Effect of IQOS introduction on cigarette sales: evidence of decline and replacement

Trends in Tobacco Use among 9th Graders in Sweden, 1991-2020

Tobacco use was measured with self-reports of lifetime use of cigarettes and snus to examine trends in tobacco use among Swedish 9th graders over the period 1991-2020. Annual school surveys with nationally representative samples of 9th-grade students in Sweden covering the period 1991-2020 with a total sample of 163,617 students. We distinguished between the use of cigarettes only, use of snus only, dual use (use of both cigarettes and snus), and total tobacco use (use of any of these tobacco products). In addition to a graphical description of trends in the various measures of tobacco use, the correlation between these trends was calculated with the Pearson correlation coefficient (Rxy). The prevalence of total tobacco use declined from 72% in 1991 to 36% in 2020. The declining trend in total tobacco use was positively correlated with the trend in dual use (Rxy = 0.98) and the trend in cigarette use only (Rxy = 0.87). The trend in total tobacco use was, on the other hand, negatively correlated with snus use only (Rxy = -0.41), and snus use only was negatively correlated with cigarette use only (Rxy = -0.71). The situation became different after 2017 when total tobacco use increased as a result of an increasing prevalence of snus use. The sharp decline in tobacco use among 9th graders in Sweden over the past three decades is driven by declining cigarette use. The correlations between the various forms of tobacco use suggest that snus use may have contributed to the decline in cigarette use and, by that, overall tobacco use. The situation changed after 2017 when a sharp rise in snus use seems to have increased total tobacco use among adolescents in Sweden. A possible explanation behind this development is the introduction of a new form of snus called "All white snus", which was introduced in Sweden in 2014.

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.

Comparing Effectiveness, tolerability, and Acceptability of Heated Tobacco ProductS vs. refillable Electronic cigarettes For cIgaREttes substitution: CEASEFIRE randomized controlled trial (Preprint)

BACKGROUND

People who smoke and who face challenges trying to quit or wish to continue to smoke may benefit by switching from traditional cigarettes to noncombustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and electronic cigarettes (ECs). HTPs and ECs are being increasingly used to quit smoking, but there are limited data about their effectiveness.

OBJECTIVE

We conducted the first randomized controlled trial comparing quit rates between HTPs and ECs among people who smoke and do not intend to quit.

METHODS

We conducted a 12-week randomized noninferiority switching trial to compare effectiveness, tolerability, and product satisfaction between HTPs (IQOS 2.4 Plus) and refillable ECs (JustFog Q16) among people who do not intend to quit. The cessation intervention included motivational counseling. The primary endpoint of the study was the carbon monoxide-confirmed continuous abstinence rate from week 4 to week 12 (CAR weeks 4-12). The secondary endpoints included the continuous self-reported ≥50% reduction in cigarette consumption rate (continuous reduction rate) from week 4 to week 12 (CRR weeks 4-12) and 7-day point prevalence of smoking abstinence.

RESULTS

A total of 211 participants completed the study. High quit rates (CAR weeks 4-12) of 39.1% (43/110) and 30.8% (33/107) were observed for IQOS-HTP and JustFog-EC, respectively. The between-group difference for the CAR weeks 4-12 was not significant (P=.20). The CRR weeks 4-12 values for IQOS-HTP and JustFog-EC were 46.4% (51/110) and 39.3% (42/107), respectively, and the between-group difference was not significant (P=.24). At week 12, the 7-day point prevalence of smoking abstinence values for IQOS-HTP and JustFog-EC were 54.5% (60/110) and 41.1% (44/107), respectively. The most frequent adverse events were cough and reduced physical fitness. Both study products elicited a moderately pleasant user experience, and the between-group difference was not significant. A clinically relevant improvement in exercise tolerance was observed after switching to the combustion-free products under investigation. Risk perception for conventional cigarettes was consistently higher than that for the combustion-free study products under investigation.

