Background:
A major objective of FCTC Article 9, which calls for tobacco product regulation, is to eliminate or reduce tobacco industry product design strategies that have been shown to lead smokers to believe that some cigarettes are less harmful than others. However, nearly all of the studies documenting beliefs about harm perceptions have come from high-income countries; little is known whether the same misperceptions about harmfulness are present in low-middle income countries (LMICs)― where 80% of the world's smokers reside. This study measured the level of perceptions of harmfulness of light and menthol cigarettes among smokers from 10 LMICs of the International Tobacco Control (ITC) Project.

Methods:
Cross-sectional analyses of ITC surveys in Bangladesh, Brazil, China, India, Kenya, Malaysia, Mauritius, Mexico, Thailand, and Zambia were conducted using the country's most recent survey wave (ranging from 2011 to 2016). Adult smokers were asked whether each of three design features— (1) light/low tar, (2) filters, and (3) menthol—were less harmful.

Results:
The percentage of smokers with erroneous beliefs was variable but substantial: 'light cigarettes are less harmful': 21% (Mexico) to 66% (China); 'low tar cigarettes are less harmful': 41% (Zambia) to 71% (China); 'menthol cigarettes are less harmful': 11% (Brazil) to 52% (China); 'filters reduce harm': 36% (Mexico) to 82% (China); 'if a cigarette tastes lighter, it is less harmful': 39% (Zambia) to 71% (Kenya).




[POH 10 LMICs ITC]



Conclusions:
A substantial proportion of smokers in the 10 LMICs erroneously believe that light, low tar, and menthol cigarettes are less harmful, and that filters reduce harm. This is particularly disturbing in China, where prevalence of industry-induced misconceptions was the highest for 4 of the 5 measures. These findings point to the necessity of Article 9 regulations to restrict/ban product design features that mislead consumers about the harmfulness of tobacco products, particularly in LMICs.