Perceptions of Heated Tobacco Products (HTPs) Versus Cigarettes and e-Cigarettes in Relation to Likelihood of Trying HTPs or Suggesting HTPs to Those who Smoke Cigarettes.

INTRODUCTION: Heated tobacco products (HTPs), like IQOS, are marketed as innovative, stylish, harm-reduction products distinct from cigarettes and e-cigarettes. Research is needed to better understand how adults who are newly introduced to HTPs perceive them relative to cigarettes and e-cigarettes, and the impact of these perceptions on use outcomes. AIMS AND METHODS: We analyzed 2021 cross-sectional survey data from 1914 adults who never used HTPs from the United States and Israel, two countries where IQOS has unique histories and markets. Exploratory factor analysis examined perceptions of HTPs (vs. cigarettes and e-cigarettes) across 12 perception measures (eg, innovative, trendy, harmful, addictive). Multivariable linear regression examined these factors in relation to self-reported likelihood to: (1) "try HTPs in the next year" (1 = not-7 = extremely) and (2) "suggest IQOS to a friend who smokes cigarettes" (1 = not-5 = very), controlling for demographics and past-month cigarette and e-cigarette use (10.1% dual use, 15.4% cigarette-only, 5.7% e-cigarette-only, 68.8% neither). RESULTS: Four factors were identified: HTPs' health and utility ("health-utility") and design and appeal ("design-appeal") versus cigarettes and versus e-cigarettes, separately. More favorable perceptions of HTP versus e-cigarette design-appeal (B = 0.30, 95% CI = 0.18, 0.41) were associated with greater likelihood to try HTPs. More favorable perceptions of HTP versus cigarette design-appeal (B = 0.38, 95% CI = 0.26, 0.51) and health-utility (B = 0.25, 95% CI = 0.13, 0.36), and HTP versus e-cigarette design-appeal (B = 0.32, 95% CI = 0.20, 0.45) were associated with greater likelihood to suggest HTPs to smokers. CONCLUSIONS: Monitoring perceptions of HTPs versus cigarettes and e-cigarettes is critical given the role of such perceptions in HTP use and their population-level impact. IMPLICATIONS: This study examined the relationship of perceptions of HTPs relative to cigarettes and e-cigarettes, with regard to adults' self-reported likelihood to use HTP or to suggest HTPs to those who smoke cigarettes. Favorable perceptions of HTPs' design and appeal versus e-cigarettes correlated with greater likelihood to try HTPs. Favorable perceptions of HTPs' design and appeal, as well as health and utility, versus cigarettes and e-cigarettes correlated with greater likelihood to suggest HTPs to those who smoke. Findings underscore the need for ongoing surveillance of HTP marketing and consumer perceptions to inform regulatory efforts and estimate the population-level impact of HTPs and other tobacco products.

IQOS news media coverage in Israel: a comparison across three subpopulations.

BACKGROUND: Philip Morris International's (PMI) IQOS, a leading heated tobacco product globally, entered the Israeli market in 2016. IQOS and/or electronic cigarette use is higher in Israel's Arab population (2.8% vs 1.2% of Jews). However, previous research indicated possible targeting of the Ultra-orthodox Jewish population with more IQOS paid ads. This paper examined how IQOS is framed in news media articles directed at three subpopulations in Israel: Arab, Ultra-orthodox Jews and general public. METHODS: Media articles (January-October 2020) were obtained from Ifat media and were coded using abductive coding. Characteristics of articles (photo and article content) targeting each subpopulation were compared using χ2, Fisher's exact test, one-way analysis of variance and median test, as appropriate. RESULTS: Of the 63 unique articles identified, 16 targeted Arab, 24 Ultra-orthodox Jews and 23 general public. Arab and Ultra-orthodox Jewish media significantly differed from the general public's media in their positive framing of PMI (100% Arab and 75% Ultra-orthodox Jews vs 52% general public, p=0.004), and IQOS (100% Arab and 88% Ultra-orthodox Jews vs 61% general public, p=0.006). Arab media differed from others by highlighting IQOS' retail locations (81% vs 17% Ultra-orthodox Jews and 13% general public), social benefits (88% vs 8% Ultra-orthodox Jews and 17% general public) and reflecting content from PMI's press release (100% vs 46% Ultra-orthodox Jews and 35% general public; ps <0.001). CONCLUSIONS: IQOS was framed more positively in media targeting minority populations (Arab and Ultra-orthodox Jews), compared with general public. Arabic media in particular emphasised IQOS' retail accessibility and social benefits. These findings highlight the need for media surveillance and regulation, especially of minority-oriented media.