CONCLUSIONS

Switching to HTPs elicited a marked reduction in cigarette consumption among people who smoke and do not intend to quit, which was comparable to refillable ECs. User experience and risk perception were similar between the HTPs and ECs under investigation. HTPs may be a useful addition to the arsenal of reduced-risk alternatives for tobacco cigarettes and may contribute to smoking cessation. However, longer follow-up studies are required to confirm significant and prolonged abstinence from smoking and to determine whether our results can be generalized outside smoking cessation services offering high levels of support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03569748; https://clinicaltrials.gov/ct2/show/NCT03569748.

Nicotine dependence of cigarette and heated tobacco users in Japan, 2019: a cross-sectional analysis of the JASTIS Study

OBJECTIVES

Japan is currently the biggest market of heated tobacco products (HTPs) in the world. Little is known about nicotine dependence among HTP users. Thus, the objective was to assess the association of type of tobacco use and time-to-first-use, a marker of nicotine dependence.

METHODS

A cross-sectional analysis of the 2019 data from an internet cohort study was conducted. The analytical sample consisted of 2147 current (≥1 day use in the past 30 days) HTP and/or conventional cigarette users, aged 25+ years. Marginal structural binomial regression was used to estimate nicotine dependence prevalence ratios (PRs) for each category of tobacco use (exclusive daily cigarette, exclusive HTP (≥1 day), dual HTP+daily cigarette, dual HTP+non-daily cigarette), relative to exclusive, non-daily cigarette smoking.

RESULTS

Using a 5 min cut-off for time-to-first-use, the prevalence of nicotine dependence was higher among dual users of HTP and daily cigarettes (PR=1.38; 95% CI: 1.05 to 1.82) and exclusive, daily cigarette users (PR=1.48; 95% CI: 1.15 to 1.91), relative to exclusive, non-daily cigarette users. However, nicotine dependence among exclusive HTP users, and dual HTP+non-daily cigarette users, did not differ from that of exclusive, non-daily cigarette users. When using 15 and 30 min cut-offs, all types of users, including exclusive HTP, had higher levels of nicotine dependence relative to exclusive, non-daily cigarette users.

CONCLUSIONS

Regardless of HTP use, daily cigarette users had higher prevalence of nicotine dependence compared with non-daily cigarette users. Exclusive HTP users had similar (or potentially higher) dependence compared with exclusive, non-daily cigarette users. Longitudinal studies are needed to interrogate the public health implications of growing HTP use worldwide.

Ischemic Heart Disease and Chronic Obstructive Pulmonary Disease Hospitalizations in Japan Before and After the Introduction of a Heated Tobacco Product

To substantiate the beneficial effects of switching from cigarette smoking to heated tobacco products (HTP), this study conducted a time-trend analysis using data from the Japanese Medical Data Center (JMDC) database. Specifically, we assessed hospitalization numbers for chronic obstructive pulmonary disease (COPD) exacerbations and acute ischemic heart disease (IHD) before and after the introduction of HTPs in the Japanese market. This study replicated a previous study using a different Japanese real-world data source (Medical Data Vision). We retrieved the number of hospitalizations associated with the International Classification of Diseases-10 codes for COPD and IHD from 2010 to 2019−5 years before to 4 years after introducing HTPs in the Japanese market—from the JMDC database. Then, we used interrupted time-series analyses to test the hypothesis that the introduction of HTPs is associated with a reduction in hospitalizations for COPD (all codes), COPD exacerbation, COPD exacerbation plus lower respiratory tract infections (LRTI), and IHD, adjusting for age, sex, seasonality, and flu vaccination rates. Analysis of all available data from the JMDC database revealed a significant reduction in the number of hospitalizations for COPD (all codes; P = 0.0001) and IHD using Diagnosis Procedure Combination data on causative disease flags (P < 0.00001). We also observed a non-significant reduction in hospitalizations for COPD plus LRTI as well as IHD after HTP introduction in Japan. This study confirmed the findings of our previous study where a decrease in hospitalizations due to COPD exacerbation after the introduction of HTPs in Japan was also shown. Nevertheless, these findings warrant further research to evaluate the impact of HTPs on the health of populations in other countries where these products have been introduced.

