Patterns of cigarette, heated tobacco product, and nicotine vaping product use among Korean adults: Findings from the 2020 ITC Korea Survey.

INTRODUCTION: Non-combustible nicotine products (NCNPs), such as heated tobacco products (HTPs) and nicotine vaping products (NVPs) have gained a significant nicotine market share in South Korea. This descriptive study examined patterns of regular cigarette and NCNP use among South Korean adults. METHODS: Data were from the 2020 International Tobacco Control Korea Survey and included 4016 adults (aged ≥19 years) in the Republic of Korea who were regularly (at least weekly) using at least one NCNP (NVP/HTP, n=2117) and/or smoked cigarettes (n=3763) at the time of the survey. Weighted descriptive estimates were computed to assess respondents' nicotine product use among all respondents (exclusive, dual, or triple use). Thereafter, we identified sociodemographic characteristics associated with NCNP use (n=2117). RESULTS: Among Korean adults who were smoking cigarettes, 83.1% (95% CI: 81.6-84.6) did so exclusively, and 16.9% (95% CI: 15.4-18.4) smoked cigarettes and used NCNPs. Among those who used HTPs (n=1877), 14.9% (95% CI: 11.5-18.4) did so exclusively, 59.6% used HTPs and smoked cigarettes (95% CI: 55.4-63.1), 4.2% used HTPs and vaped (95% CI: 11.5-18.4), and 21.6% (95% CI: 18.9-24.2) used all three products. Of adults who used HTPs and smoked cigarettes, 86.6% smoked daily. Among those who vaped (n=865), 13.3% did so exclusively (95% CI: 9.4-17.1), 55.6% (95% CI: 49.6-61.5) vaped and smoked cigarettes, 5.1% (95% CI: 1.7-8.6) used HTPs and vaped, and 26.1% (95% CI: 22.1-30.1) used all three products. Of adults who vaped and smoked cigarettes, 82.4% (95% CI: 77.1-87.7) smoked daily. CONCLUSIONS: Cigarettes remain the most commonly used nicotine product in South Korea, and among adults using heated tobacco and/or vaping products, the majority were also smoking. Research is urgently needed to assess whether adults who are using an NCNP are doing so to quit, or rather to complement their cigarette smoking.

Prevalence and reasons for use of heated tobacco products among Malaysian adults who smoked: Findings from the 2020 International Tobacco Control Malaysia Survey.

INTRODUCTION: There have been rapid expansions in heated tobacco products (HTPs) outside of Japan and the Republic of Korea. In November 2018, HTPs were first introduced in Malaysia and since then, no studies have been conducted on Malaysians' use of HTPs. This study is the first to examine the prevalence of HTP use and reasons for use among Malaysian adults who smoked cigarettes. METHODS: Data came from the 2020 ITC Malaysia Survey, a web-based survey of a nationally representative sample of adults who smoked (n=1047) aged 18 and older. They were asked on ever heard of, ever used, and currently using HTPs, and their reasons for using HTPs. RESULTS: Overall, 25.4% (n= 324; 95% CI:22.3%-28.7%) of Malaysians who smoked reported ever used HTPs with 6.7% (n=85; 95% CI:22.3%-28.7%) were using them daily and 8.1% (n=110; 95% CI:6.4% -10.2%) were using HTPs non-daily. Most of them (57.2%) who dual use were of aged 25-39 and 97.3% were males. Among those who smoked daily, almost half (49.3%) were also using HTP daily. Among those who used HTPs daily and non-daily, curiosity (84.2%, 95% CI:78.4%-90.0%), taste (83.2%, 95% CI:77.3%-89.1%), and appealing technology (78.5%, 95% CI:71.3%-85.6%) were the most reported reasons. Among those who used HTPs daily, curiosity was the top reason (87.9%, 95% CI:78.9%-93.4%), while among non-daily, taste good was the top reason (81.9%, 95% CI:71.9%-88.8%). CONCLUSIONS: The very high use of HTPs among Malaysians who smoked requires continued public health surveillance that can inform the regulation of these novel tobacco products.

Public support for tobacco endgame policies in South Korea: Findings from the 2020 International Tobacco Control Korea Survey.