Low compliance and proliferation of IQOS purchase cues at points-of-sale: a comparative study before and after Israel's display ban.

INTRODUCTION: It is unclear how tobacco companies respond to increasing restrictions on points-of-sale (POS) (eg, advertisement ban, display ban), especially regarding newer products, such as IQOS, a heated tobacco product. This study compared POS marketing strategies for IQOS (and HEETS tobacco sticks) before and after Israel implemented a display ban and plain packaging. METHODS: Audits of stores selling IQOS (n=87) in four Israeli cities were conducted, 16-20 months post display ban and plain packaging introduction, including previously audited stores (n=60) (prior to the implementation of these measures). Descriptive analyses and matched pre-post comparisons were conducted to assess regulatory compliance and marketing strategies over time. RESULTS: Almost all stores (90.8%) were non-compliant with the display ban; but most were compliant with plain packaging (81.6%) and advertisement ban (83.5%) regulations. Following the display ban, there was a significant increase in the number of IQOS/HEETS internal advertisements (21.7% vs 41.7%, p=0.023). These were mostly compliant with the advertisement ban (ie, did not mention the brand name explicitly), and appeared in the form of generic signs or flags and/or special displays. The percentage of stores featuring the IQOS device increased (1.7% to 20.0%, p=0.003), as did the percentage carrying at least four HEETS flavours (36.7% to 63.3%, p=0.006). CONCLUSION: This sample of Israeli stores selling IQOS showed low compliance with the display ban. The increase in signs/special displays, mostly compliant with the advertisement ban, could serve as purchase cues circumventing the intent of the legislation. Regulatory efforts should consider more specific legislative language and comprehensive enforcement plans.

Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults.

The marketing of heated tobacco products (HTPs), like IQOS, influences consumers' perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. 'Go smoke-free…') across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.

Evaluating the Impact of a Game (Inner Dragon) on User Engagement Within a Leading Smartphone App for Smoking Cessation: Randomized Controlled Trial.

BACKGROUND: Smartphone apps are a convenient, low-cost approach to delivering smoking cessation support to large numbers of individuals. Yet, the apps are susceptible to low rates of user engagement and retention. OBJECTIVE: This study aims to test the effects of a new game module (called Inner Dragon) integrated into Smoke Free (23 Limited), a leading smoking cessation app with established efficacy. The primary outcomes measured user engagement with the app. METHODS: A 2-arm, parallel-group, randomized controlled trial was conducted in the United States with an 8-week follow-up. Adult individuals who smoked ≥1 cigarettes daily and planned to quit smoking within 7 days were recruited and randomized (N=500), with equal allocation. Both groups received free access to the original Smoke Free app with "core" features of its smoking cessation program (eg, a diary and craving log). The treated group received additional access to the integrated Inner Dragon game that incorporated several game mechanics designed to increase user engagement. User engagement outcomes were the number of unique app sessions, average minutes per session, days with a session, and program adherence. Self-reported and verified smoking abstinence and app satisfaction were also assessed. The main analysis estimated the intention-to-treat effect of access to Inner Dragon on each outcome. Further analyses assessed effect modification by participant characteristics and the association of intensity of game use with program adherence and abstinence. RESULTS: Overall, user engagement was greater for treated versus control participants: they had 5.3 more sessions of Smoke Free (mean 29.6, SD 36.5 sessions vs mean 24.3, SD 37.9 sessions; P=.06), 0.8 more minutes per session (mean 6.9, SD 5.4 min vs mean 6.1, SD 5.2 min; P=.047), and 3.4 more days with a session (mean 14.3, SD 15.3 days vs mean 11.9, SD 14.3 days; P=.03). Program adherence, based on the number of times core features of the original Smoke Free app were used, was higher for treated versus control participants (mean 29.4, SD 41.3 times vs mean 22.6, SD 35.6 times; P=.03). Self-reported 7-day and 30-day point-prevalence abstinence and verified 7-day point-prevalence abstinence at 8 weeks did not significantly differ by study group. The mean repeated 1-day prevalence of quitting was higher among the treated group versus the control group (mean 17.3%, SD 25.6 vs mean 12.4%, SD 21.3; P=.01). App satisfaction and the motivation to (stay) quit did not differ by study group. Higher intensity of game use was associated with increased program adherence and self-reported abstinence. CONCLUSIONS: Findings suggest that the Inner Dragon game increased user engagement and program adherence. Additional refinements to the game design may clarify whether the game increases abstinence rates. Overall, it is feasible to deploy games and gamification to enhance user engagement in existing smoking cessation interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05227027; https://clinicaltrials.gov/study/NCT05227027.

Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy.

STUDY OBJECTIVE: Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects. METHODS: We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer. RESULTS: Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress. CONCLUSION: The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

IQOS Marketing Strategies and Expenditures in the United States From Market Entrance in 2019 to Withdrawal in 2021.

INTRODUCTION: IQOS entered the U.S. market in October 2019, then received the Food and Drug Administration (FDA)'s modified risk tobacco product authorization (MRTPA) allowing use of "reduced exposure" claims in marketing in July 2020. A May 2021 court decision regarding patent infringement required IQOS' removal from the U.S. market in November 2021. AIMS AND METHODS: Using 2019-2021 Numerator marketing data, this study characterized ad occurrences and expenditures-including allocation per ad content (headline theme, imagery) and media type and channel-pre- and post-MRTPA; exploratory analyses characterized the post-court to withdrawal period separately. RESULTS: The study period entailed 685 occurrences and $15 451 870 in expenditures. The proportions of occurrences across the three periods (pre-MRTPA, post-MRTPA, and post-court) were 39.3%, 48.8%, and 12.0%, respectively (p < .001); the proportions of expenditures were 8.6%, 30.0%, and 61.5%. Overall, 73.1% of ad occurrences were via online display; 99.6% of expenditures occurred in print. Per occurrences, prominent pre-MRTPA headline themes included "future" (40.2%), "real tobacco" (38.7%), "get IQOS" (35.3%), and "innovation or technology" (20.1%); post-MRTPA, prominent themes included "not burned or heat control" (32.7%), "reduced exposure" (26.4%), and "distinct from e-cigarettes" (20.7%). Visuals mainly depicted the product alone (pre-MRTPA: 86.6%; post-MRTPA: 76.1%), but increasingly featured women (pre-MRTPA: 8.6%; post-MRTPA: 21.5%). The most prominent media channel theme pre-MRTPA was "technology" (19.7%), but post-MRTPA included "women's fashion" (20.4%) and "entertainment or pop culture/gaming" (19.0%). CONCLUSIONS: IQOS leveraged MRTPA in ads, continued marketing post-court decision, and targeted key consumer groups (ie, women). Marketing surveillance of products granted MRTPA is needed, domestically and in other countries, to assess its use and impact. IMPLICATIONS: Philip Morris (PM) leveraged IQOS' MRTPA from the U.S. FDA, and continued marketing IQOS after its withdrawal from the U.S. market due to a patent-infringement-related court decision. Notably, IQOS marketing increasingly targeted key consumer groups (eg, women). Given IQOS' potential return to the United States, PM's use of FDA's MRTPA to promote IQOS as a risk reduction product in other countries, and FDA's MRTPA for other products, it is crucial to monitor products receiving MRTPA, their marketing, and their population impact, domestically and in other countries.

Industry marketing of tobacco products on social media: case study of Philip Morris International's IQOS.