Analysis of mainstream emissions, secondhand emissions and the environmental impact of IQOS waste: a systematic review on IQOS that accounts for data source

OBJECTIVE

To highlight the general features of IQOS literature focusing on the chemical analysis of IQOS emissions.

DATA SOURCES

PubMed, Web of Science and Scopus databases were searched on 8 November 2021 using the terms 'heated tobacco product', 'heat-not-burn', 'IQOS' and 'tobacco heating system' with time restriction (2010-2021). The search yielded 5480 records.

STUDY SELECTION

Relevant publications on topics related to IQOS assessment were retrieved (n=341). Two reviewers worked separately and reached agreement by consensus.

DATA EXTRACTION

Data on author affiliation and funding, article type and date of publication were extracted. Publications were categorised depending on their focus and outcomes. Data on IQOS emissions from the chemical analysis category were extracted.

DATA SYNTHESIS

Of the included publications, 25% were published by Philip Morris International (PMI) affiliates or PMI-funded studies. PMI-sponsored publications on emissions, toxicology assessments and health effects were comparable in number to those reported by independent research, in contrast to publications on IQOS use, market trends and regulation. Data on nicotine yield, carbonyl emissions, other mainstream emissions, secondhand emissions and IQOS waste were compared between data sources to highlight agreement or disagreement between PMI-sponsored and independent research.

CONCLUSIONS

Our analysis showed agreement between the data sources on nicotine yield from IQOS under the same puffing conditions. Also, both sources agreed that IQOS emits significantly reduced levels of some emissions compared with combustible cigarettes. However, independent studies and examination of PMI's data showed significant increases in other emissions from and beyond the Food and Drug Administration's harmful and potentially harmful constituents list.

Tobacco 21 adoption decreased sales of cigarette brands purchased by young people: a translation of population health survey data to gain insight into market data for policy analysis

INTRODUCTION

Policies raising the minimum age of sale of tobacco products to 21 (T21) proliferated at state and local levels across the USA before a federal policy was adopted. Evidence of the effectiveness of these policies is building and lags implementation. This study exploits demographic patterns of cigarette brand purchasing to evaluate the effectiveness of T21.

METHODS

To capture the effect of T21 implementation on cigarette sales, we used universal product code-level data from Nielsen Scantrack data covering January 2015 to October 2019. We used the 2015 to 2018 National Survey on Drug Use and Health to identify cigarette brands where smokers under 21 comprised a disproportionately high (young) and low (old) share of consumption. We fit fixed-effects linear regressions in Nielsen designated market areas to test if sales of young or old cigarette brands were changed by T21. Unadjusted models controlled for time and T21 implementation date. Adjusted models controlled for price, seasonality and unemployment. A permutation test of 5000 randomised placebo T21 policies were fit to determine how well the true date of implementation fit sales data stratified by brand group.

RESULTS

Sales of disproportionately young brands declined after T21 implementation. T21 policy implementation dates fit disproportionately young brand sales trends better than 99% of adjusted randomised placebo models. T21 implementation fit disproportionately old brand sales trends better than just 1% of adjusted randomised placebo models.

CONCLUSION

This study adds compelling empirical evidence that T21 decreased purchases of the cigarette brands consumed disproportionately by young people, the policy's target demographic.

Multiple Tobacco Product Use Conceptual Framework: A 2021 Update on Evidence

INTRODUCTION

One-third of adults in the United States who use tobacco regularly use two or more types of tobacco products. As the use of e-cigarettes and other noncombusted tobacco products increases-making multiple tobacco product (MTP) use increasingly common-it is essential to evaluate the complex factors that affect product use.

AIMS AND METHODS

In this update to our 2019 conceptual framework, we review and evaluate recent literature and expand the model to include ways in which MTP use may be affected by market factors such as the introduction of new products and socioenvironmental factors like marketing and advertising.

RESULTS AND CONCLUSIONS

MTP use patterns are complex, dynamic, and multiply determined by factors at the level of individuals, products, situations or contexts, and marketplace. Substitution, or using one product with the intent of decreasing use of another, and complementarity, or using multiple products for different reasons or purposes, explain patterns in MTP use. Moreover, substitution and complementarity may inform our understanding of how market changes targeted at one product, for instance, new product standards, bans, product pricing, and taxation, affect consumption of other tobacco products. New data from natural experiments and novel laboratory-based techniques add additional data and expand the framework.

