Awareness of Marketing of Heated Tobacco Products and Cigarettes and Support for Tobacco Marketing Restrictions in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey

Heated tobacco product use frequency, smoking quit attempts, and smoking reduction among Mexican adult smokers

INTRODUCTION

Heated tobacco products (HTPs) are promoted as less harmful than cigarettes; nonetheless, whether HTPs help smokers quit is uncertain.

METHODS

Data from 4067 Mexican adult smokers surveyed longitudinally every four months (November 2019-March 2021) were analyzed. Mixed-effects multinomial models regressed HTP use frequency (no use=reference; monthly; weekly; and daily use) on sociodemographics and tobacco/nicotine-related variables. Among participants who completed at least two surveys (n=2900) over four months, the duration of their longest smoking quit attempt (SQA) between surveys (SQAs: <30 days; ≥30 days; no SQA=reference) was regressed on HTP use frequency, and changes in the number of cigarettes smoked per day were regressed on HTP initiation between surveys, adjusting for covariates.

RESULTS

Consistent predictors of all HTP use frequencies (monthly, weekly, or daily vs no use) were daily smoking >5 cigarettes (ARRR=1.69 [95% CI: 1.12-2.55], 1.88 [95% CI: 1.26-2.81] and 6.46 [95% CI: 3.33-12.52], respectively); e-cigarette use (ARRR =5.68 [95% CI: 3.38-9.53], 6.54 [95% CI: 4.06-10.55] and 2.59 [95% CI: 1.26-5.30]); lower HTP risk perceptions (ARRR=2.12 [95% CI: 1.50-30.00], 2.25 [95% CI: 1.63-3.10] and 2.00 [95% CI: 1.25-3.22]); exposure to HTP information inside (ARRR=2.13 [95% CI: 1.44-3.15], 2.13 [95% CI: 1.49-3.05] and 3.72 [95% CI: 2.28-6.09]) and outside stores (ARRR=2.36 [95% CI: 1.56-3.57], 2.32 [95% CI: 1.65-3.25] and 2.44 [95% CI: 1.41-4.24]) where tobacco is sold; having family (ARRR=2.46 [95% CI: 1.54-3.91], 2.90 [95% CI: 1.93-4.37] and 2.96 [95% CI: 1.52-5.77]) and friends (ARRR=5.78 [95% CI: 3.60-9.30], 4.98 [95% CI: 3.22-7.72] and 6.61 [95% CI: 2.91-15.01]) who use HTPs. HTP use frequency was not associated with quit attempts, except for monthly HTP use predicting SQAs lasting ≥30 days (ARRR=2.12 [95% CI: 1.17-3.85]). Initiation of HTP use was not associated with changes in smoking frequency. Limiting analysis to those who intend to quit smoking also yielded null results.

CONCLUSIONS

Among Mexican adult smokers, frequency of HTP use was mostly not associated with either cessation behaviors or changes in cigarette consumption, suggesting that HTPs have limited to no effectiveness for smoking cessation.

Projecting the impact of implementation of WHO MPOWER measures on smoking prevalence and mortality in Japan

OBJECTIVE

This study aimed to quantify the long-term impact of implementing the WHO Framework Convention on Tobacco Control (FCTC) compliant tobacco control measures, MPOWER, on smoking prevalence and mortality in men and women aged ≥20 years in Japan.

DESIGN

A Stock-and-Flow simulation model was used to project smoking prevalence and mortality from 2018 to 2050 under eight different scenarios: (1) maintaining the 2018 status quo, (2) implementation of smoke-free policies, (3) tobacco use cessation programmes, (4-5) health warning about the dangers of tobacco (labels, mass media), (6) enforcement of tobacco advertising bans or (7) tobacco taxation at the highest recommended level and (8) all these interventions combined.

RESULTS

Under the status quo, the smoking prevalence in Japan will decrease from 29.6% to 15.5% in men and 8.3% to 4.7% in women by 2050. Full implementation of MPOWER will accelerate this trend, dropping the prevalence to 10.6% in men and 3.2% in women, and save nearly a quarter million deaths by 2050. This reduction implies that Japan will only attain the current national target of 12% overall smoking prevalence in 2033, 8 years earlier than it would with the status quo (in 2041), a significant delay from the national government's 2022 deadline.

CONCLUSIONS

To bring forward the elimination of tobacco smoking and substantially reduce smoking-related deaths, the government of Japan should fulfil its commitment to the FCTC and adopt stringent tobacco control measures delineated by MPOWER and beyond.

IQOS and cigarette advertising across regulatory periods and population groups in Israel: a longitudinal analysis

BACKGROUND

Tobacco regulation recently changed in Israel, including a partial advertisement ban. We assessed the impact of regulatory changes on Philip Morris International's (PMI) IQOS and cigarette advertisements.

