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This study describes market trends of flavor capsule cigarettes (FCCs) and menthol (non-capsule) cigarettes (MNCCs) across 78 countries from 2010 to 2020 and examines country-level factors associated with market shares of these products.Market share and retail volume data came from the Euromonitor Passport database and country-level data came from the World Health Organization (WHO), World Bank, and International Monetary Fund. Multivariable linear fixed effects panel regression analyses were conducted to evaluate the relationship between predictor variables and the market shares of menthol (non-capsule) cigarettes and flavor capsule cigarettes.The overall market share (i.e. the percentage retail volume out of total retail volume of all cigarette types) increased from 0.23% in 2010 to 4.5% in 2020 for FCCs and decreased from 5.0% to 3.8% for MNCCs. Market shares of FCCs grew most rapidly in the Americas region and among upper middle-income countries. Market shares of MNCCs remained stable across most regions and were highest in the Western Pacific and Africa regions. The overall market share of FCCs was positively associated with the unemployment rate (β=0.28; 95% CI: 0.12-0.44, p=0.001), and inversely associated with the percent of the population aged 15-29 years (β= -0.57, 95% CI: -0.98 - -0.15, p=0.008), percent of urban population (β= -0.88; 95% CI: -1.28 - -0.48, p0.001), GDP PPP per capita (β= -0.13; 95% CI: -0.24 - -0.03, p=0.015), and age-standardized prevalence of cigarette smoking (β= -0.93; 95% CI: -1.38 - -0.49, p0.001). In contrast, the overall market share of MNCCs was positively associated with urbanicity (β=0.24; 95% CI: 0.08-0.40, p=0.003), and negatively associated with the unemployment rate (β= -0.09; 95% CI: -0.17 - -0.02, p=0.014).Global sales of flavor capsule cigarettes grew substantially in the last decade, surpassing menthol (non-capsule) cigarettes, which also continued to be high in many regions. There is a need for increased efforts to address flavors and novel tobacco products, features that are known to appeal to youth.

Objective To assess the attitudes of flavored and unflavored cigarette smokers towards tobacco control policies, including the EU flavors ban and to explore the ban impact on smoking behaviors. Methods The research analysis include data from Wave 1 of the EUREST PLUS-ITC Europe Survey Project in Germany, Greece, Hungary, Poland, Romania, and Spain, and data from other ITC surveys conducted in England and the Netherlands. All cross-sectional data were collected in 2016 among 10,760 adult current smokers. The attitudes towards various tobacco control policies have been compared among menthol, other flavored and unflavored cigarette smokers. The univariate data analysis adjusted to few confounding factors was made with the use of SPSS Complex Samples Package. Results Findings show that menthol smokers are much less likely to support a ban on tobacco additives and flavors than other cigarette smokers but they are more supportive of smoking ban in public places. After the enforcement of the ban, 16% of menthol cigarette smokers and 10% of other flavored cigarette smokers reported the intention to quit smoking. However, the percentage of those menthol and other flavored smokers who declare quitting smoking after the ban implementation varies substantially with countries. Furthermore, almost one of three menthol cigarette smokers (27%) say they will find a way to get menthol tobacco product banned. Conclusions Attitudes of menthol and other flavored cigarettes towards various tobacco control policies differ substantially in the analyzed countries. Therefore, tobacco control and smoking cessation programs should be adapted to country needs. A special attention must be focused on smoking cessation offer addressed to those menthol cigarette smokers who intend to quit smoking after the flavors ban and on preventing the risk of illicit trade in menthol cigarettes.