IMPLICATIONS

A substantial proportion of people who use tobacco use more than one product. This review synthesizes and evaluates recent evidence on the diverse factors that affect MTP use in addition to expanding our framework. Our review is accompanied by suggested research questions that can guide future study.

Heated tobacco products for smoking cessation and reducing smoking prevalence

BACKGROUND

Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence.

OBJECTIVES

To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence.  SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers.  RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible.

MAIN RESULTS

We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes.  There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence.

AUTHORS' CONCLUSIONS

No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from  all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed.  The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.

Effects of IQOS health warnings and modified risk claims among young adult cigarette smokers and non-smokers

INTRODUCTION

Heated tobacco products, including Marlboro IQOS, are available globally. In the USA, IQOS was authorised to be advertised with claims about reduced toxicant exposure relative to cigarettes. The effects of such modified risk claims and health warnings have not been studied among young adult cigarette smokers and non-smokers.

METHODS

In 2020, US young adult (18-30 years, n=1328) cigarette smokers and non-smokers viewed an IQOS ad in a 4 (modified risk claim variations or none) by 3 (warning variations or none) between-subjects experiment. Outcome measures assessed perceived credibility and effectiveness of the health or risk message for discouraging IQOS use, perceived harms, efficacy beliefs, and IQOS use intentions.

RESULTS

Smokers reported significantly higher (p<0.05) perceived credibility, lower perceived effectiveness, higher efficacy beliefs about switching to IQOS and higher intentions to use IQOS than non-smokers. Among smokers, health warnings increased perceived credibility (p<0.001) and effectiveness (p<0.05), but claims did not affect outcomes examined. Among non-smokers, warnings and claims increased perceived credibility, and warnings increased perceived effectiveness (p<0.003). The reduced exposure claim increased non-smokers' intentions to use IQOS (b=0.40, 95% CI 0.07 to 0.73).

CONCLUSIONS

Among young adult smokers, health warnings increased perceived effectiveness at discouraging IQOS use and perceived credibility. Among non-smokers, warnings and claims increased perceived credibility and warnings increased perceived effectiveness, but the Food and Drug Administration-authorised reduced exposure claim increased intentions to use IQOS. Research is warranted to understand how the content of modified risk claims and health warnings for IQOS affects IQOS use in this population.

New tobacco products, old advertising strategies: point-of-sale advertising in Guatemala

OBJECTIVE

Capsule cigarettes, electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are now readily available in Guatemala. As in most countries, the point-of-sale (POS) remains an important marketing channel for the tobacco industry. Therefore, we sought to characterise the POS marketing of these products in the two largest cities in Guatemala.

METHODS

Convenience stores were randomly surveyed in mid and high socioeconomic status (SES) neighbourhoods in Guatemala City (n=60) and Quetzaltenango (n=15) in 2019. We adapted a previously implemented checklist to assess the availability of interior advertising of capsule cigarettes, e-cigarettes and HTP. Data entry was done in Kobo toolbox and analysis in STATA.

RESULTS

All stores sold conventional and flavoured capsule cigarettes, 78% e-cigarettes and 68% HTP. Most cigarette advertising was for capsule cigarettes. E-cigarettes were more likely to be sold in Guatemala City (96%) than in Quetzaltenango (13%). HTPs were only found in Guatemala City (85%), with no difference between high and medium SES neighbourhoods. Median number of ads for cigarettes and capsule cigarettes was higher in the high SES neighbourhood. Most e-cigarettes (83%) and HTP (74%) were found <50 cm from candy. E-cigarettes and HTP were available in a wide range of flavours. All stores that sold HTP had flavoured HEETS (amber, bronze, turquoise, yellow, blue and purple).