METHODS

Weekly number of ads and weekly adspend of PMI's IQOS and cigarettes were analysed descriptively and using Quasi-Poisson regressions over time, across regulatory periods and in relation to subpopulations (general public, Arab, Russian and Ultra-Orthodox), from 25 December 2016 to 4 August 2020. Exponentiated coefficients (a value >1 indicates an increase) and 95% CIs are reported.

RESULTS

The average weekly number of ads and the average weekly adspend of IQOS were higher than cigarettes (42.22 vs 26.76 ads/week and 59 409 vs 45 613 new Israeli shekels/week; p<0.001 for both) during the study period, with exclusive IQOS advertisements during market penetration (December 2016 to May 2017). Variation in both outcomes was observed with regard to regulatory decisions. After the advertisement ban, there was a significant decrease in the weekly number of ads (IQOS: ß=0.04, 95% CI 0.002 to 0.20; cigarettes: ß=0.05, 95% CI 0.01 to 0.15) and weekly adspend (IQOS: ß=0.15, 95% CI 0.07 to 0.29; cigarettes: ß=0.31, 95% CI 0.17 to 0.53) for both products. The Ultra-Orthodox had significantly higher average weekly ads compared with the Arab population (IQOS: 0.67 vs 0.07; cigarettes: 2.74 vs 0.13; p=0.02 for both) but lower adspend.

CONCLUSIONS

IQOS and cigarette advertisements varied over time and appeared to have been impacted by regulatory changes. PMI invested more in IQOS advertisements than in cigarettes, with a partial advertisement ban decreasing both products' advertisements. PMI might be targeting the Ultra-Orthodox Jewish population which has a low smoking rate. Further research and surveillance are needed to better understand targeting strategies in order to inform tobacco control policy.

PMI's IQOS and cigarette ads in Israeli media: a content analysis across regulatory periods and target population subgroups

BACKGROUND

IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes.

METHODS

Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test.

RESULTS

The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging.

CONCLUSIONS

IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.

Perception of heated tobacco products and support for regulations: a cross-sectional study in Hong Kong

BACKGROUND

Hong Kong has proposed banning the sale of heated tobacco products (HTPs). Perceptions of reduced harms and effectiveness for quitting combustible cigarettes (CCs) of HTPs due to their promotions may erode public support for regulations. We assessed the associations between perceptions of HTPs and support for regulations in Hong Kong.

METHODS

In two population-based landline surveys conducted in 2018-2019, 1985 respondents (51.4% male; 22.7% aged 60+ years) reported perceived relative harm of HTPs to CCs and effectiveness for quitting CCs, and support for five HTP regulations (ban on promotion and advertisements, use in smoke-free areas, sales to minors, registration before sale, sale licence) and a total ban on sale. Current and former smokers were oversampled due to low prevalence. Descriptive statistics were weighted to the general population. Associations were analysed, adjusting for sociodemographic characteristics, smoking status and ever HTP use.

RESULTS

27.4% (N=515) of respondents perceived HTPs as less harmful, and 18.8% (N=1299) perceived them as effective for quitting CCs. Support was generally high (at least one regulation, 99.1%, N=1959; all five regulations, 66.8%, N=1114; total ban, 63.5%, N=946). Perceptions of reduced harm were associated with lower support for all five regulations (adjusted risk ratio 0.85, 0.75 to 0.96) and a total ban on sale (0.58, 0.51 to 0.66). Results were similar for perceptions of effectiveness for quitting.

CONCLUSIONS

Lower support for HTP regulations and a total ban on sale were associated with perceptions of reduced harm and effectiveness for quitting CCs of HTPs in Hong Kong.

The online promotion strategies of e-cigarette and heated tobacco product retailers in South Korea following the COVID-19 pandemic: Implications for regulation

INTRODUCTION

The surge in popularity of e-cigarettes and heated tobacco products (HTPs) in South Korea, driven by perceived health benefits and COVID-19-related concerns, has led to increased advertising claims about their safety despite ongoing debates about their health effects. This study explores the marketing strategies of online e-cigarette and HTP retailers in South Korea pre- and post-COVID-19, examining potential misleading claims and providing a foundation for future regulatory measures.

METHODS

We conducted a comprehensive study of eight major e-commerce platforms and three dominant search engines in South Korea to analyze the marketing and advertising strategies of e-cigarettes and heated tobacco products (HTPs) (n=774). Using specific keywords, promotional strategies were identified and categorized, after which statistical analysis was conducted to understand the frequency and proportion of these strategies, highlighting differences between HTP and e-cigarette sellers.

RESULTS

Our analysis reveals a significant rise in the number of online retailers selling e-cigarettes and HTPs following the COVID-19 pandemic, with the promotional strategies 'Stay home and vape' and 'Trendy' being the most prevalent. Trends also indicate a shift in promotional strategies over the years, with a marked increase in health reassurance themes and appeals to trendiness, particularly targeting female consumers, which were used significantly more at HTPs stores.

