Philip Morris International introduces new heat-not-burn product, IQOS, in South Korea

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of Publications on Heated Tobacco Products With Conventional Cigarettes and Implied Desirability of the Products According to Tobacco Industry Affiliation: A Systematic Review

INTRODUCTION

Heated tobacco products (HTPs) have been advertised as "reduced-harm" tobacco products compared to conventional cigarettes (CC); however, no direct evidence supporting HTPs being desirable for human health exists. A previous systematic review reported that evidence on HTPs published in 2017 or earlier was primarily drawn from industry-related papers. We aimed to investigate whether tobacco industry-affiliated studies are more likely to conclude that HTPs are more desirable than CC.

METHODS

PubMed and Ichushi-Web were searched up to March 15, 2022, for studies on HTPs published in 2017 or after. We selected studies that assessed any measures of HTPs and CC, including secondary analyses using gray literature in English or Japanese. We excluded review articles except for a meta-analysis that met the aforementioned criteria. Data on the authors' affiliations, grant, conflict of interest, category of research subjects, and interpretation were extracted. Research members in two groups independently assessed the papers; discrepancies were solved by discussion between the groups.

RESULTS

Overall, 134 studies met the criteria. Eighty-seven (64.9%) of them were affiliated with the tobacco industry. Of the 134 studies, 56.3% (49/87) of the industry-affiliated studies versus 19.1% (9/47) of nonindustry-affiliated studies concluded that HTPs were more desirable than CC (p < .01). No study investigated clinically relevant outcomes, such as disease occurrence.

CONCLUSIONS

Publications on HTPs in the biomedical literature from January 2017 to March 2022 were dominated by tobacco industry-affiliated studies. More than half of them concluded that HTPs were more desirable than CC compared to independent studies.

IMPLICATIONS

Tobacco industry advertises HTPs as "reduced-harm" tobacco products compared to CC. HTP users tend to consider HTPs as alternative tobacco products less harmful than CC (ie, products for "harm reduction"). Our results demonstrated that papers written by tobacco industry-affiliated authors concluded that HTPs were more desirable than CC compared to papers by independent authors. However, all their judgments were based on surrogate outcomes. Surrogate outcomes are not necessarily linked to clinically relevant outcomes such as disease occurrence. Further studies on HTPs using clinically relevant outcomes are warranted by independent authors from tobacco industry.

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.

Nicotine, Humectants, and Tobacco-Specific Nitrosamines (TSNAs) in IQOS Heated Tobacco Products (HTPs): A Cross-Country Study

Heated Tobacco Products (HTPs) purport to reduce exposure to tobacco-related toxicants compared to combustible cigarettes. This cross-sectional study examined the content of nicotine, two humectants (propylene glycol (PG) and vegetable glycerin (VG)), and four tobacco-specific nitrosamines (TSNAs: NNN, NNK, NAT, and NAB) in the tobacco filler of a popular HTP brand (IQOS). Non-menthol and menthol IQOS sticks were purchased from nine countries between 2017 and 2020 and were classified into two versions ("Bold" and "Light") using Philip Morris's flavor descriptors. The average nicotine concentration was 4.7 ± 0.5 mg/stick, and the highest nicotine concentration was found in products from Japan (5.1 ± 0.2 mg/stick). VG was the dominant humectant found in all sticks, with an average concentration of (31.5 ± 2.3 mg/stick). NNN, NNK, and NAT were substantially higher in the "Bold" sticks than the "Light" sticks. Significant differences between countries for TSNAs were also observed: the NAT and NAB contents were the highest in the "Light" products from Canada (192.5 ± 24.1 and 22.9 ± 1.0 ng/stick, respectively); the NNK concentration was the highest in the "Bold" products from Poland (64.8 ± 7.9 ng/stick); and the highest NNN concentrations were observed in the "Bold" products from South Africa (488.9 ± 26.7 ng/stick). As NNN and NNK are known human carcinogens, and as humectants like PG and VG can degrade into toxic carbonyl compounds upon heating, monitoring the concentration of these chemicals in HTPs is important for protecting users' health and ensuring compliance with regulations.

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.

Testicular tissue response following a 90-day subchronic exposure to HTP aerosols and cigarette smoke in rats

Background

Researches have shown that chronic inhalation of cigarette smoke (CS) disrupts male reproductive system, but it is unclear about the mechanisms behind reproductive damages by tobacco toxicants in male rats. This study was designed to explore the effects of heated tobacco products (HTP) aerosols and CS exposure on the testicular health of rats.

Materials and Methods

Experiments were performed on male SD rats exposed to filtered air, HTP aerosols at 10 μg/L, 23 μg/L, and 50 μg/L nicotine-equivalent contents, and also CS at 23 μg/L nicotine-equivalent content for 90 days in five exposure groups (coded as sham, HTP_10, HTP_23, HTP_50 and Cig_23). The expression of serum testosterone, testicular tissue inflammatory cytokines (IL-1β, IL-6, IL-10, TNF-α), reactive oxygen species (ROS), superoxide dismutase (SOD) and malondialdehyde (MDA), NLRP3 inflammasome-related mRNAs and proteins (NLRP3, ASC, and Caspase-1), the degree of pyroptosis and histopathology were investigated.

Results

The results demonstrated that HTP_50 and Cig_23 caused varying degrees of oxidative damage to rat testis, resulting in a decrease of sperm quantity and serum testosterone contents, an increase in the deformity rate, expression levels of proinflammatory cytokines, and NLRP3 inflammasome-related mRNA, and an increase in the NLRP3, ASC, and Caspase-1-immunopositive cells, pyroptosis cell indices, and histopathological damage in the testes of rats. Responses from the HTP_10 and HTP_23 groups were less than those found in the above two exposure groups.

Conclusion

These findings indicate that HTP_50 and Cig_23 induced oxidative stress in rat testes, induced inflammation and pyroptosis through the ROS/NLRP3/Caspase-1 pathway, and destroyed the integrity of thetesticular tissue structure.