Introduction Since May 2020, the ban on production and sale of menthol and other flavored cigarettes will come into force in the European Union countries. Then millions of cigarette smokers can quit smoking or switch to other tobacco products, both conventional and novel. Study aim To assess the prevalence, socio-demographic characteristics, cessation behaviors and attitudes of menthol and other flavored cigarette smokers towards tobacco control policies and programs. Material and Methods Cross-sectional data were collected in 2016 among 10,760 adult current smokers from 8 European countries (EUREST-PLUS ITC Europe Project). Smokers of menthol, other flavoured, unflavored tobacco, or no usual brand were compared on smoking prevalence, socio-demographic characteristics, tobacco dependence, motivation to quit, self-efficacy, prior cessation behaviours, and attitudes towards tobacco control measures. The univariate data analysis adjusted to few confounding factors was made with the use of SPSS Complex Samples Package. Results Study results shows that around 7% of adults in all 8 analyzed European countries smoke menthol cigarettes and around 3% other flavored cigarettes. However, prevalence of menthol smoking substantially varies between countries (0.4% in Spain to 12.4% in England). Compared to other groups, menthol cigarette smokers are younger, more likely to be female, better educated, had higher household income, and smoked fewer cigarettes. In comparison to smokers of unflavored cigarettes, smokers of menthol and other flavoured cigarettes are less likely to smoke daily, tend to be less dependent and have higher quitting self-efficacy. In comparison to all other smokers, menthol smokers are less likely to support a ban on sale of flavored tobacco products, including menthol cigarettes. After enforcement of the ban, around a fifth of all menthol and flavored cigarette smokers intends to switch to another brand, and a third to reduce the amount they smoked or to quit smoking. Conclusions The EU TPD ban on sale of flavored cigarettes will affect one in ten smokers in the countries surveyed and provides an opportunity for targeting these groups with tobacco control policies and cessation programs. Lower tobacco dependence rates found in smokers of menthol and other flavored cigarettes may lead to greater success rates if quit attempts are strengthened by smoking cessation programs. However, smokers of different cigarette flavours in Europe differ on a range of smoking and cessation characteristics and may need different, target-tailored approaches.

Introduction Article 20 of the European Union (EU) Tobacco Products Directive (TPD) sets forth provisions on electronic cigarette (e-cigarette) product regulation, such as child-proof packaging and protection against e-liquid refilling without leakage. The aim of the current study was to examine frequencies and correlates of experiencing undesirable events during e-cigarette use related to e-cigarette product design parameters prior to the implementation of the EU TPD. Material and Methods The EUREST-PLUS ITC Europe Wave 1 survey was conducted with adult cigarette smokers from June to September 2016 across Germany, Greece, Hungary, Poland, Romania, Spain. Results Among our sample of adult cigarette smokers, one in five reported having ever used e-cigarettes. Prevalence of current e-cigarette use (daily or weekly) was very low (1.5%). Major undesirable events, such as battery exploding or catching fire (1.9%) or overheating (11%) were uncommon. Among those reporting at least monthly use and whose usual/current brand has a tank that you fill with liquids, 18.8% experienced spilling during refill and 18.5% experienced e-liquid leaking during use. Nearly one-quarter reported that the e-liquid cap was easy for a child to open. Conclusions In light of the EU TPD establishing standards around e-cigarette design parameters to mitigate undesirable events and risks during e-cigarette use, these findings further support the need for its implementation, as well as for monitoring undesirable events experienced during e-cigarette use once Article 20 is fully implemented. Acknowledgements EUREST-PLUS is a Horizon2020 project conducted by researchers throughout Europe from both the six participating countries as well as other institution partners within Europe and abroad. Partnering organizations include the European Network on Smoking Prevention (Belgium), Kings College London (United Kingdom), German Cancer Research Centre (Germany), University of Maastricht (The Netherlands), University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), the University of Waterloo (Canada), the Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium). Funding The EUREST-PLUS Project takes place with the financial support of the European Commission, Horizon 2020 HCO-6-2015 program (EUREST-PLUS: 681109; C. Vardavas) and the University of Waterloo (GT. Fong). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GT. Fong was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E. Fernández is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR139) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.