CONCLUSIONS

The study highlights the need for stricter regulation due to the potential health risks posed by the aggressive marketing strategies of e-cigarette and HTP online retailers in South Korea, amplified by the COVID-19 pandemic.

Associations of individual characteristics and socioeconomic status with heated tobacco product harmfulness perceptions in Japan: A nationwide cross-sectional study (INFORM Study 2020)

IntroductionIn Japan, heated tobacco products (HTPs) are promoted by the tobacco industry as reduced-risk tobacco products despite the lack of evidence for this claim. This study determined the distribution of HTP-harmfulness perception and identify the explanatory factors associated with the perception of HTP as less harmful than conventional cigarettes.MethodsA nationwide cross-sectional survey was conducted with Japanese people aged 20 years or older (INFORM Study 2020) using a self-administered questionnaire. We performed descriptive analysis and weighted logistic regression analysis to examine the relationship between explanatory factors (e.g., individual characteristics, socioeconomic status, and trusted sources of cancer information) and the perception of HTPs as less harmful.ResultsAmong 3,420 participants (response rate: 35.2%), the proportions of those who perceived HTPs as less harmful were 40.3% and 18.3% for users and non-users of tobacco, respectively. For participants aged 20-39 years, the proportion were 49.9% and 30.4%, respectively. Among 1,160 non-tobacco users who were familiar with HTPs, male, aged under 39 years, and had lower education were associated with the perception of HTPs as less harmful. Trusted sources of cancer information were not associated with the perception of HTPs as less harmful.ConclusionsThis study showed that, among non-tobacco users, being male, aged under 39 years, and lower education were associated with a perception of HTPs as less harmful. Public health stakeholders should provide the latest evidence about HTP harmfulness in their daily practice, and strengthen the regulations on HTP marketing directed at both tobacco- and non-tobacco users.

Electronic device or regulated tobacco product? Learning from the diffusion of heated tobacco products in Spain

OBJECTIVES

Tobacco companies have introduced heated tobacco product (HTP) in many countries and marketed it on the grounds that it is a less harmful alternative to health. However, tobacco companies have been widely criticized for taking advantage of a loophole that allows electronic devices to circumvent regulations limiting tobacco advertising. This work aims to determine whether HTPs respected the rules that regulate tobacco advertising when it was introduced in Spain.

STUDY DESIGN

This is an observational epidemiological study.

METHODS

Using monthly time series data from September 2016 to June 2020, we analyzed whether the adoption of HTPs has followed the same behavior patterns as other brands that were introduced under the same conditions of use. The Bass model is used to analyze the diffusion of HTPs, and 30 other traditional cigarette brands introduced under the same conditions as this HTPs.

RESULTS

The adoption of HTPs in Spain has been like that of brands of slim cigarettes that are mistakenly considered to be healthier than traditional cigarettes. The results indicate that the use of HTPs has spread in the same way as additive-free and ultra-slim cigarette brands.

CONCLUSIONS

Policymakers should keep in mind that laws should restrict any marketing of tobacco products that promotes positive connotations between tobacco use and being healthy. If manufacturers are allowed to classify a category and/or brand of tobacco products as less harmful to health, the imitation effect is very high, leading to the proliferation of smoking.

Effect of IQOS introduction on Philip Morris International cigarette sales in Spain: a Logarithmic Mean Divisa Index decomposition approach

OBJECTIVE

Philip Morris International, has already introduced its heated tobacco product, IQOS, in many countries and marketed it on the grounds that it is a less harmful alternative to health. The company claims that its intention is for its brand's traditional cigarette smokers to replace these with IQOS has rarely been independently tested.

METHOD

Using time series data from September 2016 to June 2020, we analyze whether Heets sales have been accompanied by an improvement in the position of Philip Morris International in the market or if they have merely replaced lost sales of the rest of the brands sold by that tobacco company.

RESULTS

Sales of traditional cigarettes of all the brands marketed by PMI have been replaced by IQOS since the introduction of this heated tobacco product in Spain. Almost all of the variations observed in IQOS sales are due to the positioning of this product as a substitute for the range of traditional cigarettes marketed by Philip Morris International.

CONCLUSIONS

As there is still no consensus that HTPs are explicitly less harmful to health, health authorities must control messages suggesting improved health outcomes thanks to HTP usage when compared to traditional cigarettes. Such messages could generate a false sense of security and lead to an increase in the consumption of tobacco. In Spain Heets in a category that has a lower tax burden than the category of traditional cigarettes. Tax authorities must consider this migration and the impact this may have on tax collection.