Exhaled Carbon Monoxide Level and Practices among Tobacco and Nicotine Adult Users in Klang Valley, Malaysia

Tobacco and nicotine derivatives uses are multiple in nature. These include conventional cigarettes (CCs), heated tobacco products (HTPs), and electronic cigarettes (ECs). This study aims to determine the practices, nicotine dependency profile, association with exhaled carbon monoxide (eCO) level, and pulmonary function (PF) among adult product users and non-smokers. This cross-sectional study involved smokers, nicotine users, and non-smokers from two public health facilities in Kuala Lumpur from December 2021 to April 2022. Data on socio-demography, smoking profile, nicotine dependency level, anthropometry, eCO monitor, and spirometer measurements were recorded. Out of 657 respondents, 52.1% were non-smokers, 48.3% were CC only smokers, poly-users (PUs) (27.3%), EC-only users (20.9%), and HTP-only users (3.5%). EC use was prevalent among the younger aged, tertiary educated, and females; HTP use was prevalent among those of an older age and CC users was common among lower educated males. The highest median eCO (in ppm) seen were as follows: in CC users only (13.00), PUs (7.00), EC users (2.00), HTP users (2.00), and the least was observed among non-smokers (1.00), which is significantly different across the groups (p <0.001). Comparison of practice between the different product users showed significant differences in age of product initiation (p <0.001, youngest in CC users in PUs), duration of product use (p <0.001, longest in exclusive CC users), cost per month (p <0.001, highest in exclusive HTP users) and attempt to quit product (p <0.001, CC use in PUs had the highest attempt to quit), while there is no significant difference in Fagerström score across the groups. Among EC users, 68.2% successfully switched from smoking CCs to ECs. The findings suggest that EC and HTP users are exhaling less CO. The use of these products in a targeted approach may manage nicotine addiction. Switching practice was higher among current EC users (from using CCs), hence emphasizing the need of switching encouragement and total nicotine abstinence later on. Lower eCO levels in the PU group, (as compared to CC-only users) and high quit attempt rate among in CC use in PUs may indicate attempt of PUs in reducing CC use through alternative modalities such as ECs and HTPs.

A content analysis of heated tobacco product business in Hong Kong on Facebook

Heated tobacco products (HTPs) are increasingly popular in Hong Kong (HK) even though they have not been formally launched and the sale of duty-not-paid tobacco sticks is illegal. We investigated how Facebook was used against regulations to sell HTPs in HK. We screened Facebook pages run by HTP businesses targeting HK users in June 2019 and included pages with over 300 "Likes" for inductive content analysis by coding their "About" descriptions and all posts including comments published since January 2017. HTPs included heating devices, accessories, and tobacco sticks. Various attributes were recorded including methods of customer inquiries (telephone, Instant Messaging [IM], address), business responses (comments or private messages, PM), and services provided (warranty/repair). Among 30 pages (50.9% of all 59 eligible pages with related information on HTPs), two-thirds provided phone numbers (66.7%), IM accounts (65.5%), and addresses (66.7%). Most pages sold heating devices (26, 86.7%) and accessories (22, 73.3%) with over 72% providing phone numbers, IM accounts, or addresses. Only 8 pages (26.7%) sold tobacco sticks with 75.0% providing telephone numbers but fewer provided IM accounts (62.5%) and addresses (50.0%). All pages responded using PMs and only 12.5% also used comments. Warranty/repair services were provided by 43.3% of the pages. We found Facebook pages were used as dedicated stores to promote and sell HTPs including heating devices, accessories, and even illicit tobacco sticks in HK, a non-official market.

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

Perceptions of Heated Tobacco Products (HTPs) and Intention to Quit Among Adult Tobacco Users in Korea

BACKGROUND

The popularity of heated tobacco products (HTPs) has been growing globally but, limited information exists on tobacco use behaviors and its impact on tobacco control. This study investigates awareness and perception of HTPs among tobacco users and whether perceptions of HTPs are associated with HTP use and intention to quit.

METHODS

We invited 2,000 tobacco users aged 19-65 years with countrywide representation to an online survey in November 2018. Information on general characteristics, tobacco use behaviors, awareness and perception of HTPs, and intention to quit were gathered. Multinomial logistic regression analysis and ANCOVA were used for estimation of association and comparison.

RESULTS

Among all tobacco users, 36.8% were classified as ever users, whereas 28.3% had used HTPs in the past 30 days, which was higher than expected. Users of liquid-based e-cigarettes (odds ratio [OR] 1.578; 95% confidence interval [CI], 1.210-2.056) and poly-product users (OR 2.029; 95% CI, 1.121-3.671) showed higher intention to quit within 1 month when compared to users of conventional cigarettes (CCs), whereas HTP users and dual product users did not. HTP users rated HTPs more favorably than CCs in terms of smoke, smell, harm, aid in quitting, design, and price than users of other products did (P-value < 0.001).

CONCLUSION

We find that positive perception of HTPs following strategic marketing from tobacco companies could have contributed to a greater increase in HTP use than expected in Korea. However, HTPs might not be considered substitutes for CCs for quitting tobacco use because a significant proportion of dual product users reported a lower intention to quit.

Heated debates on regulations of heated tobacco products in South Korea: the news valence, source and framing of relative risk/benefit

BACKGROUND

We analyse news representations of the regulation of heated tobacco products (HTPs) in South Korea, the country where HTP use is among the highest in the world despite conflicts between the government and the HTP manufacturers.

METHODS

We analysed a total of 571 print and TV news covering HTP regulations, published between 2017 and 2018, the time period when HTPs were introduced to the country and various regulations of HTPs were proposed and implemented. We assessed the prevalence and associations among specific types of HTP regulations that were discussed, valence towards regulation, sources, framing of the relative health risks/benefits of HTPs compared with conventional cigarettes.

RESULTS

Taxation (55.2%) and warning labels (25.7%) were two regulation topics covered the most. Almost equal proportions of pro-regulation (2.5%) and anti-regulation valence (2.2%) were found in taxation-related news, while pro-regulation valence appeared more frequently for other restrictions, including warning labels (pro=9.5% vs anti=1.4%), marketing restrictions (pro=6.9% vs anti=0%) and integration of HTPs into smoke-free policies for cigarettes (pro=8.7% vs anti=0%). The government (59%), followed by the tobacco industry (39.4%), was the source cited most often across news stories while the presence of tobacco control advocates was low (4.9%). As for framing, there was no significant difference in the prevalence of stories mentioning reduced harm (31.7%) and equal or more harm (33.6%) of HTPs compared with cigarettes.

CONCLUSIONS

We provide implications for governments and tobacco control advocates on building consensus for applying cigarette equivalent taxes and pictorial warning labels to HTPs.

Early adoption of heated tobacco products resembles that of e-cigarettes

BACKGROUND

Heated tobacco products (HTP) generate nicotine-containing aerosol by heating tobacco rather than burning it. The US Food and Drug Administration (FDA) has recently authorised the sale of one HTP brand, iQOS, in the USA. This study examined the awareness, use and risk perceptions of HTP in the USA following FDA authorisation.

METHODS

A national probability sample of 20 449 US adults completed an online survey between November 2019 and February 2020. In addition to assessing awareness and use of HTP, two ratios were calculated: the ratio of those who experimented with HTP given that they had heard about it (E/H) and the ratio of those who currently used HTP given experimentation (C/E). These ratios for HTP were compared against those for e-cigarettes from a similar national survey in 2012.