Introduction Safety data on the chemical content of the electronic cigarette liquids depending on their flavors are scarce. Aims and objectives: This study aimed to identify and evaluate the content of e-liquids according to their flavor in the most common e-liquid products in the EU. Methods Within the Horizon2020, EUREST-PLUS study, 122 of the most commonly sold e-liquids in 9 European Countries (France, Poland, Germany, the Netherlands, United Kingdom, Spain, Romania, Hungary and Greece) were randomly selected and purchased. E-liquids were then divided into 7 groups according to their flavor. These groups are: Tobacco (35), Fruits (44), Menthol-mint (9), Non-alcoholic drinks (10), Alcohol (5), Desserts-sweets (11) and other flavors (8). A qualitative chemical analysis was performed using gas chromatography-mass spectrometry technique companied with solid phase microextraction (GC-SPME-MS), while the identification of the compound was done by NIST or Wiley library. Results After analyzing the total number of the samples, 232 compounds were detected in total. The 101 of these compounds were detected in Fruit flavor, 52 in the Tobacco flavor, 30 in the Non-alcoholic drinks flavor, 26 in the Desserts-sweets flavor, 24 in the alcohol flavor, 12 in the other flavors category and 15 in menthol-mint flavor. Of the detected compounds, Nonanal and Oxime-, methoxy-phenyl were the most frequently detected compound (15 and 14 times in tobacco flavor respectively) and also present in all flavors. These compounds are strong irritants to skin and eye. Additionally, banana oil, which was detected in 12 Fruit flavor samples and in most flavors, can cause skin, eye and respiratory irritation, narcotic effects and damage to organs through prolonged or repeated exposure Conclusions To our knowledge, this is the first study to examine the chemical content of the most common e-liquids in the EU depending on the flavor, indicating that several flavors could be more hazardous. Stricter strategies for these products are necessary. Funding This work was supported by a grant from the European Commission (Horizon2020 HCO-6-2015; EUREST-PLUS: 681109; Vardavas).

Introduction The current study explores quitting behaviours and use of cessation assistance among adult tobacco users with probable anxiety or depression (PAD) and in six European (EU) Member States (MS). Material and Methods The EUREST-PLUS ITC Wave 1 Europe Survey was conducted with a nationally representative cross-sectional sample of 6,011 adult cigarette smokers from six European Union (EU) Member States (MS) (Germany, Greece, Hungary, Poland, Romania, Spain) in 2016. Results Our study found that one in five smokers sampled from six EU MS had a diagnosis, treatment or positive screen for anxiety or depression, with rates of PAD varying between EU MS. Results of the multivariable logistic regression analysis showed that respondents with PAD were more likely to have made a quit attempt in the last 12 months (AOR 1.75; 95%CI 1.45-2.11), compared to respondents without PAD. Among those respondents with PAD who used support the most frequently reported quit method was prescription-based quit smoking pharmacotherapy (15.4%) followed by e-cigarettes (13.7%) and NRT (11.3%). Person-to-person behavioral support (i.e. local quit services, face-to-face advice from a doctor or other health care professional, telephone or quitline services) was reported significantly more frequently among respondents with PAD compared to those without PAD. Conclusions Given both pharmacological and non-pharmacological quit smoking aids have been shown to be safe, acceptable and effective for people with and without mental illness it is important that their use be promoted among smokers with anxiety and depression alongside behavioral counseling. Our findings support the need for interventions targeting health care professionals in providing smoking cessation assistance among this population of smokers. Acknowledgements EUREST-PLUS is a Horizon2020 project conducted by researchers throughout Europe from both the six participating countries as well as other institution partners within Europe and abroad. Partnering organizations include the European Network on Smoking Prevention (Belgium), Kings College London (United Kingdom), German Cancer Research Centre (Germany), University of Maastricht (The Netherlands), University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), the University of Waterloo (Canada), the Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium). Funding The EUREST-PLUS Project takes place with the financial support of the European Commission, Horizon 2020 HCO-6-2015 program (EUREST-PLUS: 681109; C. Vardavas) and the University of Waterloo (GT. Fong). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GT. Fong was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E. Fernández is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR139) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.