CONCLUSION

We found a high prevalence of advertising for capsule cigarettes, e-cigarettes and HTP at the POS. The POS, a crucial advertising channel for the tobacco industry, is now being used for new products and therefore needs to be urgently regulated.

Heated Tobacco Products and Nicotine Pouches: A Survey of People with Experience of Smoking and/or Vaping in the UK

Background: To gauge the public health impact of new nicotine products, information is needed on use among different populations. Aims were to assess in adults who smoked, vaped, did both or had recently stopped: (1) awareness, ever and current use of heated tobacco products (HTPs) and nicotine pouches (NP), (2) characteristics associated with ever use, (3) reasons for use of and satisfaction with HTPs, (4) characteristics associated with interest in use of HTPs. Methods: Online survey in the UK in 2019, n = 3883. (1) Proportion aware, ever and current (≥monthly) use; (2) ever use regressed onto socio-demographics and smoking/vaping; (3) frequency of reasons for HTP use and satisfaction; (4) interest in trying HTPs regressed onto socio-demographics and smoking/vaping status. Results: Awareness was 34.8% for HTP and 15.9% for NP; current use was 3.2% and 2.7%. Being <45 years, higher education, living in London and currently both smoking and vaping were associated with ever having used the products. Curiosity was the most common reason for HTP use (79.8%) and 72.0% of ever HTP users found them at least as satisfying as smoking. Among those not currently using HTPs, 48.5% expressed any interest-lower among those aged over 65 and higher among those smoking and vaping. Conclusions: In this sample of adults with a history of nicotine use, very few currently used heated tobacco products or nicotine pouches. Satisfaction with and interest in HTPs were substantial. The low level of use is unlikely to substantially reduce the public health impact of smoking.

Identification of biomarkers specific to five different nicotine product user groups: Study protocol of a controlled clinical trial

Background

Assessing biomarker profiles in various body fluids is of large value to discern between the sole use of nicotine products. In particular, the assessment of the product compliance is required for long-term clinical studies. The objective of this study was the identification of biomarkers and biomarker patterns in body fluids, to distinguish between combustibles, heated tobacco products, electronic cigarettes, oral tobacco and oral/dermal nicotine products used for nicotine replacement therapy (NRT), as well as a control group of non-users.

Methods

A controlled, single-center study was conducted with 60 healthy subjects, divided into 6 groups (5 nicotine product user groups and one non-user group) based on their sole use of the products of choice. The subjects were confined for 76 h, during which, free and uncontrolled use of the products was provided. Sample collections were performed according to the study time schedule provided in Table 2. The primary outcome will be validated through analysis of the collected biospecimens (urine, blood, saliva, exhaled breath and exhaled breath condensate) by means of untargeted omics approaches (i.e. exposomics, breathomics and adductomics). Secondary outcome will include established biomarker quantification methods to allow for the identification of typical biomarker patterns. Statistical analysis tools will be used to specifically discriminate different product use categories.

Results/Conclusions

The clinical trial was successfully completed in May 2020, resulting in sample management and preparations for the quantitative and qualitative analyses. This work will serve as a solid basis to discern between biomarker profiles of different nicotine product user groups. The knowledge collected during this research will be required to develop prototype diagnostic tools that can reliably assess the differences and evaluate possible health risks of various nicotine products.

The Role of Novel (Tobacco) Products on Tobacco Control in Italy

In Italy, electronic cigarettes have spread since 2010 and heated tobacco products (HTP) since 2016. We investigated their public health consequences on conventional cigarette smoking, taking advantage of a series of cross-sectional studies annually conducted between 2001 and 2019 in Italy. Every year, the sample, including around 3000 individuals, was representative of the general Italian population aged ≥15 years. In Italy, smoking prevalence steadily declined from 29.1% in 2001 to 20.6% in 2013, then increased to 22.0% in 2019. In 2017-2019, current electronic cigarette users were 2.1% and in 2019 current HTP users were 1.1%. Among 498 ever electronic cigarette users, 23.2% started or re-started smoking and 15.7% quit smoking after electronic cigarette use; of 49 ever HTP users, 19.1% started or re-started smoking combusted cigarettes and 14.6% quit smoking after HTP use. The availability of novel products in Italy resulted in a halt of the decreasing trend in smoking prevalence. For the first time, we observed an increase of Italians inhaling nicotine, concurrently with the spread of novel (tobacco) products. More importantly, the use of novel products appears to increase-rather than decrease-the likelihood of smoking conventional cigarettes. Considering this evidence, we see no argument to justify the huge fiscal and regulatory benefits these products continue to have, at least in Italy.