RESULTS

Overall, 8.1% of respondents had heard of HTP. Only 0.55% had tried and 0.10% were current users. The rate of experimentation among those who heard about HTP and the rate of current use among experimenters were, however, similar to those for e-cigarettes in 2012: E/H and C/E for HTP were 6.8% and 18.2%, respectively; and 10.7% and 17.8%, respectively for e-cigarettes. The majority of respondents considered HTP either less harmful than (11.6%), or equally harmful as e-cigarettes (42.7%).

CONCLUSIONS

Only a small fraction of US population in 2020 have tried any HTP. However, the similarity in early adoption rates following awareness, suggests that future adoption for HTP may be similar to that for e-cigarettes, if HTP are marketed more aggressively.

“It’s Like Jogging Next to the Highway”: A Qualitative Analysis of the Motivations and Experiences of Single-, Dual-, and Ex-Users of IQOS in The Netherlands

The popularity of heated tobacco products (HTPs) is of concern, as most users are dual users exposed to emissions of both HTPs and conventional cigarettes. Furthermore, HTPs may appeal to young people and non-smokers. This study aims to build intelligence on user experiences in order to inform policy development. We conducted five semi-structured focus group interviews with single-, dual-, and ex-users of the HTP IQOS. The discussions focused on initiation and use, experiences and perception, and knowledge and information needs. We performed a thematic analysis of the transcripts. All users smoked cigarettes and/or roll your own (RYO) tobacco before using HTP. We found that almost all users started using IQOS after being introduced to it by others. Single users successfully quit smoking cigarettes using the IQOS, liked the taste, and experienced physical benefits. Dual users experienced more satisfaction from smoking cigarettes and used the IQOS for specific occasions, such as social situations or in places with smoking bans. All IQOS users described themselves as smokers and considered using the IQOS as an alternative way of smoking. Regulators may consider providing reliable and easily accessible information and regulating points of sale, promotional activities, and product properties such as flavors and devices in order to reduce product attractiveness and discourage use.

Evolution of tobacco products: recent history and future directions

Declines in cigarette smoking prevalence in many countries and the consolidation of the tobacco industry have prompted the introduction of other forms of nicotine delivery. These include electronic nicotine delivery systems (ENDS), heated tobacco products (HTPs) and oral nicotine products (ONPs). Evolving over time, some of these products now deliver nicotine at levels comparable to cigarettes and may serve as effective substitutes for smokers. However, certain products, especially ENDS like JUUL, have also appealed to youth and non-smokers, prompting concerns about expanding nicotine use (and potentially nicotine addiction). The tobacco industry could shift away from primarily promoting cigarettes to promoting ENDS, HTPs and/or ONPs, though at this time it continues to heavily promote cigarettes in low and middle-income countries. Differing regulatory regimes may place upward and downward pressures on both cigarettes and these newer products in terms of population use, and may ultimately drive the extent to which cigarettes are or are not displaced by ENDS, HTPs and/or ONPs in the coming decade.

Perceived relative harm of heated tobacco products and electronic cigarettes and its association with use in smoke-free places: A cross-sectional analysis of Korean adults

INTRODUCTION

Electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are often considered to be less harmful and safer than combustible cigarettes (CCs). As a result, numerous tobacco product users opt to use e-cigarettes or HTPs as a safer alternative, though the safety of these products is not fully warranted. The present study aimed to assess the various attitudes towards e-cigarettes and/or HTPs among Korean tobacco product users and their associations with the practical use of e-cigarettes and/or HTPs in private or smoke-free public places.

METHODS

A cross-sectional study using self-administered questionnaires was conducted from March 2019 to July 2019 on 2971 adult tobacco product users. Attitude towards e-cigarettes and/or HTPs, as well as the relative harm perceptions, in association with their practical use in private or smoke-free areas, were also analyzed.

RESULTS

Among those surveyed, 46.8% were exclusive users (CC-only smokers 23.5%, e-cigarette-only users 10.7%, HTP-only users 12.7%), and 47.6% were poly-users. Compared with non-e-cigarette or non-HTP users, current e-cigarette or HTP users perceived e-cigarettes or HTPs as less harmful than CCs and they were more acceptable to e-cigarettes or HTPs being used indoors. Their positive attitudes were associated with their more frequent use at home or in their car. Less number of participants supported that the government should regulate e-cigarettes or HTPs in the same way as CCs, their attitude being associated with more frequent use in smoke-free public places.

CONCLUSIONS

E-cigarettes or HTPs users have more positive attitudes toward their tobacco products than non-e-cigarette or non-HTP users. Those with more positive attitudes toward e-cigarettes or HTPs are closely related to their use in smoke-free places.

Awareness of heated tobacco products among US Adults - Health information national trends survey, 2020

Introduction: Heated Tobacco Products (HTP) have the potential to attain high uptake in the US. The current study estimated the prevalence of awareness, prevalence of use and the factors associated with awareness of HTP among US adults. Methods: This study included 3201 respondents from the Health Information National Trends Survey (HINTS) 5 Cycle 4 (2020). The prevalence of awareness of HTP and ever use of HTP among US adults were estimated. Multivariable logistic regression was conducted to identify the factors associated with awareness of HTP. Results: About 15% of the adult US population were aware of HTP, while 2.2% had ever used HTP. Age between 35 and 49 years (aOR, 1.9; 95% CI, 1.3-2.9; p-value = 0.003), male sex (aOR, 1.7; 95% CI, 1.0-2.7; p-value = 0.04), lower income ($0-$9,999) (aOR, 3.0; 95% CI, 1.3-6.9; p-value = 0.01), smoking on some days (aOR, 3.4; 95% CI, 1.2-9.4; p-value = 0.02) and moderately or extremely worrying about getting cancer (aOR, 1.7; 95% CI, 1.1-2.7; p-value = 0.03) were associated with higher odds of being aware of HTP; whereas, belief that there are so many cancer prevention recommendations, it's hard to know which ones to follow (aOR, 0.5; 95% CI, 0.3-0.8; p-value = 0.009) was associated with lower odds of being aware of HTP. Conclusions: A significant proportion of US adult population were aware of HTP in 2020. Given the recent high proliferation of e-cigarettes, potential health effects of the HTP products should be monitored by the regulators closely. Adequate surveillance and policy interventions are warranted in this regard.

Heated Tobacco Products Impair Cell Viability, Osteoblastic Differentiation, and Bone Fracture-Healing

BACKGROUND

The negative impact of cigarette smoking on bone union has been well documented. However, the impact of heated tobacco product (HTP) use on bone fracture-healing remains unclear. The present study investigated the effect of HTPs on preosteoblast viability, osteoblastic differentiation, and fracture-healing and compared the effects with those of conventional combustible cigarettes.

