Cigarette flavours and design features available near schools before plain packaging implementation in Uruguay

Background: The tobacco industry continually develops marketing strategies to reach potential new consumers. One of these strategies is marketing the cigarette itself through design appeals and fl avours. Uruguay is the second country to implement plain packaging legislation for cigarettes in the Americas in 2020. This study aimed to explore fl avouring and design features of tobacco products available near Uruguay schools immediately before the implementation of standardized plain package legislation, to monitor tobacco industry tactics. Methods: A fi eldwork protocol was adapted from the one developed at Johns Hopkins University and implemented in fi fteen neighbourhoods in Montevideo, Uruguay, across different socioeconomic areas. The protocol included surveying retailers near schools, purchasing tobacco, and coding per its characteristics. Results: Among the surveyed retailers, 86.67% sold fl avoured cigarettes. Twenty-three unique tobacco products were purchased. Appealing design features were identifi ed in 73.9% of the packs and 34.78% of the products were fl avoured cigarettes. Flavoured cigarettes lacked the child protection warning in a greater proportion than non-fl avoured ones. The most frequently found fi lter designs concerned the activation of fl avour with capsule designs (33.3%) and features meant to imitate technological symbols that appeal to youth. Conclusions: This study shows an increase in availability of fl avoured cigarettes in Uruguay immediately before plain packaging implementation. In countries developing plain packaging legislation fl avour proliferation and modifi cation of design features must be monitored and addressed. Research Article Cigarette fl avours and design features available near schools before plain packaging implementation in Uruguay Laura Llambi1*, Mauricio Minacapilli1, Mary Barros2, Carolina Parodi1, Valentina Gonzalez Peluffo1 and Virginia Nuñez1 1Internal Medicine Department, Tobacco Cessation Clinic, Hospital de Clinicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay 2Psychology Department, Tobacco Cessation Unit, Hospital de Clinicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay Received: 15 July, 2021 Accepted: 30 July, 2021 Published: 31 July, 2021 *Corresponding author: Laura Llambi, Internal Medicine Department, Tobacco Cessation Clinic, Hospital de Clinicas, Facultad de Medicina, Universidad de la República, Montevideo, Avda. Italia s/n esq. Las Heras. Piso 11. Zip Code: 11600, Montevideo, Uruguay, Tel: +598 99 625 962; E-mail:


Introduction
Tobacco use is the leading cause of preventable death worldwide. As tobacco control laws scale up in some countries, the tobacco industry is developing strategies to reach potential new consumers. These strategies have international impact and involve globalisation of tobacco trade, research and marketing tactics. Due to more signifi cant restrictions on advertising, promotion, and sponsorship of tobacco products, these strategies include new cigarette fl avours and packaging designs [1,2]. The use of appealing designs and fl avours could encourage experimentation among young people [3,4]. Pack design, the cigarette itself, and its fi lter are important factors for smokers' choice and brand loyalty [5][6][7] .
Sometimes cigarette packaging is designed to provide text messages associated with health, modernity, or vitality to consumers [8]. Some fl avoured cigarettes contain fl avour capsules inside the fi lter, which the smoker squeezes to break the capsule and release a fl avourful liquid. Some design features on packs are intended to imitate technological features.
Citation: Llambi  For example, a pack may appear to have a 'power' or 'play' button; the buttons (illustrations made to look like buttons) may be used by some brands to indicate how to change the taste to menthol by 'turning on' (squeezing) something inside the cigarette. Flavoured cigarettes are appealing to kids, adolescents, and young adults, in whom they are believed to promote initiation [3,9,10], increase addictiveness [11] and decrease risk perception [12].
Additionally, fl avours like menthol act synergistically with nicotine through biological mechanisms on acetylcholine receptors in the brain. They produce sensory reinforcement, intensifying symptoms of withdrawal, and altering metabolism by increasing its bioavailability [13].
Uruguay recently passed the plain packaging legislation, which was fully implemented in February 2020 [14]. Thus, it became the second country in the Americas region and the fi rst in South America to adopt this strong tobacco control measure.
The current legislation prohibits the advertisement, promotion, and sponsorship of tobacco products, including the display of packs at the points of sale. Likewise, deceptive terms such as 'light' or 'mild' have been banned; pictorial health warnings cover 80% of packaging surfaces, and cigarette companies are required to adhere to a single presentation (one brand variant) per brand family [15,16].
The development of new fl avoured tobacco products with unique design characters was observed coincidentally with plain packaging implementation in countries such as Australia and the United Kingdom [17,18] Consequently, experts recommended that countries developing plain packaging legislation should explore these other strategies that accompany the product, primarily to broaden the regulations and prevent the development of these new tobacco attractions.
The study examined the availability of fl avourings and design features in tobacco products in Uruguay immediately before the implementation of plain package legislation. Particularly, the study aimed to explore which characteristics were available among retailers near schools, as these products are particularly attractive to youth. This information could help tailor further policies globally, and serve as baseline data to monitor the issue after plain packaging implementation.