SIGNIFICANCE: Newer tobacco products might be particularly likely to use social media as they emerge in the global market. Little is known about the official use of social media in marketing heated tobacco products (HTPs). This study examined Philip Morris International's (PMI) social media marketing globally of its leading HTP, IQOS. METHODS: PMI IQOS country-specific official websites were accessed (N=59) in May to September 2022 and social media accounts listed were recorded. Accounts were then coded for their number of posts in the past month and year and for their number of subscribers. Posts on online accounts with at least one past-month post were categorised to describe the post's function: instructional, general advertising, price promotions or event promotions. RESULTS: Of the 59 country websites, 45 (76.3%) listed at least one social media account; of these, an average of 2.5 accounts (SD=0.8) were listed. Across websites, 111 accounts were identified: 42 Facebook, 23 YouTube, 21 Twitter, 19 Instagram, 2 Telegram, 1 LinkedIn, 1 KakaoTalk, 1 VK and 1 LINE. Across YouTube, Twitter and Instagram, accounts made 2550 past-year posts and had ~490 961 subscribers. Of the 165 past-month posts, 101 (60.1%) functioned as general advertising, 30 (17.9%) instructional, 29 (17.3%) event promotions and 8 (4.8%) price promotions. CONCLUSION: Social media posts were used to engage consumers with advertising, event promotions, product use instructions and price promotions. The study provides evidence of the company-sponsored official marketing of an HTP via social media globally, underscoring the need for monitoring and tobacco control regulatory efforts in the digital arena.

IQOS marketing strategies in the USA before and after US FDA modified risk tobacco product authorisation.

INTRODUCTION: Given that the US Food and Drug Administration (FDA) authorised reduced exposure messaging to be used in IQOS marketing, we examined: (1) IQOS ad content; (2) advertising media channels and (3) changes in advertising efforts over time. METHODS: We conducted a mixed-methods study regarding IQOS ad content (headlines, themes, images), ad occurrence characteristics (including content, media channels and adspend) in the USA from August 2019 to April 2021 using Numerator advertising/marketing data. RESULTS: Across 24 unique ads and 591 occurrences (84.6% online, 8.0% print, 7.4% mobile), there was $4 902 110 total adspend (98.9% allocated to print). Across unique ads, occurrences and adspend, prominent themes included 'real tobacco' (45.8%, 47.4%, 30.1%, respectively), less odour/ash (29.2%, 21.0%, 29.9%) and switching from cigarettes (25.0%, 19.5%, 69.4%), and images mainly featured the product alone (58.2%, 61.4%, 99.5%) or with women (25.0%, 19.1%, 0.3%). Per occurrences and adspend, the most prominent media channel themes (eg, magazine/website topics) were technology (19.3%, 10.6%), women's fashion (18.1%, 26.2%), weather/news (9.0%, 15.3%) and entertainment/pop culture/gaming (8.5%, 23.1%). Ad themes appearing only post-FDA authorisation included switching from traditional cigarettes, same-day/home-delivery, convenience (eg, use indoors), reduced exposure to some dangerous substances, science/research and distinction from e-cigarettes. Overall adspend per occurrence increased postauthorisation (p=0.016); the highest adspend per unique ad (69.3% of total) focused on ads featuring reduced exposure. CONCLUSIONS: Regulatory efforts must be informed by ongoing surveillance of IQOS marketing efforts and its impacts, particularly how specific consumer subgroups (eg, tobacco non-users, women, young people) are impacted by marketing exposure.

IQOS marketing strategies at point-of-sales: a cross-sectional survey with retailers.

BACKGROUND: The point-of-sale (POS) is adapting to marketing restrictions, societal changes and the inclusion of new products, such as heated tobacco products (eg, Philip Morris International's (PMI) IQOS device and HEETS sticks). We aimed to assess (1) PMI's influences on IQOS/HEETS POS marketing and (2) the implications of the new legislation (POS display ban and plain packaging) for retailers. METHODS: A cross-sectional survey of 43 IQOS/HEETS POS owners/managers in five Israeli cities assessed POS and participant characteristics, marketing strategies, attitudes towards IQOS, and POS implications of the legislation and COVID-19, including industry reactions. Bivariate analysis explored differences between POS selling of the IQOS device versus POS selling of HEETS only. RESULTS: A higher proportion of those carrying IQOS (n=15) (vs HEETS only) had special displays (100% vs 17.9%, p<0.001) and interacted with specific IQOS salespersons (73.3% vs 28.6%, p=0.013). Common promotions were financial incentives based on HEETS sales for retailers (37.5%) and price discounts on HEETS for customers (48.7%). Most indicated positive attitudes towards IQOS (72.1%; eg, 'less harmful'), opposition to the legislation (62.7%), limited government assistance to implement the legislation (62.8%), and industry provision of display cases and/or signage to comply with the legislation (67.4%). CONCLUSION: PMI uses similar tactics to promote IQOS at POS as they previously used for combustible products, including direct promotional activities with retailers, and circumvented legislation by using special displays and signage. Governments need to ban these measures and support retailers with clear practical guidance regarding the implementation of marketing restrictions at POS.