BACKGROUND: Strong public support can increase the likelihood of adopting tobacco control policies. We assessed support for six commercial tobacco endgame policies in South Korea: limiting the nicotine in cigarettes, banning all additives in cigarettes, restricting the number of places where cigarettes are sold, and banning the manufacture and sales of cigarettes (unconditionally, with the provision of cessation support and with alternative tobacco products available). METHODS: Data were obtained from 4740 adults who completed the 2020 International Tobacco Control Korea Survey. Participants were categorised based on their nicotine use: (1) did not use any products, (2) vaped and/or used heated tobacco products (HTPs) but did not smoke cigarettes, (3) smoked cigarettes only and (4) smoked cigarettes and vaped and/or used HTPs. Attitudes towards the policies were classified as supportive, undecided or opposed. Weighted multinomial logistic regression models assessed support levels according to nicotine use. RESULTS: Support was highest for limiting the nicotine content in cigarettes (68.4%; 95% CI 64.6% to 72.3%) and restricting the number of retailers (68.1%; 95% CI 64.5% to 71.7%), and lowest for banning cigarette sales if alternative products are made available (45.0%; 95% CI 40.9% to 49.1%). People who did not use any products were most likely to support endgame policies, except for banning cigarette sales with alternatives available. The proportion of undecided participants exceeded 10% (range 13%-25%) for all policies. CONCLUSION: There is a strong public support for tobacco endgame policies in South Korea. Further research should prioritise the development of strategies to ensure the effective implementation of highly supported policies.

Evaluation of the effectiveness of the Indian government's policies to strengthen health warning labels on smokeless tobacco products: findings from the 2010-2019 Tobacco Control Project India Surveys.

BACKGROUND: Smokeless tobacco (SLT) packaging in India had a single symbolic (a scorpion) health warning label (HWL) in 2009 covering 40% of the front surface. In 2011, it was replaced with four pictorial images. In 2016, HWLs were enlarged to 85% on the front and back. This study aimed to assess the effectiveness of the old (symbolic and smaller images) and larger HWLs. METHODS: Data were from the Tobacco Control Project India Survey and included respondents who used SLT in Wave 1 (2010-2011, n=5911), Wave 2 (2012-2013, n=5613) and Wave 3 (2018-2019, n=5636). Using a repeated-measures design, weighted logistic regression models assessed whether there were changes in seven HWL effectiveness measures within the domains of awareness, salience, cognitive and behavioural responses. A cohort design was employed to test whether HWL effectiveness in Waves 1 and 2 was associated with quitting SLT in Waves 2 and 3, respectively. RESULTS: The 2011 HWL revision did not result in any significant changes in HWL effectiveness. There was no significant change in HWL awareness and salience after larger HWLs were introduced in 2016, but respondents were more likely to consider SLT health risks (Wave 2=17.9%, Wave 3=33.6%, p<0.001) and quitting SLT (Wave 2=18.9%, Wave 3=36.5, p<0.001). There was no change in HWLs stopping SLT use (Wave 2=36.6%, Wave 3=35.2%, p=0.829); however, respondents were more likely to avoid looking at HWLs (Wave 2=10.1%, Wave 3=40.2%, p<0.001). Effectiveness of older, symbolic and smaller pictorial HWLs was not associated with quitting SLT. DISCUSSION: There was no significant change in HWL effectiveness following the revision from a symbolic to a pictorial image, but enlarging pictorial images resulted in some improved cognitive and behavioural effects. Results suggested wear-out of HWL salience and that the effectiveness of warnings depends on both their design and time since implementation.

Perceptions of harmfulness of heated tobacco and nicotine vaping products compared to cigarettes, and the association of advertising exposure on harm perceptions among adults who smoke in South Korea: Cross-sectional findings from the 2020 ITC Korea Survey.