Methods
The fi eldwork protocol was adapted from the Tobacco Packet Surveillance System (TPackSS) of Johns Hopkins University [19]. It was implemented in 15 neighbourhoods in Montevideo, Uruguay, sampled for convenience, corresponding to fi ve neighbourhoods per each of the three socioeconomic (low, middle, and high) areas, as per the National Socioeconomic Index [20]. One high school or college (hub) in each of the 15 neighbourhoods was selected based on density, safety, and school size while avoiding geographic overlap. Field workers had a training session and were provided with a printed manual with data collection procedures. Two data collectors surveyed two tobacco retailers (kiosks, small warehouses, and mini markets) near each of the 15 schools to obtain data between 1 June and 30 August 2019, six months before implementation of plain packaging. The retailers were selected by data collectors, starting from the selected hub based on the commercial activity nearby. After the fi rst retailer was visited, a visual inspection procedure was repeated: if no commercial activity was seen, data collectors walked in a right-hand direction up to fi ve blocks in search of a second retailer, until they identifi ed two per hub. At each store, data collectors disclosed that they were participating in a study about fl avoured cigarettes. The vendor was asked which tobacco product brands (fl avoured or non-fl avoured) were available at the store, and a pack of each different product was purchased. The responses were registered on paper forms, and the packs were labelled and stored in plastic bags. The same procedure was applied for subsequent retailers in a bid to acquire products not previously purchased. Each unique pack was photographed, and its characteristics were entered into a database. The variables were coded, inspired by the TPackss Features and Appeals Codebook. A pilot plan was conducted before the start of the study.
The packs were carefully observed by three researchers, wording and design were noted, and the packs were opened and emptied. Features of the cigarette, namely paper, fi lter, and fi lter contents were then coded according to their fl avour capsules and number, colour, and characteristics. Statistical software SPSS Version 20 was used (IBM Corp., Armonk, NY, USA).

Results
Thirty retailers were visited and surveyed. Twenty-three unique tobacco products were purchased, including 21 cigarette packs and two rolling tobacco packs. No specimen provided information on the contents of nicotine, tar, or carbon monoxide, and only 9 out of the 23 (39.1%) had some warning of protection for minors, such as not being available for sale to persons under 18 years of age.

Package design features
Appealing design features were found in 17 of the 23 packs (73.9%), such as fancy prints (30.4%), metallic or shiny fi nishes (21.7%), relief or bas-relief (21.7%), and contrasting colours and holographic images (13%). Many of the packs had two types of appeal (see Table 1). In 7 of the 23 packs (30.4%), lexical features related to quality or luxury were found using words like 'fi nest', 'premium', 'class A', or 'quality'. In 8 (34.8%) cases, the package contained language alluding to freshness, relaxation, enjoyment, or sensation ( Figure 1).

Discussion
Our study found that more than one-third of the tobacco products available at retailers near youth educational centres across all socioeconomic level areas in Uruguay were capsulefl avoured. Notably, fi ve of the eight fl avoured cigarettes brands used in this study were not available in 2016, according to the research conducted by Deatley, et al. [21]. They used a similar protocol, indicating an apparent increase in varieties over three years in Uruguay. This is consistent with the fi ndings of Scollo et al. and Moodie, et al. [17,18] in countries that implemented plain packaging legislation. Our study found that the majority of retailers sold at least one fl avoured cigarette brand (86.67%), this percentage is higher than that found in Bolivia (77.4%) and Brazil (80%), similar to that of Chile (85.2%), and lower than that of Argentina (88.5%) and Peru (95.0%) [22].
The variety of fl avoured cigarettes within the same brand was restricted to one, as national regulations require having a single presentation per brand, to avoid elements that may induce smokers to believe a variant to be less harmful