Development of a cervical cancer prevention text-messaging program for women living with HIV.

Cervical cancer screening and human papillomavirus (HPV) vaccination are critical for those immunocompromised due to human immunodeficiency virus (HIV). Health education programs, including text messaging, can effectively improve knowledge of cervical cancer and recommended screening. This paper describes the data-driven development of a 4-week text-messaging intervention to improve HPV and cervical cancer knowledge among women living with HIV (WLH). This study reports data from surveys (n = 81; January 2020 to September 2021) and focus group discussions (FGDs, n = 39; April-June 2020) conducted among WLH in the DC area. While most WLH revealed that their usual sources of health information were through in-person group sessions, they pointed out that these were impractical options due to the coronavirus 2019 pandemic. They noted that a text-messaging intervention was feasible and acceptable. FGD participants' responses structured around the Protection Motivation Theory constructs informed the text-messaging library, covering topics such as (I) understanding of cervical cancer and HPV, (II) cervical cancer prevention and (III) HPV self-sampling. The utilization of low-cost and easily accessible health education interventions, such as mobile-based text messaging, can effectively increase knowledge and awareness of cervical cancer in populations that have been historically difficult to access and during times when health services are disrupted such as during a global pandemic or public health emergency.

E-cigarette and combusted tobacco abstinence among young adults: Secondary analyses from a U.S.-based randomized controlled trial of vaping cessation.

OBJECTIVE: To examine patterns of abstinence from e-cigarettes, combusted tobacco products (CTPs), both, or neither among young adults enrolled in a U.S.-based randomized trial of a text message vaping cessation intervention. METHODS: At baseline, 1829 young adult e-cigarette users were categorized as Exclusive E-cigarette Users (no past 30-day CTP use; n = 1036, 56.6%) or Dual Users (past 30-day CTP use; n = 793, 43.4%). Four groups were defined at 7-months: 1) Dual Abstinent, 2) Exclusive Vaping, 3) Exclusive CTP Use, and 4) Dual Users. The proportion of participants who were Dual Abstinent was the outcome of interest. RESULTS: At follow-up, 22.1% (95% CI: 20.3, 24.1) of participants were Dual Abstinent, 44.8% (95% CI: 42.5, 47.1) reported Exclusive Vaping, 6.3% (95% CI: 5.2, 7.5) reported Exclusive CTP Use, and 26.8% (95% CI: 24.8, 28.9) were Dual Users. A higher proportion of participants randomized to Intervention were Dual Abstinent (25.9%, 95% CI 23.1, 28.9) compared to Control (18.5%, 95% CI 16.0, 21.1; p = .0002). Analyses of treatment effects on dual abstinence by baseline tobacco product use favored Intervention over Control among both Exclusive E-cigarette Users (p = .019) and Dual Users (p = .0014). CONCLUSION: A text message vaping cessation intervention was effective in promoting dual abstinence from e-cigarettes and CTPs among young adults. The advantage of treatment over control was equivalent for Exclusive E-cigarette Users and Dual Users. Rates of dual abstinence were higher among exclusive vapers than dual users, signaling the need for more research to optimize cessation programs for poly-tobacco users.

Electronic Nicotine Product Cessation and Cigarette Smoking: Analysis of Waves 3 and 4 From the PATH Study.

