Dear Editor,
Flavored tobacco products remain a persistent and complex challenge for global tobacco control. This editorial first outlines the role of flavors in promoting initiation and dependence, then turns to Iran’s specific context, before broadening to global patterns, inequities, industry targeting, and finally policy responses. The piece concludes by emphasizing the need for comprehensive and context-specific regulation.
Flavored Tobacco Products and Global Health
Flavored tobacco products represent one of the most persistent and complex challenges to global tobacco control. Although the dominant product type varies across countries, flavors consistently act as a powerful driver of uptake and sustained use. By masking the harshness of smoke and creating a smoother, more appealing sensory experience, flavors encourage early experimentation, particularly among youth and women, and contribute to sustained nicotine dependence. Whether through menthol cigarettes in the United States, e-cigarettes in Europe, or fruit-flavored hookah in the Middle East and North Africa, flavors make tobacco more attractive, more addictive, and harder to quit. Their widespread use, coupled with targeted industry marketing, has created an urgent global health threat that transcends cultural and geographic boundaries.
Iran’s Context
In Iran, tobacco use has traditionally been dominated by cigarettes and waterpipe. According to the 2021 national STEPs survey (stepwise approach to non-communicable disease risk-factor surveillance), 14% of adults reported current tobacco use, with far higher prevalence among men (25%) than women (4%) (1). Hookah use is especially widespread among youth, with lifetime use estimated at 34% among high school students and 32% among university students. Importantly, hookah tobacco in Iran is almost always flavored, usually with fruit additives, making it the dominant form of flavored tobacco in the country. Flavors mask harshness, enhance palatability, and amplify nicotine’s reinforcing effects (2). This combination makes flavored products both more appealing and more addictive. Menthol and fruit additives intensify cravings, prolong dependence, and complicate cessation. For example, individuals who smoke menthol cigarettes consistently show lower quit rates even after adjusting for socioeconomic and demographic factors, suggesting that flavors alter neurobiological pathways of dependence (3).
Global Patterns
While flavored tobacco products take different forms across regions, their influence on initiation and dependence is remarkably consistent. In the United States, over 80% of youth report initiating tobacco use with a flavored product (4). In Iran, waterpipe use is socially embedded in cafés, family gatherings, and peer networks, where flavored smoke carries less stigma, especially for women (5, 6). Young women often cite flavor as their primary reason for waterpipe use (7). These patterns reveal how flavors exploit social norms and contexts, normalizing use among populations historically less likely to smoke.
Inequities and Vulnerabilities
Flavored tobacco also deepens inequities in tobacco burden. In the U.S., Black individuals are disproportionately likely to initiate smoking with menthol/mint cigarettes, while Hispanic youth more often begin with candy- or fruit-flavored products (8). Educational gradients are also evident: Those with higher education are less likely to initiate with menthol but more likely to initiate with candy/fruit flavors. Beyond sociodemographics, mental health is another axis of vulnerability. Ganz et al. found that individuals with severe anxiety and depression are more likely to initiate and persist with flavored products, such as menthol cigarettes and flavored cigarillos (9). Together, these findings show how flavors intersect with race, socioeconomic status, gender, and mental health, creating compounded disadvantages (10).
Targeted Marketing
The tobacco industry has long targeted marginalized groups with flavored products. In the U.S., menthol cigarettes have been disproportionately promoted to Black communities through billboard ads, retail discounts, and sponsorship of cultural events (11). Globally, flavored hookah and e-cigarettes are advertised in cafes, music venues, and on social media, often portraying them as safe, trendy, or culturally acceptable. In the Middle East, flavored hookah is aggressively marketed with bright packaging and fruit imagery that obscure health risks. These strategies represent predatory marketing, deliberately exploiting vulnerabilities to secure long-term consumers among groups already facing health inequities.
Policy Responses
Some countries have implemented strong regulations on flavored tobacco. The European Union, Canada, Turkey, and U.S. states such as Massachusetts and California have enacted bans on menthol or other flavored products. Evidence suggests these bans reduce flavored tobacco use and promote cessation. In the EU, menthol bans led to declines in menthol smoking and higher quit rates, especially among women (12). In Ontario, Canada, a menthol ban disproportionately increased quit attempts and success rates among menthol smokers (13). California’s comprehensive ban produced immediate declines in flavored tobacco use among adolescents (14). However, partial bans and enforcement gaps undermine impact, underscoring the need for comprehensive measures.
By contrast, Iran’s tobacco control policies remain limited to taxation, warning labels, and advertising restrictions, with little focus on flavored hookah. This regulatory gap leaves flavored hookah widely available in cafés, restaurants, and households, normalizing use and undermining prevention efforts. Stronger regulations targeting flavored waterpipe tobacco could align Iran’s policies with international best practices and better protect youth and women.
Conclusions
Flavored tobacco functions as a Trojan horse in the global tobacco epidemic: It conceals harms, enhances addiction, and worsens inequities. Evidence across settings from menthol cigarettes in the U.S. to flavored hookah in Iran shows that flavors drive initiation and sustain dependence. Comprehensive bans with strong enforcement remain the most effective solution. Yet policies must also be context-specific: In the U.S., flavored e-cigarettes deserve urgent attention, while in Iran, flavored hookah should be the primary regulatory target.
Ultimately, a coordinated global ban on flavored tobacco products could prevent cross-border trade, reduce industry exploitation of cultural loopholes, and protect future generations from enduring harms. Far from being a marginal issue, flavored tobacco lies at the center of the tobacco epidemic. Only through decisive, tailored, and comprehensive regulation can the global health community advance toward tobacco endgame goals and narrow persistent inequities in tobacco-related disease and mortality.