METHODS

Cigarette smoke extracts (CSEs) were generated from combustible cigarettes (cCSE) and HTPs (hCSE). CSE concentrations were standardized by assessing optical density. Preosteoblast (MC3T3-E1) cells were incubated with normal medium, cCSE, or hCSE. The cell viability was assessed via MTT assay. After osteoblastic differentiation of CSE-exposed cells, alkaline phosphatase (ALP) activity was assessed. To assess the in vivo effects of CSEs, a femoral midshaft osteotomy was performed in a rat model; thereafter, saline solution, cCSE, or hCSE was injected intraperitoneally, and bone union was assessed on the basis of micro-computed tomography (μCT) and biomechanical analysis 4 weeks later.

RESULTS

MC3T3-E1 cell viability was reduced in a time and concentration-dependent manner when treated with either cCSE or hCSE. ALP activity after osteoblastic differentiation of cCSE-treated cells was significantly lower than that of both untreated and hCSE-treated cells (mean and standard deviation, 452.4 ± 48.8 [untreated], 326.2 ± 26.2 [cCSE-treated], and 389.9 ± 26.6 [hCSE-treated] mol/L/min; p = 0.002). Moreover, the levels of osteoblastic differentiation in untreated and hCSE-treated cells differed significantly (p < 0.05). In vivo assessment of the femoral midshaft cortical region revealed that both cCSE and hCSE administration significantly decreased bone mineral content 4 weeks after surgery compared with levels observed in untreated animals (107.0 ± 11.9 [untreated], 94.5 ± 13.0 [cCSE-treated], and 89.0 ± 10.1 mg/cm3 [hCSE-treated]; p = 0.049). Additionally, cCSE and hCSE-exposed femora had significantly lower bone volumes than unexposed femora. Biomechanical analyses showed that both cCSE and hCSE administration significantly decreased femoral maximum load and elastic modulus (p = 0.015 and 0.019).

CONCLUSIONS

HTP use impairs cell viability, osteoblastic differentiation, and bone fracture-healing at levels comparable with those associated with combustible cigarette use.

CLINICAL RELEVANCE

HTP use negatively affects bone fracture-healing to a degree similar to that of combustible cigarettes. Orthopaedic surgeons should recommend HTP smoking cessation to improve bone union.

Assessment of IQOS Marketing Strategies at Points-of-Sale in Israel at a Time of Regulatory Transition

INTRODUCTION

IQOS, a tobacco heating system, and accompanying tobacco sticks (HEETS) entered the Israeli market in 2016, prior to rapid regulatory change. This study assessed IQOS marketing strategies and regulatory compliance at IQOS/HEETS point-of-sale (POS) in Israel in December 17, 2019-January 7, 2020, after the ban on advertisement went into effect in March 8, 2019.

METHODS

Research staff audited 80 randomly-selected IQOS/HEETS POS in 4 cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data was linked to neighbourhood characteristics, including socioeconomic status (SES), ethnicity, and proximity (under 300 meters) to schools.

RESULTS

Almost half of the stores (48.7%) were convenience stores. HEETS were visible to the customers in 46.1% of POS, 35% carried at least four HEETS colours, 20.0% had IQOS/HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was 8.7 USD (range: 7.5-11.3 USD), 27% more than the least expensive cigarette pack, and 39% less than the most expensive cigarette. HEETS promotions were uncommon. Compliance with the newly-introduced advertisement ban was fairly high for HEETS (94.8%). Only one POS was located in a low-SES area; 68.7% were in close proximity to a school.

CONCLUSION

The relatively limited IQOS/HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher SES populations, as indicated by pricing and POS neighbourhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research.

IMPLICATIONS

Globally, the point-of-sale is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the point-of-sale provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS/HEETS marketing at point-of-sale suggests that primary marketing strategies may shift to online or other forms/channels as regulatory contexts become more progressive/restrictive. Ongoing surveillance of IQOS via online marketing and point-of-sales, specifically with regard to product placement and proximity to schools, is needed.

Do Young Adults Attend to Health Warnings in the First IQOS Advertisement in the U.S.? An Eye-Tracking Approach

INTRODUCTION

In October 2019, a heated tobacco product (HTP) IQOS debuted in the United States. This study examined young adults' attention and cognitions in response to an IQOS ad that carried two mandated textual health warnings (Surgeon General's warning and nicotine warning), and how their vaping and smoking status may interact with attention patterns to affect attitude and intention to use IQOS.

METHODS

In November 2019, college students (N = 164) viewed IQOS' first U.S. magazine ad and two distractor ads. Viewing patterns were recorded with eye-tracking. Masked recall and aided recognition, attitude and intention towards IQOS use were later assessed with self-report. Ordinary Least Squares (OLS) regressions and moderated mediation analyses examined the associations between visual attention and viewers' cognitions about IQOS use.

RESULTS

Promotional content attracted significantly more attention compared to the warnings. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. For ever-vapers, greater attention allocation to the promotional content in the IQOS ad was associated with more favorable attitude toward IQOS use, which was in turn positively associated with intention to use IQOS. Attention allocation to the warnings did not affect attitude or intentions, regardless of tobacco use status.

CONCLUSIONS

The results revealed the effects of IQOS promotional content overshadowed the two health warnings in influencing young people's attitude and intention to use IQOS. Young adults who vaped were more vulnerable to HTP advertising with respect to future use and vaping may be a gateway to HTP use.

IMPLICATIONS

This is the first eye-tracking study examining attention and cognitions associated with the new IQOS ad exposure among young adults. Promotional content in the ad attracted significantly more attention than the two warnings combined. Attention to the Surgeon General's warning but not to the nicotine warning was associated with recall and recognition of the warning's content. Greater attention allocation to the promotional content led to a more favorable attitude toward IQOS use which was associated with increased intention to use IQOS for ever-vapers. However, greater attention allocation to the warnings did not affect attitude or intentions to use IQOS.

PMI's heated tobacco products marketing claims of reduced risk and reduced exposure may entice youth to try and continue using these products

IMPORTANCE

Philip Morris International (PMI) is seeking Food and Drug Administration's (FDA) authorisation to market IQOS as a modified risk tobacco product and to make marketing claims of reduced risk and reduced exposure. Such claims may be misunderstood by youth, thereby increasing their risk for tobacco initiation.

OBJECTIVE

To assess youth (mean age 19.3, SD=1.7) understanding and perceptions of PMI's proposed consumer marketing claims of reduced risk and reduced exposure, we embedded a randomised controlled experiment into a survey of 450 California youth (April to August 2018). Participants were randomised to see 'reduced exposure', 'reduced risk' or neither claim. Perceptions of IQOS-related health risks and general harm and understanding of the term 'switching completely' as used in PMI's proposed claims were compared.

RESULTS

Mean expectancies to experience specific health risks did not differ by claim exposure. The reduced exposure group's perceptions of general harm did not differ from those of controls nor from the reduced risk group. The reduced risk group had the largest proportion who perceived IQOS as moderately/less harmful (n=78, 52%); controls the largest proportion perceiving IQOS as quite/extremely harmful (n=91, 63%). While 71% of the sample understood the term 'switch completely' correctly as used in the reduced risk (n=194, 71%) and reduced exposure (n=206, 72%) claims, more than 1 in 4 did not.

