly to the tobacco or introduced into the cigarette filter, or it can be applied to the cigarette packaging (see section 3.4.).

The fate of menthol in the cigarette has only been investigated by the tobacco industry. Philip Morris showed with 14C-labelled menthol that 29% of the activity went into the mainstream smoke, and 98.9% was as unchanged menthol (Jenkins et al. 1970). The transfer of menthol from tobacco into smoke was investigated by another company in 11 cigarette brands; the values ranged from 19 to 31% (Brozinski et al. 1972).

A report by Schmeltz and Schlotzhauer raised concerns about the pyrolysis of menthol. The authors pyrolysed menthol under nitrogen at 860°C and analysed the pyrolysate by paper-chromatography and thin-layer chromatography. They found approximately 400 µg benzo[a]pyrene per g menthol (Schmeltz and Schlotzhauer 1968). However, under normal smoking conditions, the menthol evaporates before being burned. The question was investigated again later on by Baker and Bishop who heated menthol at 30°C per second from 300 to 900°C under a flow of 9% oxygen in nitrogen. The products were analysed by gas chromatography and mass spectrometry. The authors found that 99% of the menthol was unchanged in the gas phase; additional products were menthon (0.9%) and menthen (0.1%) (Baker and Bishop 2004a).

Some companies have investigated the influence of tobacco additives on the composition of smoke constituents. For example, Philip Morris studied experimental cigarettes with many additives. They prepared two sets of cigarettes containing, among other additives, 18,000 ppm menthol, yielding 13 mg menthol per cigarette (Carmines 2002). The cigarettes were machine-smoked and compared to control cigarettes without ingredients added. The benzo[a]pyrene content in the smoke of menthol cigarettes was significantly higher compared to the smoke of the control cigarettes. The smoke of the control cigarettes contained 5.1 ng benzo[a]pyrene per cigarette in comparison to 5.63 and 5.51 ng benzo[a]pyrene per cigarette in menthol cigarettes (Rustemaier et al. 2002).

Recent reviews on health effects of menthol in cigarettes published by the tobacco industry have maintained its claim that menthol does not pose any adverse health effects when used as an additive in cigarettes (Heck 2010 Werley et al. 2007). The hypothesis that smoking mentholated cigarettes increases lung cancer risk compared with smoking non-mentholated cigarettes was tested in several epidemiological studies. Sidney and colleagues found a 1.45-fold increase of the relative risk for men smoking mentholated cigarettes for 20 years and more (Sidney et al. 1995), whereas three other studies (Brooks et al. 2003, Carpenter et al. 1999, Stellman et al. 2003) did not find a difference between menthol smokers and non-menthol smokers.

Menthol has a cooling effect on the skin or mucosal surfaces. The perceived temperature effect is not caused by evaporation of menthol. Furthermore it is not due to vasodilatation, but is due to a specific action on sensory nerve endings (Eccles 1994). Menthol activates a transient receptor potential channel (TRPM8). This channel is expressed in small-diameter primary sensory neurons (Clapham et al. 2005). The use of menthol causes a subjective sensation of improved airflow without any change in nasal airway resistance, breathing pattern or ventilation (Eccles 1994, Nishino et al. 1997). Furthermore, menthol has a local anaesthetic activity (Galeotti et al. 2001).

It is important to take into account that this cooling and anaesthetic effect may mask early symptoms of tobacco induced respiratory disease (Garten and Falkner 2003). In a follow-up paper, it was postulated, that there is a greater opportunity for exposure and transfer of the contents of the lungs to the pulmonary circulation. For the smoker of mentholated cigarettes this could result in a greater exposure to nicotine and the particulate matter of the smoked cigarette (Garten and Falkner 2004). Additionally, it was postulated that menthol increases the absorption with other chemicals through permeability and increased salivation. This would mean that menthol facilitates the absorption of other substances from the smoke (Ahijevych and Garrett 2004, Eccles 1994). Two recent biomarker studies addressed the question if the use of mentholated cigarettes would lead to higher exposure to toxic compounds from smoke (Heck 2009, Muscat et al. 2009). Muscat and colleagues investigated a group of 525 smokers and stratified them for sex and race. In the United States, African American smokers preferred mentholated cigarettes (90% of men and and 82% of women); whereas European Americans smoked predominantly non-mentholated cigarettes (percentage of menthol cigarettes smoked was 25% and 31%, respectively). European Americans smoked significantly more cigarettes per day than African Americans. There were no significant differences in the mean concentrations of all cigarette smoke metabolites (plasma cotinine, urinary cotinine, plasma thiocyanate and urinary 4-N-nitrosomethylamino)-1-(3-pyridyl)-1-butanol (NNAL)) between menthol and non-menthol cigarette smokers in African Americans and European Americans, after adjustment for sex and other factors (Muscat et al. 2009). However, the ratio of NNAL-glucuronide to NNAL, a possible indicator of lung cancer risk, was significantly lower in menthol versus non-menthol cigarette smokers. The NNAL-Gluc/NNAL ratio was 34% lower in European Americans (P <0.01) and 22% lower in African Americans (Muscat et al. 2009). In subsequent human liver microsome studies, menthol inhibited the rate of NNAL-O-glucuronidation and NNAL-N-glucuronidation. These results suggest that menthol may modify the detoxification of the potent lung carcinogen NNAL (Muscat et al. 2009).