INTRODUCTION: Identifying predictors of electronic nicotine product (ENP) cessation can inform ENP cessation interventions. High rates of cooccurring ENP and cigarette (dual) use and transitions between these products underscore the importance of considering cigarette smoking status when assessing and addressing ENP cessation. AIMS AND METHODS: We analyzed waves 3 (W3) and 4 (W4) of the Population Assessment of Tobacco and Health (PATH) study to identify (1) W3 socio-demographics, tobacco and ENP use characteristics, and psychosocial correlates of W3 cigarette smoking status (non-smoker, former, and current) among W3 adult ENP users, and (2) W3 predictors of W4 combined ENP and cigarette smoking abstinence relative to use of one or both products. RESULTS: At W3, 65.6% of ENP users concurrently smoked cigarettes. Adjusted multinomial regression results indicated that different W3 socio-demographics, tobacco and ENP use characteristics, and psychosocial correlates were significantly associated with distinct W3 cigarette use profiles. At W4, 9.9% of individuals were abstinent from both products. These individuals were less likely to: (1) be current smokers (vs. non-smokers) or be advised to quit using tobacco, compared with cigarette only or dual users, and (2) use ENPs daily or live in a household allowing ENP use, compared with ENP only or dual users (p < .05). CONCLUSIONS: ENP cessation approaches need to be tailored to the distinct cigarette use profiles of ENP users. Dual users and daily ENP users may require more intensive interventions to achieve the cessation of both products. Supportive physical environments, such as home vape-free policies, may facilitate ENP cessation. IMPLICATIONS: This analysis contributes to advancing the nascent literature on predictors of electronic nicotine product (ENP) cessation, which can guide the development of ENP cessation interventions by indicating which populations, psychosocial and environmental constructs, and cooccurring behaviors interventions should target. This research also highlights the importance of considering cigarette smoking status when designing ENP cessation interventions and defining intervention outcomes.

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 and/or HEETS point-of-sale (POS) in Israel in December 17, 2019 to January 7, 2020, after the ban on advertisement went into effect in March 8, 2019. AIMS AND METHODS: Research staff audited 80 randomly selected IQOS and/or HEETS POS in four cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data were linked to neighborhood characteristics, including socioeconomic status, ethnicity, and proximity (under 300 m) 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 colors, 20.0% had IQOS and/or HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was US $8.7 (range: US $7.5-11.3), 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-socioeconomic status area; 68.7% were near a school. CONCLUSIONS: The relatively limited IQOS and/or HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher socioeconomic status populations, as indicated by pricing and POS neighborhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research. IMPLICATIONS: Globally, the POS is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the POS provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS and/or HEETS marketing at POS suggests that primary marketing strategies may shift to online or other channels as regulatory contexts become more progressive and/or restrictive. Ongoing surveillance of IQOS via online marketing and POSs, specifically with regard to product placement and proximity to schools, is needed.

Proximity of IQOS and JUUL points of sale to schools in Israel: a geospatial analysis.

SIGNIFICANCE: Exploring proximity and density of heated tobacco product (HTP) and electronic nicotine delivery system (ENDS) points of sale (POS) to schools is critical for understanding youth marketing exposure and informing policy and enforcement to protect youth. This study examined IQOS and JUUL POS (prominent HTPs and ENDS), specifically their proximity to and density around schools in Israel. METHODS: Using geospatial analysis and IQOS/JUUL website data, distance matrices were used to calculate distance from each school in Israel (grades 1-12) to the nearest POS and number of POS within 1 km, accounting for schools' neighbourhood socioeconomic status (SES) ranking. RESULTS: An average of 8.7 IQOS POS and 5.2 JUUL POS were within walking distance (1 km) from schools. Average distances from schools to nearest IQOS and JUUL POS were 954 m (median=365 m) and 1535 m (median=579 m), respectively. The percentages of schools with at least one IQOS or JUUL POS within 1 km were 86% and 74%, respectively. The average numbers of POS within 1 km of schools in low-SES, middle-SES, and high-SES neighbourhoods were 7.5, 9.9, and 7.6 for IQOS and 4.1, 5.9, and 5.5 for JUUL, respectively. Median distances from schools in low-SES, middle-SES, and high-SES neighbourhoods to nearest POS were 428 m, 325 m, and 403 m for IQOS and 1044 m, 483 m, and 525 m for JUUL. CONCLUSIONS: Youth experience high environmental exposure to IQOS and JUUL POS, particularly IQOS. POS were more densely located near schools in middle-SES neighbourhoods. Thus, regulating HTP and ENDS POS near schools and in certain neighbourhoods is key to reducing youth population impact in Israel and elsewhere.