CONCLUSIONS

FDA and other regulators must use caution when considering allowing claims of reduced risk or reduced exposure to appear on retail tobacco packaging. Youth misunderstand such claims, and misperceptions of harm are known to lead to tobacco-use initiation.

Are Heated Tobacco Product Users Less Likely to Quit than Cigarette Smokers? Findings from THINK (Tobacco and Health IN Korea) Study

Since the advent of heated tobacco products in June 2017 in South Korea, the sale of heated tobacco products accounted for 10.5% of total tobacco sales in 2019. However, the decreasing trend in total tobacco sales is gradually weakening and the number of visitors using stop smoking services has also dropped. This study examines the association between the use of new tobacco products and related products and cessation behaviors. A cross-sectional study using a self-administered questionnaire was conducted from March 2019 to July 2019 for 2831 adult tobacco users. The difference in rates of quit attempts using the type of tobacco products and related products in the past year were noted (55.6% (any cigarette smoker), 46.7% (any e-cigarette user), and 39.6% (any heated tobacco product user)). About a 30% increase in quit attempts was observed for the triple users of either conventional cigarette or heated tobacco product than exclusive users. Exclusive heated tobacco product and e-cigarette users were approximately 40% and 20% less likely to quit the product they used than exclusive cigarette smokers, respectively. These findings can explain recent occurrences in South Korea, such as the reduction of visitors at smoking cessation clinics and the attenuation of the decline in tobacco sales.

Association between Intention to Quit Cigarette Smoking and Use of Heated Tobacco Products: Application of Smoking Intensity Perspective on Heated Tobacco Product Users

Tobacco companies have designed sophisticated marketing strategies for heated tobacco products (HTPs), and many smokers are exposed to advertisements purporting that HTPs can replace combustible cigarettes. The present study evaluates the relationship between poly-use of tobacco products and intention to quit cigarette smoking in association with smoking intensity, a meaningful indication of one's interest in quitting cigarette smoking. A total of 36,397 current cigarette smokers who participated in the 2019 Korea Community Health Survey were evaluated. A multivariable logistic regression model was designed. Additionally, smoking-intensity-stratified analyses were conducted. A total of 4.7% of the participants reported planning to quit cigarette smoking within one month. Current dual users of combustible cigarettes and HTPs presented no significantly increased likelihood of intention to quit cigarette smoking regardless of cigarette-smoking intensity. By contrast, light and heavy daily smokers who accompanied e-cigarette use presented significant adjusted odds ratios (aORs) of 1.81 (95% confidence interval (CI): 1.04-3.14) and 1.97 (95% CI: 1.14-3.42), respectively. Occasional and daily smokers who reported using both HTPs and e-cigarettes presented no significance. The results of the present study suggested that a complete replacement of combustible cigarettes with HTPs was unlikely.

Cigarette or E-Cigarette Use as Strong Risk Factors for Heated Tobacco Product Use among Korean Adolescents

Heated tobacco products (HTPs) were first introduced in Korea in June 2017. This study examined the prevalence of current HTP use among Korean adolescents and its association with conventional cigarette (CC) or electronic cigarette (EC) use. The study analyzed nationally representative data (the 2019 Korea Youth Risk Behavior Web-based Survey) from a sample of 57,303 Korean students from grades 7–12. Multinomial logistic regression models were designed to evaluate the association between EC or CC use and HTP use. A total of 2.6% of respondents were current HTP users and 95.9% of them were dual or triple users of CC or EC. The likelihood of HTP use was higher among current CC or EC users and highest among dual users. When the association between each tobacco product and current HTP use was analyzed, the dual use tendency of HTPs and other products steadily increased with the increase of CC or EC smoking frequency. Adolescents who use ECs and/or CCs are likely to use HTPs. Thus, HTPs could be a new public health concern for adolescents in terms of dual or triple use patterns of CC or EC.

The Impact of Heated Tobacco Products on Smoking Cessation, Tobacco Use, and Tobacco Sales in South Korea

Heated tobacco products (HTPs), a hybrid between conventional and electronic cigarettes, were first launched in South Korea in June 2017. Owing to advertisements stating that HTPs are odorless, tar-free, and less harmful to health, the sales of HTPs have grown quickly enough to account for about 10% of the total tobacco market in a year. HTP use by young, highly educated, and high-income groups had a significant impact on both the overall tobacco market over the past 3 years and the smoking and quitting behaviors of smokers. Based on national smoking rate statistics, tobacco sales trends, and the number of visitors to smoking cessation clinics, the following changes have been identified: (1) The decline in current smoking rates has slowed or rose in some groups. (2) The decline in total cigarette sales has slowed but rose again in the first quarter of 2020. (3) The number of visitors to smoking cessation clinics decreased just after the advent of HTPs. These results may be due to the insufficient support of tobacco regulation policies but also coincide chronologically with the appearance of HTPs in South Korea. It is necessary to investigate the usage rate of various tobacco products, including HTPs and e-cigarettes, to examine the health risks of novel tobacco products and provide accurate information to users and policymakers. Finally, tobacco companies are continuously developing new product concepts to escape the regulation of existing cigarettes; thus, comprehensive management measures for all nicotine-containing products are needed.

Analysis of FDA's IQOS marketing authorisation and its policy impacts

BACKGROUND

Philip Morris Products SA (PMPSA) submitted a premarket tobacco application (PMTA) to US Food and Drug Administration (FDA) seeking an order permitting it to market IQOS in the USA. US law requires FDA to deny marketing authorisation if applicants fail to demonstrate that their product is 'appropriate for the protection of the public health'. FDA issued a marketing order for IQOS in April 2019, which Philip Morris is using to promote IQOS outside the USA.

METHODS

We analysed FDA's Technical Project Lead Review and marketing order for IQOS, relevant law and guidance on PMTAs and independent research on the health impacts of IQOS.

RESULTS

FDA found that the evidence PMPSA submitted did not demonstrate reduction in long-term disease risks and that IQOS aerosol emits toxins with carcinogenic and genotoxic potential, some at higher levels than conventional cigarettes. PMPSA did not appropriately consider the health impacts of dual use, the product's attractiveness to youth or data showing that consumers do not accurately perceive the addiction risks of IQOS. Despite FDA's own scientists' recommendations and independent research showing that IQOS presents serious risks to users including cytotoxic, genotoxic, hepatotoxic, cardiovascular and pulmonary risks, FDA concluded that IQOS is 'appropriate for the protection of the public health'.