A similar study has been performed and published by the tobacco industry (Heck 2009). They investigated 112 smokers (28 African Americans and 84 European Americans; 54 menthol cigarette smokers and 58 non-menthol cigarette smokers). Smokers continued smoking ad libitum throughout the one week study interval. The participants were provided with a commercially available menthol cigarette brand and several non-mentholated brands of similar smoke yield. Menthol content in smoke was determined as 0.34 mg/cigarette. Content of 4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone (NNK) was determined as 63 ng/cigarette in the mentholated brand and with a range from 45 to 80 ng NNK/cigarette in five non-mentholated brands (Heck 2009). Neither total urinary NNAL nor urinary nicotine equivalents exhibited statistically significant differences between the menthol and non-menthol cigarette smokers (Heck 2009).

Recently, a study was published from the tobacco industry on 3341 cigarette smokers (Wang et al. 2010). The participants smoked either mentholated or non-mentholated cigarettes with different tar yields. European Americans in the menthol group smoked more cigarettes than European Americans in the non-menthol group. No differences were found between menthol and non-menthol groups with respect to nicotine equivalents per day, carboxyhaemoglobin (COHb) and serum cotinine. The authors concluded that menthol did not influence the metabolism of nicotine. However, the study was not designed to answer this specific question.

The possible influence of menthol on the metabolism of nicotine was investigated in a cross-over study in 14 healthy smokers (Benowitz et al. 2004). Subjects were randomly assigned to smoke mentholated or non-mentholated cigarettes for one week, then to cross over to the other type of cigarettes for another week. The blood levels of deuterium-labelled nicotine and cotinine were measured after intravenous infusion of these compounds. It was demonstrated that, when smoking similar numbers of mentholated and non-mentholated cigarettes of similar machine-determined yield and nicotine content, the systemic intake of nicotine and carbon monoxide during non-menthol cigarette smoking is on average not affected by mentholation. Furthermore, it was shown that mentholated cigarette smoking inhibits the metabolism of nicotine. Inhibition of nicotine metabolism by menthol most likely involves inhibition of both oxidative metabolism to cotinine, and glucuronide conjugation (Benowitz et al. 2004). In vitro studies using human liver microsomes showed that menthol inhibits nicotine metabolism (MacDougall et al. 2003) However, mentholated cigarette smoking did not substantially affect cotinine metabolism. Finally, the systemic intake of menthol was determined as 12.5 mg menthol from 20 cigarettes. Thus, on average 20% of menthol contained in each cigarette is absorbed systemically by the smoker (Benowitz et al. 2004).

Studies on the influence of menthol on puff numbers and puff volume gave conflicting results. Puff numbers have been investigated in seven studies, three showing a reduced number of puffs in smokers of mentholated cigarettes (Jarvik et al. 1994, McCarthy et al. 1995, Nil and Bättig 1989). Four other studies did not show any influence of mentholation on the number of puffs (Ahijevych et al. 1996, Caskey et al. 1993, Miller et al. 1994, Pickworth et al. 2002). Puff volume was investigated in six studies, three of them showing a decrease in puff volume when smoking mentholated cigarettes (Jarvik et al. 1994, McCarthy et al. 1995, Nil and Bättig 1989). Two studies did not find any effect of mentholation on puff volume (Ahijevych et al. 1996, Miller et al. 1994) and one study even showed an increase in puff volume (Ahijevych and Parsley 1999).