Heated tobacco product use, its correlates, and reasons for use among Mexican smokers

BACKGROUND

Little is known about the use of novel heated tobacco products (HTPs) in low- and middle-income countries. We examined among smokers in Mexico the prevalence and correlates of HTP use, as well as reasons for using HTPs.

METHODS

We analyzed data from five surveys (November 2019-March 2021) of an open cohort of adult smokers (n = 6500), including an oversample of those who also use e-cigarettes. Mixed-effects multinomial logistic models were used to estimate associations between study variables and current HTP use or prior HTP trial relative to never trying HTPs.

RESULTS

The weighted prevalence of current HTP use was 1.1%. Independent correlates of current HTP use included smoking frequency, intention to quit, e-cigarette use, having partners/family-members who use e-cigarettes, friends who use HTPs, and exposure to HTP information inside/outside tobacco shops. Having partners/family members who smoke and not knowing about the harm of HTPs relative to cigarettes were associated with lower likelihood of current HTP use. Having tried HTPs was more likely among light daily smokers, those with family who use HTPs and exposure to HTP information outside shops and on newspapers/magazines. Among current users, the top reasons for using HTPs were greater social acceptability (50.6%) and lower perceived harm (34.9%) relative to cigarettes.

CONCLUSIONS

Uptake of HTPs appears relatively low among Mexican smokers, and correlates of use are similar to those for e-cigarette use. Further research is needed to determine if HTPs use promotes or impedes smoking cessation, given current HTP users are also likely to use various nicotine products.

Heated tobacco product use and hypertensive disorders of pregnancy and low birth weight: analysis of a cross-sectional, web-based survey in Japan

OBJECTIVES

Knowledge on the impact of heated tobacco product (HTP) use in pregnant women with associated maternal and neonatal risks for hypertensive disorders of pregnancy (HDP) and low birth weight (LBW) is limited. We aimed to assess the status of HTP use among pregnant women in Japan and explore the association of HTP use with HDP and LBW.

DESIGN

Cross-sectional study.

SETTING

Data from the Japan 'COVID-19 and Society' Internet Survey study, a web-based nationwide survey.

PARTICIPANTS

We investigated 558 postdelivery and 365 currently pregnant women in October 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Information on HDP and LBW was collected from the postdelivery women's Maternal and Child Health Handbooks (maternal and newborn records). We estimated the age-adjusted ORs and 95% CIs of ever HTP smokers for HDP and LBW and compared them with those of never HTP smokers in a logistic regression analysis.

RESULTS

The prevalence of ever and current HTP use were 11.7% and 2.7% in postdelivery women and 12.6% and 1.1% in currently pregnant women, respectively. Among currently pregnant women who were former combustible cigarette smokers, 4.4% (4/91) were current HTP smokers. Among postdelivery women, ever HTP smokers had a higher HDP incidence (13.8% vs 6.5%, p=0.03; age-adjusted OR=2.48, 95% CI 1.11 to 5.53) and higher LBW incidence (18.5% vs 8.9%, p=0.02; age-adjusted OR=2.36, 95% CI 1.16 to 4.87).

CONCLUSIONS

In Japan, the incidence of ever HTP use exceeded 10% among pregnant women, and HTP smoking may be associated with maternal and neonatal risks.

Occupational difference in use of heated tobacco products: a cross-sectional analysis of retail workers in Japan

OBJECTIVE

Although heated tobacco products (HTPs) have become popular worldwide, research on occupational differences in smoking HTPs remains scarce. We aimed to examine the prevalence of smoking HTPs among a working population in Japan.

SETTING, DESIGN AND PARTICIPANTS

In 2018, we conducted a cross-sectional study comprised of 7714 retail business workers in the service industry in Japan.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the definition of smoking HTPs, we identified current HTP smokers who only smoked HTPs, using five mutual categories of current smoking status (never, former, HTPs only, combustible cigarettes only and dual smokers who smoked both combustible cigarettes and HTPs). Occupational classes were classified into office workers (eg, upper non-manual workers) and other workers. ORs and 95% CIs of office workers were estimated for HTP usage, adjusted for age, sex, employment type and cigarette smoking-related health knowledge.

RESULTS

The overall prevalence of smoking HTPs was 3.0% (male 5.0%, female 2.2%). The prevalence of HTP smokers differed across occupational classes (5.6% in office workers vs 2.5% in others; p<0.05). Compared with other workers, the adjusted odds of office workers for smoking HTPs remained elevated (OR: 1.97, 95% CI: 1.40 to 2.77). Sensitivity analyses with workers of all smoking status showed the same pattern. When stratified by sex, the occupational difference only remained significant in male workers.

CONCLUSIONS

We found a positive occupational difference in smoking HTPs, particularly among male workers in the retail sector in Japan. National tobacco control should explicitly address this occupational gap and further encourage individuals to quit smoking.