CONCLUSION

FDA's decision allowing IQOS to be marketed in the USA disregarded valid scientific evidence and misapplied the public health standard mandated by law. This decision may have important health impacts, influence marketing IQOS outside the USA and erode public confidence in FDA's future PMTA decisions.

Heated Tobacco Products Have Reached Younger or More Affluent People in Japan

Background

The trend of the diffusion of heated tobacco products (HTPs) is a great concern because HTPs have become available worldwide. This study examined the sociodemographic characteristics of HTPs users in Japan, where HTPs were first launched.

Methods

This cross-sectional study used data from an online survey conducted in 2017. A total of 4,926 participants, aged 20–69 years, were included. The dependent variable was the type of tobacco products used. The independent variables were age and equivalent income. Two analyses estimated the odds ratios (ORs) for 1) being smokers compared to “non-smokers,” and 2) being “HTP smokers” compared to “only combustible cigarette smokers.” Analyses were stratified by sex. Educational attainment and occupation were also used in the sensitivity analyses.

Results

The percentages of “non-smokers,” “only combustible cigarette smokers,” and “HTP smokers” were 82.8%, 14.2%, and 3.0%, respectively. When compared to the oldest participants (aged 60–69), the youngest participants (aged 20–29) tended to be “HTP smokers” (OR 7.90; 95% confidence interval [CI], 3.09–20.22 for men and OR 9.28; 95% CI, 2.14–40.28 for women). Compared to participants with the lowest incomes (<2 million), those with the highest incomes (≥4 million) tended to use HTPs (OR 2.93; 95% CI, 1.56–5.49 in men and OR 1.82; 95% CI, 0.73–4.54 in women). These trends were consistent when analyses included only smokers. There were consistent results in other SES measurements, including educational attainment and occupation.

Conclusions

Younger or more affluent people tended to use HTPs, although smoking rates among these populations were generally lower. New tobacco control efforts are required.

Concurrent Daily and Non-Daily Use of Heated Tobacco Products with Combustible Cigarettes: Findings from the 2018 ITC Japan Survey

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Cigarette Smoking in Men and Women and Electronic Cigarette Smoking in Men are Associated with Higher Risk of Elevated Cadmium Level in the Blood

BACKGROUND

We investigated the association between blood concentration of cadmium and smoking status including use of electronic cigarettes (E-cigars).

METHODS

We used data from the Korea National Health and Nutritional Survey 2013 and 2016. A total of 4,744 participants (2,162 men and 2,582 women) were included and were categorized into five groups (Non-smokers, E-cigar non-users in past-smokers, E-cigar users in past-smokers, E-cigar non-users in cigarette-smokers and E-cigar users in cigarette-smokers). Cadmium blood concentration was categorized into tertiles. All sampling and weight variables were stratified, and analysis to account for the complex sampling design was conducted.

RESULTS

In both genders, the geometric cadmium concentration was significantly different according to smoking status (both genders, analysis of variance P value < 0.001). In men, E-cigar users were significantly higher than the non-smokers (P value = past-smokers, 0.017; cigarette-smokers, < 0.001) when fully adjusted. Compared with non-smokers, fully-adjusted odds ratios (95% confidence intervals) for the highest cadmium tertiles of E-cigar non-users in cigarette-smokers and E-cigar users in cigarette-smokers were 6.56 (3.55-12.11) and 5.68 (1.96-16.50) in men and 2.74 (1.42-5.29) and 1.29 (0.10-17.44) in women.

CONCLUSION

Conventional cigarette smoking in men and women and E-cigar use in men are associated with higher risk of elevated blood cadmium level. Preventive management of cadmium exposure monitoring in conventional cigarette-smokers and E-cigar users may be needed.

Heated tobacco products: Cigarette complements, not substitutes

BACKGROUND

In Korea, the sale of the first heated tobacco product (HTP), IQOS®, commenced in June 2017. This study evaluates the rates of HTP use and examines HTP users' smoking patterns of various tobacco products.

METHODS

The study analyzed the 2018 Korea Community Health Survey data of a Korean provincial division, which includes 11 cities and 14 counties. Of 21,100 participants, the proportion of current HTP users was calculated and their smoking patterns, in regard to cigarette use, were examined. A multinomial logistic regression model was used to evaluate the related factors of HTP use.

RESULTS

The proportion of current HTP users (HTP use within the past 30 days) was 2.13% of the study population. Of these current HTP users, 96.25% were dual users of cigarettes. The adjusted odds ratio (AOR) for current HTP use increased proportionately with frequency and amount of cigarette consumption with statistical significance. The AOR values showed a quadratic curve, descending after the peak value for moderate daily smokers (10-19 cigarettes/day) (P_trend<0.001, P_quadratic<0.001). Current cigarette smokers who also used HTPs were not associated with an intention to quit cigarette smoking within a month.

CONCLUSIONS

Given the smoking pattern of HTP users in terms of mutual use with cigarettes, HTPs might not be an alternative to cigarettes as tobacco companies claim.

Association of alcohol and drug use with use of electronic cigarettes and heat-not-burn tobacco products among Korean adolescents

Background

The tobacco industry has aggressively introduced new and diverse products in the market, including electronic cigarettes (e-cigarettes) and heat-not-burn (HNB) tobacco products, to which adolescents are readily susceptible. Conventional cigarettes have a well-established relationship with adolescent risky behaviors such as alcohol and drug use; however, no studies exist on the association between alcohol consumption and use of e-cigarettes or HNB tobacco products among Korean adolescents. This study evaluated alcohol-related behaviors and drug use in relation to whether a Korean nationally representative adolescent sample had ever used e-cigarettes and HNB tobacco products.

Methods

Data from the 2018 Korean Youth Risk Behavior Web-based Survey were analyzed. The final study sample comprised 60,040 adolescents. Chi-square and logistic regression were used to examine whether the ever having used e-cigarettes and HNB tobacco products was associated with alcohol-related behaviors and drug use. P-values for trends were calculated to examine the dose-response relationship for each variable.

Results

Respondents with higher drinking frequency, drinking quantity, alcohol intoxication, alcohol availability, and drug use were more likely to report having used e-cigarettes and HNB tobacco products, thus implying a significant relationship between substance use and novel tobacco product (P < .001).

Conclusions

Our findings suggest that at-risk adolescents who are engaged in other forms of risk-taking behaviors are prone to attract the experimentation with e-cigarettes or HNB tobacco products. Thus, smoking cessation programs related to substance use should be implemented, and there is an urgent need to monitor and regulate these products effectively.

Evolving IQOS packaging designs change perceptions of product appeal, uniqueness, quality and safety: a randomised experiment, 2018, USA

BACKGROUND

Globally, the tobacco industry is promoting heated tobacco products. These products may represent a strategy to promote dual use of tobacco products. One product, IQOS from Philip Morris International, is being proposed in the USA for marketing as a less harmful product. The visual design of tobacco products can influence consumers by implying product characteristics. Thus, we sought to test the impact of IQOS packaging designs on cognitive, affective and behavioural intention responses.