The results of studies on the CO exhalation in smokers of mentholated and non-mentholated cigarettes are contradictory. In a study with experimental cigarettes smokers inhaled defined volumes of cigarette smoke. The experimental cigarettes had been injected with 0 mg, 4 mg or 8 mg of menthol. The CO content in exhaled air increased from 5.6 ppm to 6.1 ppm and reached 8.1 ppm CO after use of 8 mg menthol cigarettes (Miller et al. 1994). Clark and colleagues did find a non-significant difference of 40.3 ppm CO (mentholated cigarettes) against 35.8 ppm CO (non-mentholated cigarettes) (Clark et al. 1996). In a study in women, smokers of non-mentholated cigarettes showed a higher CO exhalation (10.6 ppm) than smokers of mentholated cigarettes (6.5 ppm) (Ahijevych et al. 1996). In a cross-over study, Benowitz and colleagues did not find any significant difference in the blood carboxyhaemoglobin content in smokers of mentholated and non-mentholated cigarettes (Benowitz et al. 2004). Six other studies also did not show significant differences between CO uptake or CO exhalation in smokers of mentholated or non-mentholated cigarettes (Caskey et al. 1993, Heck 2009, Jarvik et al. 1994, McCarthy et al. 1995, Nil and Bättig 1989, Pickworth et al. 2002).

Menthol may increase the degree of dependence, or promote maintenance of smoking behaviour. Several findings suggest that menthol is involved in tobacco addiction. Some investigators have found that menthol cigarette use increases cotinine levels, and a significant correlation between cotinine and nicotine dependence has been reported, as well as a reduction in time to first cigarette of the day (Pomerleau et al. 1990).

Greater smoking urgency among menthol compared to non-menthol adolescent cessation-treatment seekers has been reported (Collins and Moolchan 2006). Evaluating the tobacco industry documents, it was shown that cigarettes with low contents of menthol appeal to young smokers, new smokers, and smokers that do not like the harshness of the smoke. This can be due to the fact that lower contents of menthol in the smoke cover the harshness of the smoke, whereas a large dose of menthol causes harshness. On the other hand, cigarettes with a higher concentration of menthol appeal to smokers who are used to the harshness of the smoke (Kreslake et al. 2008b).

Menthol is one of the most prominent additives in tobacco. If it is added in milligram amounts to cigarettes it dominates the taste of the smoke and the application is usually mentioned in the brand name. Menthol has a cooling effect on mucosal surfaces and a local anaesthetic activity. The use of menthol causes a subjective sensation of improved airflow without any change in nasal airway resistance, breathing pattern or ventilation. It has been proposed, that the cooling and local anaesthetic effects could lead to deeper inhalation of the smoke and higher exposure to other smoke constituents, but current data are inconclusive. However, menthol has been shown to inhibit the metabolism of nicotine. Furthermore, the taste of menthol could be an important reason for some smokers to consume mentholated cigarettes. It has been proposed that the addition of ammonia compounds increases the absorption of nicotine in the lungs by raising the pH in smoke, but this seems unlikely because of the high buffering capacity of the lung lining fluid.\

7.3 What are the current trends in tobacco use?

The SCENIHR opinion states:

Tobacco use in the European Union

Manufactured cigarettes are by far the most preferred tobacco products in the 27 Member States of the European Union. Cigarettes constitute well over 90% of the tobacco sold whereas tobacco used in pipes and for RYO cigarettes (roll your own) amounts to about 5%. In most Western EU countries, smoking prevalence among men and women has in general stabilised or is decreasing. The number of smokers has also started to decrease in some countries in the eastern part of EU, although generally it is only stabilizing among men, with no clear overall trends, and in some cases a slight rise in prevalence among women is being recorded. In the EU as a whole the situation has been stable over the last decade (WHO 2007a).

The use of smokeless tobacco (snus) is common among males in Sweden. The sale of snus is banned in all other countries in the EU but other oral tobacco products may be sold. In the United Kingdom, both male and female migrants from the Indian subcontinent use a wide variety of smokeless tobacco products. Elsewhere, smokeless tobacco use is rare but a wide variety of tobacco products do find their way to Europe through immigration (SCENIHR 2008). Similarly, waterpipe smoking is spreading through cultural influence, mainly by migrants from the Middle East. However, during recent years, waterpipe use has become increasingly popular among teenagers in the general population.