Correlates of Awareness and Use of Heated Tobacco Products in a Sample of US Young Adults in 2018-2019

INTRODUCTION

Tobacco companies have devoted increased resources in recent years to developing and marketing heated tobacco products (HTPs) as alternatives to combustible products like cigarettes. However, little is known about correlates of awareness and use of these products in American young adults.

METHODS

Two thousand four hundred ninety-seven young adults (mean age = 21.6) completed survey items on HTP awareness and lifetime use in 2018-2019. Logistic regression models compared young adults who were (1) unaware of HTPs (reference group) with those who were, (2) aware of HTPs, and (3) had ever used HTPs on demographic, tobacco, and other substance use characteristics. Among current smokers, these groups were compared on cigarette use, dependence, and readiness to quit.

RESULTS

Approximately 12% of respondents (n = 293) were aware of HTPs, and 5% (n = 134) reported lifetime HTP use. Controlling for demographics, HTP awareness and use were both associated with greater use of all types of tobacco products, number of different tobacco products, and use of marijuana and other drugs. Among current smokers, HTP awareness and use correlated with heavier cigarette consumption, greater dependence, and past-month marijuana use, but not with recent quit attempts or thinking about quitting cigarettes.

CONCLUSIONS

Awareness and use of HTPs among young adults were associated with greater use of tobacco products and other substances and, among current smokers, with greater cigarette dependence (but not cessation-related factors). As these products become increasingly available in the United States, additional surveillance and monitoring activities are needed to better understand use patterns, consequences, and reasons for using HTPs.

IMPLICATIONS

Few studies have examined factors associated with awareness and use of heated tobacco products (HTPs) among US young adults. HTP awareness and lifetime use correlated with a range of factors, including male gender, white race/ethnicity, and tobacco and other substance use. Lifetime use of HTPs was low (5%); most lifetime HTP users reported history of other tobacco use, but a sizeable minority (14%) reported no other tobacco product use history. Among current cigarette smokers, cigarette dependence, poly-tobacco use, and marijuana use-but not cigarette cessation attempts or contemplation-were associated with greater likelihood of awareness and use of HTPs.

Factors that influence smokers' and ex-smokers' use of IQOS: a qualitative study of IQOS users and ex-users in the UK

BACKGROUND

One of the most widely available heated tobacco products is IQOS by Philip Morris International. However, there is a lack of independent research exploring IQOS initiation and subsequent use among smokers and ex-smokers.

AIMS

To (1) explore the reasons why smokers and ex-smokers use and continue/discontinue IQOS and (2) consider implications for future research and policy.

PARTICIPANTS

Adult (18+) current (n=22) and ex-users (n=8) of IQOS who either currently smoked or quit smoking in the last 2 years.

METHODS

Qualitative interview study in London, UK.

RESULTS

Six main factors influenced initiation and use of IQOS: (1) Health-wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm. (2) Financial-including high start-up costs, but cheaper ongoing costs than smoking. (3) Physical-mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes. (4) Practical-issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use. (5) Psychological-similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology. (6) Social-improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some.

CONCLUSION

For some, IQOS facilitated smoking substitution. Factors such as packaging, labelling, risk communication, price and smoke-free policies appear to influence initiation and use.

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.