METHODS

From existing IQOS packages used globally, we developed three IQOS packages that decreasingly linked the product to the Marlboro brand. In September to October 2018, we assigned participants randomly to one package in an online experiment. All participants (n=954) were US adults reporting current smoking and no colour blindness. The experiment used quota sampling to ensure diversity by gender, sexual orientation, race, ethnicity and education. Measures were informed by the Context of Consumption Framework. To assess differences in ratings, we conducted non-parametric Kruskal-Wallis tests with post hoc comparisons using Dunn's test.

RESULTS

We found significant differences in cognitive indicators including appeal (H=6.87, p=0.03), uniqueness (H=15.68, p<0.01), brand equity-quality (H=122.35, p<0.01) and perceived safety compared with other tobacco products (H=14.27, p<0.01). Participants rated packages similarly on affective and behavioural intention measures. All were rated low for talking to others about the product and high for interest in trying with a coupon.

CONCLUSION

Linking or separating IQOS products with a well-established cigarette brand changes how adult smokers respond to the product. Regulators should consider the visual design of packaging.

Awareness and interest in IQOS heated tobacco products among youth in Canada, England and the USA

Introduction

Heated tobacco products (HTPs), such as IQOS, have been introduced in a growing number of international markets. However, little is known about perceptions of HTP products among youth.

Methods

Data are from Wave 1 of the International Tobacco Control Youth Tobacco and E-cigarette Survey (2017), a web-based cohort survey of 16- to 19-year-olds from Canada, England, and the United States (US). Respondents (n=12,064) were shown an image of IQOS and asked about their awareness, interest in trying, and susceptibility to trying the product. Youth awareness, interest in trying, and susceptibility to trying IQOS were analyzed using descriptive statistics, and logistic regression models were used to examine correlates of these outcomes.

Results

Overall, 7.0% of youth reported awareness of IQOS (England=5.6%, Canada=6.4%, and US=9.1%) and 38.6% expressed interest in trying the product (England=41.8%, Canada=33.0%, and US=40.9%). Within each country, all key outcomes varied by smoking status: greater proportions of youth who were currently smoking or had a history of smoking reported being aware of, interested in trying, and susceptible to trying IQOS. Interest and susceptibility to trying IQOS were associated with male sex, current tobacco use, and current e-cigarette use. Across all countries, susceptibility to trying IQOS (25.1%) was higher than for tobacco cigarettes (19.3%), but lower than for e-cigarettes (29.1%).

Conclusions

Awareness of heated tobacco products, such as IQOS, is emerging among youth in Canada, England, and the US. Interest in trying these products is very high among smokers, but also present among non-smokers.

[Systematic analysis of the scientific literature on heated tobacco]

INTRODUCTION

The tobacco industry (TI) reports that heated tobacco reduces risk of tobacco use and will replace cigarettes. An analysis of the scientific literature was conducted in order to enlighten professionals and decision-makers.

METHOD

After a Medline query in February 2018, a systematic analysis was conducted.

RESULTS

Of the 100 papers published in 2008-2018, 75 have authors affiliated or linked to TI. Emissions contain gases, droplets and solid particles, so are smokes. The main products are: THS2.2 (Iqos®) which heats mini-cigarettes at 340°C, the THP1.0 (Glo®) which heats at 240°C sticks delivering about half as much nicotine, Ploom® which uses reconstituted tobacco microcapsules heated at 180°C. Under the experimental conditions, there is a reduction of toxic emissions and biological effects, but the expected risk reduction is not demonstrated. Symptoms related to passive smoking are described. The 4 epidemiological articles report that heated tobacco is used in 10 to 45% of cases by non-smokers and demonstrate the effectiveness of TI promotion campaigns. Thus, the THS2.2 is more a gateway to smoking (20%) than an exit door (11%); moreover, it is not expected risk reduction among the 69% who are mixed users.

CONCLUSIONS

While reducing emissions is documented, reducing the risk to the smoker who switches to heated-tobacco remains to be demonstrated. On the other hand, the worsening of the global tobacco risk related to the promotion of the products by the TI is anticipated, justifying that the authorities take the appropriate measures to control the promotion of heated tobacco.

Heated tobacco products likely appeal to adolescents and young adults

BACKGROUND

Beginning in the 1960s in the USA and globally since 1998, tobacco companies have beenaggressively promoting heated tobacco products (HTP). In 2016, Philip Morris International (PMI) applied to the US Food and Drug Administration (FDA) seeking authorisation to market their IQOS HTP system and flavoured 'HeatSticks' in the USA as a modified-risk tobacco product (MRTP).

METHODS

We systematically evaluated the publicly available data PMI submitted to FDA in its MRTP application to determine whether PMI's IQOS product meets the US Tobacco Control Act's standard for MRTP claims. We examined whether PMI provided sufficient data showing tobacco users will not initiate with IQOS, that youth will not misperceive the MRTP-related claims being made concerning IQOS, and how youth perceive health risks associated with IQOS.

RESULTS

PMI's own studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS and will not perceive these products as risk-free. Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.

CONCLUSION

PMI's own data and available evidence from scientific studies conducted independent of the tobacco industry regarding how novel tobacco products are currently being marketed suggest that introduction of IQOS will result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.

Heated tobacco product regulation under US law and the FCTC

Tobacco companies are marketing new 'heated tobacco products' (HTPs) composed of battery-powered holders, chargers and tobacco plugs or sticks. The non-tobacco HTP components have escaped effective regulation under many countries' tobacco control laws because they are packaged and sold separately from the tobacco-containing components. In the USA, HTPs cannot be marketed unless the Food and Drug Administration determines that allowing their sale would be 'appropriate for the protection of the public health'. Philip Morris International (PMI) is seeking permission to market its IQOS HTP in the USA with 'modified risk tobacco product' (MRTP) claims that it reduces exposure to harmful substances and is less harmful than other tobacco products. However, PMI has not submitted adequate scientific evidence required by US law to demonstrate that the product is significantly less harmful to users than other tobacco products, that its labelling would not mislead consumers, or that its marketing-with or without MRTP claims-would benefit the health of the population as a whole. Parties to the WHO Framework Convention on Tobacco Control (FCTC) must take measures to reduce tobacco use and nicotine addiction, and prevent false or misleading tobacco product labelling, advertising and promotions; the introduction of new HTPs must be assessed according to these goals. All components of HTPs should be regulated at least as stringently as existing tobacco products, including restrictions on labelling, advertising, promotion and sponsorship, sales to minors, price and taxation policies and smokefree measures. There is nothing in US law or the FCTC that prevents authorities from prohibiting HTPs.