Trajectories of ENDS and cigarette use among dual users: analysis of waves 1 to 5 of the PATH Study.

INTRODUCTION: Concurrent electronic nicotine delivery system (ENDS) and cigarette (dual) use is harmful. Identifying longitudinal trajectories of ENDS and cigarette use among dual users can help to determine the public health impact of ENDS and inform tobacco control policies and interventions. OBJECTIVES: (1) To identify independent and joint trajectories of ENDS and cigarette use among wave (W) 1 adult dual users across W1 to W5 of the Population Assessment of Tobacco and Health (PATH) Study; and (2) identify W1 predictors of ENDS and cigarette joint trajectory group membership. METHODS: We used group-based trajectory modelling to estimate independent and joint trajectories of ENDS and cigarette use from wave 1 (W1; 2013-2014) to wave 5 (W5; 2018-2019) among W1 adult established dual users of ENDS and cigarettes (n=545) from the PATH Study. We used multinomial logistic regression to identify W1 predictors of joint trajectories. RESULTS: Two ENDS (early quitters=66.0%, stable users=34.0%) and three cigarette (stable users=55.2%, gradual quitters=27.3%, early quitters=17.5%) trajectories of W1 were identified. In joint trajectory analysis, 41.6% of participants were early ENDS quitters and stable cigarette users; 14.8% early ENDS quitters and gradual cigarette quitters; 14.6% stable ENDS users and stable cigarette users; 11.2% stable ENDS users and gradual cigarette quitters; 10.3% early ENDS quitters and early cigarette quitters; and 7.4% stable ENDS users and early cigarette quitters. Cigarette and ENDS use frequency, nicotine dependence, cannabis use and other non-combusted tobacco product use predicted trajectory group membership (p values <0.05). CONCLUSIONS: Most dual users maintained long-term cigarette smoking or dual use, highlighting the need to address cessation of both products. Continued monitoring of trajectories and their predictors is needed, given ongoing changes to the ENDS marketplace.

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

BACKGROUND: IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes. METHODS: Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test. RESULTS: The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging. CONCLUSIONS: IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.

Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults.

BACKGROUND: IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for 'reduced exposure' marketing claims, which has been exploited globally. METHODS: In November-December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates. RESULTS: Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message ('IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers') was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers. CONCLUSIONS: Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.

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.

'It's like if a vape pen and a cigarette had a baby': a mixed methods study of perceptions and use of IQOS among US young adults.

Young adults' perceptions and use of heated tobacco products (HTPs) are understudied. This mixed methods study analyzed (i) Fall 2020 survey data from 2470 US young adults (meanage = 24.67; 19.5% and 25.2% past-month cigarette and e-cigarette use; 4.1% ever HTP use) assessing HTP use intentions and perceptions (1 = not at all to 7 = extremely) and (ii) Spring 2021 interview data regarding IQOS (most widely available HTP) in a subset of 40 e-cigarette users. Among survey participants, HTPs versus cigarettes and e-cigarettes showed lower use intentions (mean = 1.27 vs. mean = 1.73, mean = 2.16) but were perceived as less addictive (mean = 5.11 vs. mean = 6.28, mean = 5.82) and harmful (mean = 5.37 vs. mean = 6.65, mean = 5.62). HTPs were perceived more socially acceptable than cigarettes but less than e-cigarettes (mean = 3.39 vs. mean = 3.13, mean = 4.37). Among interviewees, most reported limited HTP knowledge. A few perceived IQOS as a hybrid of traditional cigarettes and e-cigarettes. Most perceived IQOS as harmful but less harmful than cigarettes and were uncertain in relation to e-cigarettes. Over half reported minimal interest in trying IQOS; common reasons included IQOS containing tobacco, limited flavors and use complexity. The varied perceptions of IQOS versus cigarettes and e-cigarettes underscore the need for continued surveillance of perceptions, use and marketing of IQOS to inform regulatory oversight and potential interventions.