Cancer potencies and margin of exposure used for comparative risk assessment of heated tobacco products and electronic cigarettes aerosols with cigarette smoke

Health risk associated with the use of combustible cigarettes is well characterized and numerous epidemiological studies have been published for many years. Since more than a decade, innovative non-combusted tobacco products have emerged like heated tobacco products (HTP) or electronic cigarettes (EC). Long-term effects of these new products on health remain, however, unknown and there is a need to characterize associated potential health risks. The time dedicated to epidemiological data generation (at least 20 to 40 years for cancer endpoint), though, is not compatible with innovative development. Surrogates need, therefore, to be developed. In this work, non-cancer and cancer risks were estimated in a range of HTP and commercial combustible cigarettes based upon their harmful and potentially harmful constituent yields in aerosols and smoke, respectively. It appears that mean lifetime cancer risk values were decreased by more than one order of magnitude when comparing HTPs and commercial cigarettes, and significantly higher margin of exposure for non-cancer risk was observed for HTPs when compared to commercial cigarettes. The same approach was applied to two commercial ECs. Similar results were also found for this category of products. Despite uncertainties related to the factors used for the calculations and methodological limitations, this approach is valuable to estimate health risks associated to the use of innovative products. Moreover, it acts as predictive tool in absence of long-term epidemiological data. Furthermore, both cancer and non-cancer risks estimated for HTPs and ECs highlight the potential of reduced risk for non-combusted products when compared to cigarette smoking.

Heat-not-burn tobacco products: an emerging threat to cardiovascular health

Cigarette smoking is at all-time lows globally, but the use of electronic cigarettes has increased profoundly. Recent reports of electronic cigarette or vaping use-associated lung injury may lead individuals to explore novel methods of nicotine consumption, such as heat-not-burn devices. IQOS from Philip Morris, a heat-not-burn device, became available for purchase in the United States in October 2019. Philip Morris claims that 8.8 million people have abandoned traditional cigarettes in favor of IQOS; however, evidence suggests that it may act as a gateway or complement to cigarette smoking, rather than a replacement. Surveys indicate that 96% of Korean IQOS users also smoke cigarettes, and 45% of Italian users of IQOS had never smoked cigarettes. In the United States, Canada, and England, susceptibility of youth to trying IQOS was slightly lower than electronic cigarettes, but higher than cigarette smoking. Heat-not-burn products produce mainstream and second-hand emissions of harmful chemicals, including nicotine, particulate matter, benzene, acrolein, and tobacco-specific nitrosamines. The levels of these emissions, despite being less than those of traditional cigarettes, are potentially harmful to cardiovascular health. A study of current smokers showed similar acute effects of heat-not-burn tobacco products and traditional cigarettes on heart rate, blood pressure, and arterial stiffness. Rats exposed to IQOS had similar vascular endothelial function impairment to those exposed to cigarettes. Heat-not-burn aerosol exposure of cultured macrophages elicited increased oxidative stress, although less than that induced by cigarette smoke. Further studies are needed to better understand the cardiovascular effects of heat-not-burn tobacco products.

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.

Results from a 2018 cross-sectional survey in Tokyo, Osaka and Sendai to assess tobacco and nicotine product usage after the introduction of heated tobacco products (HTPs) in Japan

BACKGROUND

For novel tobacco products that potentially reduce the risk of tobacco harm, post-market surveillance is important to observe population usage and behaviours associated with everyday use. This pilot study was performed to examine the use of tobacco products in three Japanese urban regions.

METHODS

This study was a cross-sectional epidemiological survey administered in Sendai, Tokyo and Osaka, Japan, from May 19th to June 25th, 2018. Participants were selected with a three-stage probability random sampling process that first identified primary sampling units, then households and finally individuals. Eligible participants were aged at least 20 years who were willing to participate after information about the study was provided. People younger than 20 years and those living in institutions were excluded. Questionnaires were paper based and administered door to door.

RESULTS

Responses were obtained from 4154 participants. Sixty-five percent self-reported being never, 19% current and 16% former users of any tobacco product at the time of the survey. Combustible tobacco products (almost all being cigarette) were used most (16%) followed by HTPs (5%). In the categories of combustible tobacco users and HTP users, 70% and 16%, respectively, used these products exclusively. Dual use was reported by 11% of respondents. Compared with 12 months before the survey, 12% of sole combustible tobacco products users were using HTPs exclusively or as dual users and 6% had quit tobacco products completely; 94% of sole HTP users remained sole users and 4% had quit tobacco products completely; and amongst dual users 12% had reverted to exclusive use of combustible tobacco products, 14% had switched to sole use of HTPs and 4% had quit tobacco products completely.