Heated tobacco products and combusted cigarettes: comparing global prices and taxes

BACKGROUND

Heated tobacco products (HTPs) have received excise tax rates that are lower than combusted cigarettes in most of the countries in which the products are sold as tobacco companies claimed their purported reduced risk products deserved such light touch treatment. This study sought to determine if HTPs are cheaper to use than combusted cigarettes when the cost of purchasing an expensive heating device upfront was considered.

METHODS AND DATA

Product price data for tobacco heating devices, as well as cobranded heated tobacco and combusted cigarettes for 2014-2017 for 34 countries was obtained from Euromonitor International.

RESULTS

Only in 17 of 46 country-year cases with adequate data were HTPs less expensive to use than combusted cigarettes over a year.

DISCUSSION

The tax advantages being given to HTPs may instead of providing a price signal to a consumer looking to switch, be providing a profit signal to tobacco companies to switch over to selling more HTPs and fewer combusted cigarettes. The implications of these dynamics for public health are unclear.

Revolution or redux? Assessing IQOS through a precursor product

Background

Philip Morris International (PMI) currently claims that its heated tobacco product, IQOS, reduces health risk by reducing users’ exposure to harmful and potentially harmful constituents present in tobacco smoke. Given the tobacco industry’s long history of misrepresenting and obfuscating research, independent assessment of PMI’s claims is important. Analysis of Accord, a failed but strikingly similar precursor to IQOS, may help contextualise PMI’s claims in its Modified Risk Tobacco Product (MRTP) application.

Methods

We analysed previously secret internal Philip Morris (PM) and PMI documents, public communications and MRTP application.

Results

PM marketed Accord as a ‘cleaner’ tobacco product in an attempt to address smokers’ growing health concerns without making explicit health claims. While PM communications asserted that Accord reduced users’ exposure to harmful constituents, company scientists and executives consistently stressed to both regulators and the public that such reductions did not render Accord safer. IQOS’s design and marketing are similar to Accord’s. On the basis of aerosol chemistry data, IQOS reduces user exposure to some compounds compared with Accord but raises them for others.

Discussion

IQOS appears to be a variant of Accord without consistent improvements in exposure to aerosol toxic compounds. In contrast to PM’s past claims for Accord, PMI now claims in its MRTP application that IQOS reduces health risk. This shift in stance is likely not the result of any toxicological difference between Accord and IQOS, but rather a change in the social and regulatory landscape permitting these claims.

Light and mild redux: heated tobacco products' reduced exposure claims are likely to be misunderstood as reduced risk claims

Introduction

Heated tobacco products (HTPs) are being marketed in several countries around the world with claims that they are less harmful than combusted cigarettes, based on assertions that they expose users to lower levels of toxicants. In the USA, Philip Morris International (PMI) has submitted an application to the Food and Drug Administration (FDA) in 2016 seeking authorisation to market its HTPs, IQOS, with reduced risk and reduced exposure claims.

Methods

We examined the PMI’s Perception and Behavior Assessment Studies evaluating perceptions of reduced risk claims that were submitted to the FDA and made publicly available.

Results

Qualitative and quantitative studies conducted by PMI demonstrate that adult consumers in the USA perceive reduced exposure claims as reduced risk claims.

Conclusion

The data in the PMI modified risk tobacco product IQOS application do not support reduced risk claims and the reduced exposure claims are perceived as reduced risk claims, which is explicitly prohibited by the FDA. Allowing PMI to promote IQOS as reduced exposure would amount to a legally sanctioned repeat of the ‘light’ and ‘mild’ fraud which, for conventional cigarettes, is prohibited by the US law and the WHO Framework Convention on Tobacco Control.

Awareness and use of heated tobacco products among US adults, 2016-2017

INTRODUCTION

Although heated tobacco products (HTP) have been on and off the commercial market for the past three decades (eg, Premier, Eclipse and Accord), they have not received widespread consumer acceptance as an alternative to combustible cigarettes. This may change with recent product innovations, shifts in consumer preferences and the tobacco market landscape and a US regulatory environment that may permit an internationally available HTP to be sold in the USA, possibly with a reduced exposure or risk statement. This study examined the extent of awareness and use of HTP in the USA and assessed the characteristics of those aware of and using these products.

METHODS

Data came from the 2016 and 2017 Tobacco Products and Risk Perceptions Surveys of national probability samples of US adults, conducted online during September-October 2016 (n=6014) and August-September 2017 (n=5992). Weighted χ² tests and regression analyses examined changes in awareness and use of HTP between 2016 and 2017 and characteristics associated with awareness and use.

RESULTS

From 2016 to 2017, awareness of HTP among US adults increased from 9.3% to 12.4% (p<0.001), ever use increased from 1.4% to 2.2% (p=0.005) and current use increased two fold, from 0.5% to 1.1% (p=0.004). Men and adults under age 45 years had higher rates of awareness than women and those 45 and older, respectively. Non-white adults, cigarette smokers and both current and former users of electronic nicotine delivery systems were more likely to be using HTP.

CONCLUSIONS

Awareness and use of HTP in the USA are increasing. These products are more familiar to men and younger adults and may be being used disproportionately by racial/ethnic minorities. With increases in HTP availability and the potential for reduced-risk claims ahead, surveillance of patterns and consequences of use by both smokers and non-smokers is needed.

Awareness, experience and prevalence of heated tobacco product, IQOS, among young Korean adults

Introduction

Philip Morris International introduced ‘IQOS’ to the Korean market in June 2017. To monitor the use of IQOS among young Korean adults, we identified their awareness, experience and current use of IQOS.

Methods

Three months after the introduction of IQOS in Korea, we conducted an online survey with 228 general young adults, aged 19–24 years.

Results

87 participants (38.1%) were aware of IQOS, 13 (5.7%) were IQOS ever users and 8 (3.5%) were current IQOS users. All the current IQOS users were triple users of conventional cigarettes and electronic cigarettes (e-cigarettes). There were no IQOS-only users and one IQOS ever user was a non-cigarette smoker. Among the eight current IQOS users who smoked 9.1 conventional cigarettes a day on average, four smoked 10–20 HEETS sticks a day. The current IQOS users decided to use IQOS because they believed it was less harmful or to stop smoking. The current conventional cigarette smokers were much more likely to be aware of IQOS (OR 4.496; 95% CI 2.185 to 9.250) and to be IQOS ever users (OR 11.649; 95% CI 1.024 to 132.564).

Conclusion

Awareness, experience and use of IQOS among young Korean adults were relatively higher than among their Japanese counterparts. Current IQOS users were more likely to smoke conventional cigarettes and/or e-cigarettes, which contradicts the tobacco industry’s claims that conventional cigarette smokers will switch to heated tobacco products. Until obtaining robust evidence concerning heated tobacco products, the government should regulate the tobacco industry’s marketing tactics and health claims.