The latest comprehensive data from the 27 Member States were collected for 2006, (WHO 2009). Where data are missing or misleading (Cyprus and Poland) other sources have been used.

EU adult smoking rates 2006

The overall adult daily estimated smoking prevalence (population-weighted) has stabilised at around 27.5% in the EU. The estimated average smoking prevalence among males is 33.2%: in 11 (mostly Eastern European) countries the rate of male smoking is higher, while in 11 (mostly Western European) countries the male smoking prevalence is below 30% (see figure 4). The estimated average female smoking prevalence in the EU is 21.8%. In 10 (mostly Western European) countries the prevalence rate is higher, while in only three countries it is 15% or less (see figure 5).

Gender differences

In all but one country (Sweden), smoking prevalence is higher among men than among women. Data from Latvia show the widest gender gap of 29%. A small difference between male and female smoking prevalence of less than 10% can be found in 11 (mostly Western European) countries.

Figure 3: 2006 Rates of daily smokers among males in EU countries (WHO 2009)

Figure 4: 2006 Rates of daily smokers among females in EU countries (WHO 2009)

Changes in smoking prevalence

Estimates for male and female smoking prevalence for 2002 and 2005 are available for 24 of the 27 EU countries. Only relative differences of more than +/-10% have been taken into account as noteworthy changes when comparing data for these two years.

Since the 2002 European report on tobacco control policy, smoking prevalence among the male population has in general stabilised across the EU. A notable decrease has been reported for Sweden (16.5% to 14.1%), but in most countries in the EU male smoking prevalence did not show a significant change between 2002 and 2005. There was no significant change in female smoking prevalence although slight increases were observed in many countries.

In May 2010, near completion of the present report, the Special Eurobarometer 332/72.3 was published (EC 2010). This Eurobarometer, performed upon request of Directorate General Health and Consumers (SANCO) of the European Commission, reports on the results of an EU-wide telephone survey on tobacco conducted in late 2009. The survey method is standardised but the results are not directly comparable to the WHO reports quoted above. Furthermore, they are not comparable to an earlier Eurobarometer published in 2006 (EC 2006) due to changes of design (EC 2006, EC 2007a). Still, some additional information can be extracted. The Eurobarometer (EC 2010) reports the proportion of smokers as 29% (males 35%, females 25%) but does not distinguish between daily and non-daily smokers. It is not possible to ascertain whether this represents a further drop in adult daily smoking rates compared to the WHO report from 2009 (figures 4 and 5) showing data collected in 2006.

However, Eurobarometer (EC 2010) provides other data of interest. The average number of cigarettes consumed is 14.4/day, ranging from 22 in Cyprus to 10 in Sweden. Men smoke, on average, three cigarettes/day more than women. When asked to single out the most important reason for choice of brand, taste is most important for 22% of smokers in the EU 27 while price is most important for 6%. The package scored 0%. One out of 10 smokers in the EU believes that a less harmful cigarette can be identified by taste (ranging from 27% in Hungary to 3% in Denmark). Unique for the Eurobarometer (EC 2010) is the data on waterpipe smoking. On average, 11% of EU adults have tested or use a waterpipe occasionally, whereas 1% smoke it daily. Differences of use vary between countries but being a young adult appears to increase the probability of use.

Conclusions on tobacco use in different EU countries

Manufactured cigarettes are by far the most preferred tobacco products in the 27 countries of the European Union and constitute well over 90% of smoked tobacco. The overall adult daily estimated smoking prevalence (population-weighted) has stabilised at around 27.5% in 2006 (males 33.2%, females 21.8%) but higher rates are found mainly in Eastern European countries. Smoking rates have not changed significantly between 2002 and 2006. Smokeless tobacco is used by over 10% of the population in Sweden but its use is rare in other EU countries.

Brand preference, use of additives and consumption patterns

The cigarette market in the UK (and Ireland and Malta) is quite divergent from the continental European countries. This is mainly because in the UK some typical “English” brands are popular and have a large market share. Some quite surprising observations can be made when looking at the top-10 brands marketed in the UK (Hegarty 2010):

Of the top-10 brands (according to market share), three brands (Lambert & Butler King Size, Richmond King Size and Richmond Superkings) contain no additives (water is not considered as an additive).

Five brands contain up to 10 additives.