CONCLUSION

HTPs seem to be accepted as an alternative tobacco product amongst combustible tobacco users. Given complex findings for dual use, improved understanding of the motivations underlying this behaviour would be of interest.

What Is Accounting for the Rapid Decline in Cigarette Sales in Japan?

This study describes how trends in the sale of cigarettes in Japan between 2011 and 2019 correspond to the sales of heated tobacco products (HTPs) that were introduced into the Japanese market in late 2015. Data used for this study come from the Tobacco Institute of Japan and Philip Morris International. The findings show that the accelerated decline in cigarette only sales in Japan since 2016 corresponds to the introduction and growth in the sales of HTPs.

Use of Multiple Tobacco and Tobacco-Like Products Including Heated Tobacco and E-Cigarettes in Japan: A Cross-Sectional Assessment of the 2017 JASTIS Study

Information on the use of multiple tobacco and tobacco-like products (hereafter multiple tobacco products use, i.e., use of more than one product) is important for tobacco control. Use of heated tobacco products (HTPs), which first became popular in Japan, has been spreading over the world, while information about use of multiple tobacco products, including HTPs, is insufficient. We analyzed data of 10,114 responders from the 2017 Japan "Society and New Tobacco" Internet Survey (JASTIS) study. The prevalence and adjusted odds ratio (aOR) of multiple tobacco products use were estimated with inverse probability weighting using multivariable logistic regression models to approximate the results to whole Japanese estimates. Tobacco and tobacco-like products included cigarettes, cigars, e-cigarettes, HTPs, pipes/water pipes, and smokeless tobacco products. Among Japanese adults, 18.4% were single tobacco product users and 3.2% were multiple tobacco product users in 2017. Among current product users (100%), cigarettes were the most popular product in single (78.8%) and multiple (14.2%) tobacco products use, while HTPs were the second most popular product in single (5.2%) and multiple (10.6%) tobacco products use. People with no perception of risk regarding e-cigarettes/HTPs were more likely to use multiple tobacco products (aOR = 1.47, 95% CI = 1.12-1.92) than those who perceived a risk. Prevalence rates and predictors of multiple tobacco products use, including HTPs, were studied first. In multiple tobacco products use, high popularity of HTPs among current product users was revealed. Risk perception of e-cigarettes/HTPs was associated with multiple tobacco products use. This study provides baseline information on multiple tobacco products use in Japan, which will enable the examination of trends in the future.

Exhaled Carbon Monoxide Levels in Forty Resistant to Cessation Male Smokers after Six Months of Full Switch to Electronic Cigarettes (e-Cigs) or to A Tobacco Heating Systems (THS)

Cigarette smoke releases several toxic chemicals and carcinogens including carbon monoxide (CO). This study examined the levels of exhaled CO in smokers switching to electronic cigarettes (e-Cigs) or a tobacco heating system (THS) and their level of compliance six months after switching. On the basis of their own preferences, 40 male smokers unwilling or unable to stop smoking were switched to e-Cigs or THSs for six months (20 subjects in each group). Nicotine addiction and levels of carbon monoxide in the exhaled breath (eCO) were measured at baseline (the latter also at six months). The Shapiro Wilk test, graphical methods, Student T test or Mann-Whitney test were used to assess the normal distribution of variables and differences between the two groups after six months. The two groups showed no difference at baseline, but a significant higher addiction score in smokers choosing THS. E-Cig and THS showed significant reduced levels of eCO (both %COHb and COppm) after six months, which were within the range of non-smoker status. Reduced levels of %COHb did not significantly differ between the two groups, whilst the THS group had a significantly lower reduction in levels of COppm vs the e-Cig group (p < 0.05). Both e-Cigs and THSs are capable of significantly reducing eCO at least in the medium term, hence constituting a viable tobacco harm reduction approach in smokers who are unwilling or unable to stop smoking.