Background:
Flavored cigarettes tend to be perceived as more palatable, less harmful, and more attractive to youth. In 2012, the Brazilian government issued a regulation banning the use of additives in all tobacco products, including sugar and flavorings. Industry interference has impeded implementation. Although not legally required, tobacco companies in Brazil use the pack to advertise cigarette ingredients. We examine the impact the additive ban would have on packaging and the cigarette market in Brazil.

Methods:
In 2016, we purchased and coded 147 unique cigarette pack presentations from three cities in Brazil: São Paulo, Manaus, and Salvador using a systematic protocol. Two independent coders recorded the ingredient list and imagery or words advertising a flavor on each pack.

Results:
Eighty percent of the packs' ingredient lists had at least one additive that is specified in the additive ban: sugar (77%), flavoring agents (24%), plant extract (24%), clove (11%), and menthol (10%). Tobacco companies also used the pack to promote specific flavors including cinnamon, clove, mint, menthol, and cherry; 20% of the packs had at least one of these flavors. In some cases, flavors advertised on the pack were not included on the ingredient list: 23 packs were coded for menthol or mint but only 8 (35%) had menthol as an ingredient. British American Tobacco (BAT) and Philip Morris (PM) accounted for 78% of the sample. An additive was listed in the ingredients on 83% of the 77 BAT packs and 100% of the 37 PM packs.

Conclusions:
Based on this sample, implementation of the additive ban would entail most brand variants available in Brazil needing to remove additive and flavor advertisement on the pack. Historically, the industry's response to restrictive packaging requirements is more innovation in packaging design. Plain packaging should be considered with the additive ban to help reduce the appeal of cigarettes.