Two brands (Marlboro King Size Gold of PMI and Royals King Size Red of JTI) both contain over a dozen additives.

Lambert & Butler King Size is by far the most sold cigarette brand. Brands without additives have a market share of 42%, whereas those with 1 to 10 additives have a market share of 48%. Brands containing over a dozen additives have a market share of only 10%.

The “taste” of a tobacco product is not only defined by additives but also by blend-selection. English brands i.e. the typical UK brands are made predominantly from flue-cured Virginia tobacco, which contains relatively high amounts of sugars. Marlboro for instance uses the “American blend” (a mixture of Virginia, Burley and Oriental tobaccos) as a base to which many compounds are added during the manufacture.

By blending, it is possible to manufacture cigarettes with a characteristic taste, without using additives. Imperial Tobacco has thus succeeded in producing a typical brand (Lambert & Butler King Size) via the blending approach. In addition, cigarettes marketed as “additive free”, may appeal to smokers that prefer “natural products”. In Canada, the cigarette market consists almost exclusively of Virginia tobacco which is considered to contain relatively few additives. It should be noted, however, that domestically manufactured “Virginia flue-cured cigarettes” from Canada are by no means “additive-free” (Hammond and O’Connor 2008).

Tobacco products in Central and Eastern European countries before and after 1990 Before 1990, the tobacco used for making cigarettes was usually domestic black shag, and most cigarettes were made with low amounts of additives. Cigarettes were sold without filters and tar levels of 20 to 30 mg per cigarette have been reported. The average nicotine content in Poland in the 1980s was 2 mg per cigarette implying that levels were 1.5 to 2 times the level in Western Europe. After 1990, the large international tobacco companies quickly took over and cigarettes were manufactured in Central and Eastern Europe according to international standards. Most cigarettes are manufactured from light tobacco and the proportion of filter cigarettes rose to 90%. The properties of cigarettes, additives and taste enhancers are now similar to those used in Western Europe and follow the European Union requirements (Zatonski 2008). Availability, marketing, trends, taste, and attractiveness are all factors that may have contributed to the rapid market change.

Smoking prevalence among young people/Target Groups

The analysis of smoking prevalence among young people is from the European Tobacco Control Report 2007 based on the WHO Health Behaviour in School-aged Children (HBSC) study, a cross-national research study conducted every four years: 1993/1994, 1997/1998 and 2001/2002 (WHO 2007a). The 2005/2006 survey was launched in 41 countries and regions and no comparable data are yet available. Information based on a second survey instrument, the Global Youth Tobacco Survey (GYTS) was also used (GYTS Collaborative Group 2002). The GYTS was developed by the United States Centers for Disease Prevention and Control (CDC) and WHO and has been carried out in a large number of countries in the European Region (see table 5). With more and more countries carrying out and repeating the GYTS, comparisons should be possible in the coming years.

Current status

According to the HBSC study, weekly smoking prevalence rates were on average 2% among 11-year-olds, 8% among 13-year-olds, and 24% among 15-year-olds. In general, smoking prevalence rates increased more steeply between the ages of 11 and 13 years than between 13 and 15 years. The results of the HBSC and GYTS studies show that weekly smoking prevalence rates in 15-year-old boys were especially high (>30%) in some Eastern European countries (Estonia, Latvia and Slovakia). The highest smoking prevalence rates (>30%) among 15-year-old girls were found mostly in Western European countries such as Austria, the Czech Republic, Finland and Spain. The lowest smoking prevalence rates among 15-year-old boys (<15%) were in Greece and Sweden. Smoking prevalence rates among girls were below 10% only in Greece. An overview of smoking prevalence rates among young people in the EU obtained by the HBSC and GYTS studies is provided in table 5.

Table 4 Weekly smoking rates among boys and girls in EU countries (WHO 2007a)

Country	HBSC	GYTS2001/2004
1997-1998	2001-2002
Boys	Girls	Boys	Girls	Year	Boys	Girls
Austria	30	36	26.1	37.1
Belgium	28	28	21.3	23.5
Bulgaria					2002	28.7	26.4
Czech Rep.	22	18	28.7	30.6	2002	29.9	32.8
Denmark	20	28	16.7	21
Estonia	24	12	30.4	18.2	2002-3	31.8	23.0
Finland	25	29	28.3	32.2
France	28	31	26.0	26.7
Greece	18	19	13.5	14.1	2003	16.3	9.5
Hungary	36	28	28.2	25.8	2003	24.1	27.4
Ireland	25	25	19.5	20.5
Italy			21.8	24.9
Latvia	37	19	28.9	21.1	2002	30.2	22.1
Lithuania	24	10	34.9	17.9	2001	29.0	20.5
Malta			16.9	17.4
Netherlands			22.5	24.3
Poland	27	20	26.3	17.0	2003	20.8	14.3
Portugal	19	14	17.6	26.2
Romania					2004	16.8	12.8
Slovakia	28	18			2003	31.3	28.8
Slovenia			29.5	29.7	2003	24.2	28.8
Spain			23.6	32.3
Sweden	18	24	11.1	19.0
United Kingdom	25	33	21.1	27.9

Gender differences

The prevalence of weekly smoking among 15-year-old girls was higher than that of 15-year-old boys in 16 mainly Western European countries of those that implemented the HBSC study in 2001/2002 (Austria, Belgium, the Czech Republic, Denmark, Finland, France, Greece, Ireland, Italy, Malta, the Netherlands, Portugal, Slovenia, Spain, Sweden and the United Kingdom). In Austria, Belgium, Sweden and the United Kingdom, this difference was even greater than in the late 1990s. In the remaining (mainly Eastern European) countries (Estonia, Hungary, Latvia, Lithuania, Poland), smoking prevalence in girls was lower, but in many of these 10 countries, it was catching up and, in two countries (Czech Republic and Hungary), even overtaking smoking prevalence in boys. The GYTS data in general confirmed the pattern of higher rates of smoking prevalence among boys than girls in Eastern Europe.

Changes in smoking prevalence

Sixteen countries implemented the HBSC survey both in 1997/1998 and 2001/2002. A comparison of the results from these two surveys shows that weekly smoking prevalence rates in 15-year-old boys decreased in 11 (mostly Western European) countries of the 16 countries, increased in four countries and remained stable in one. The picture among 15-year-old girls is quite similar: weekly smoking prevalence rates decreased in nine out of the 16 countries, and increased in seven.

A calculation of the averages from these two HBSC surveys shows that the average weekly smoking prevalence among 15-year-old boys and girls did not change significantly between the two periods, although a slight downward trend in boys and a slight upward trend in girls can be observed.

Conclusions on smoking according to different groups of young people Weekly smoking rates among children and adolescents living in the European Union increase four-fold from about 2% at age 11 to 8% at age 13, and another 3-fold increase to 24% at age 15. The highest rates among boys are found in some Eastern EU countries whereas the highest rates among girls are seen in some Western EU countries. From the year 2000, non-significant trends towards decreased smoking among boys and increased smoking among girls have been observed. Smokeless tobacco use is common among adolescent boys in the Nordic countries but rare elsewhere.

It is clear that the tobacco industry not only has aimed to target different groups of users through advertising and promotion. They have also manipulated the cigarettes themselves. We have very limited data on market share by brand. Top ten lists have only been found from the UK (2009) and Germany (2007). Detailed information on annual cigarette sales in individual EU countries can be purchased from commercial sources, but the price is quite high.

However, even in those publications no data on brand preferences according to gender, age, ethnicity or culture/region are presented. Again, referring to section 3.12 it is conceivable that such information is collected by the manufacturers but treated as trade secrets.

Information about top selling individual brands in EU countries is available from commercial sources. In the public domain, only limited data are available. Data on brand preferences according to gender, age, ethnicity or culture/region are almost non-existent with a couple of limited reports from the UK being the exception. Referring to section 3.12 it is conceivable that such information is collected by the tobacco companies but treated as trade secrets.

Conclusions on EU

European Union tobacco smokers prefer manufactured cigarettes. The overall adult daily estimated smoking prevalence (population-weighted) had stabilised at around 27.5% in 2006 (males 33.2%, females 21.8%) but higher rates were found mainly in Eastern European countries. Smoking rates had not changed significantly between 2002 and 2005. The prevalence of weekly smoking among 15-year-old girls was higher than that of 15-year-old boys in 16 mainly Western European countries whereas the opposite was found in most Eastern European countries. In some countries (e.g. the UK) a large proportion of smokers preferred cigarettes marketed as “additive free”. Significant use of smokeless tobacco was seen only in Sweden and the UK.