INTRODUCTION: Heated tobacco products (HTPs) and nicotine vaping products (NVPs) both are legal consumer products in the Republic of Korea. Little is known about perceptions of harmfulness of HTPs and NVPs relative to cigarettes in South Korea among adults who smoke, and how exposure to marketing may be associated with harmfulness perceptions. METHODS: This study used data from the 2020 International Tobacco Control (ITC) Korea Survey, and included 3713 adult (aged 19 years) cigarette smokers who were: 1) exclusive smokers (n=1845); 2) dual HTP + cigarette consumers (n=1130); 3) dual NVP + cigarette consumers (n=224); and 4) triple consumers (all three products, n=514). Weighted multinomial regression models were conducted to estimate smokers' perceptions of harmfulness of HTPs and NVPs compared to cigarettes, NVPs to HTPs, and self-reported exposure to HTP/NVP advertising. Analyses compared the perceptions of harmfulness between the four different consumer groups, and tested whether exposure to HTP/NVP advertising was associated with perceptions of lower relative harm. RESULTS: Among all respondents, 27.5% believe that HTPs are less harmful than cigarettes and 23.4% believe that NVPs are less harmful than cigarettes. Exclusive cigarettes smokers were significantly less likely to perceive that HTPs and NVPs are less harmful than cigarettes compared to dual HTP + cigarette consumers, dual NVP + cigarette consumers, and triple consumers (all p<0.001). Half of respondents perceive NVPs as equally harmful as HTPs (14.1% perceive NVPs as more harmful than HTPs). Exposure to HTP/NVP advertising was associated with perceiving these products as less harmful than cigarettes. CONCLUSIONS: About one-quarter of Korean cigarette smokers perceive HTPs and NVPs as less harmful than cigarettes. Further investigation is required to understand how harm perceptions and HTP/NVP advertising are related to changes in product use, such as switching between products, using multiple products, or discontinuing all product use.

Global prevalence of heated tobacco product use, 2015-22: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Heated tobacco products (HTPs) are electronic devices that heat process tobacco to release an aerosol containing nicotine and other chemicals. Limited data exist on world-wide HTP use prevalence. This meta-analytic review estimated the prevalence of HTP use by country, World Health Organization (WHO) region, year, sex/gender and age. METHODS: Five databases (Web of Science, Scopus, Embase, PubMed and PsycINFO) were searched between January 2015 and May 2022. Included studies reported the prevalence of HTP use in nationally representative samples post-modern HTP device market entry (2015). A random-effects meta-analysis was used to estimate overall prevalence for life-time, current and daily HTP use. RESULTS: Forty-five studies (n = 1 096 076) from 42 countries/areas from the European Region (EUR), Western Pacific Region (WPR), Region of the Americas (AMR) and African Region (AFR) met inclusion criteria. Estimated pooled prevalence for life-time, current and daily HTP use was 4.87% [95% confidence interval (CI) = 4.16, 5.63], 1.53% (95% CI = 1.22, 1.87) and 0.79% (95% CI = 0.48, 1.18), respectively, across all years (2015-22). Life-time HTP use prevalence significantly increased by 3.39% for WPR [0.52% (95% CI = 0.25, 0.88) in 2015 to 3.91% (95% CI = 2.30, 5.92) in 2019] and 5.58% for EUR [1.13% (95% CI = 0.59, 1.97) in 2016 to 6.98% (95% CI = 5.69, 8.39) in 2020]. Current HTP use increased by 10.45% for WPR [0.12% (95% CI = 0, 0.37) in 2015 to 10.57% (95% CI = 5.59, 16.88) in 2020] and 1.15% for EUR [0% (95% CI = 0, 0.35) in 2016 to 1.15% (95% CI = 0.87, 1.47) in 2020]. Meta-regression revealed higher current HTP use in WPR [3.80% (95% CI = 2.88, 4.98)] compared with EUR [1.40% (95% CI = 1.09, 1.74)] and AMR [0.81% (95% CI = 0.46, 1.26)] and for males [3.45% (95% CI = 2.56, 4.47)] compared with females [1.82% (95% CI = 1.39, 2.29)]. Adolescents had higher life-time HTP use prevalence [5.25% (95% CI = 4.36, 6.21) than adults [2.45% (95% CI = 0.79, 4.97)]. Most studies scored a low risk of sampling bias due to their nationally representative sampling. CONCLUSION: The prevalence of HTPs use increased in the EUR and WPR between 2015 and 2020, with nearly 5% of the included populations having ever tried HTP and 1.5% identifying as current users during the study period.

Reasons for Initiation and Regular Use of Heated Tobacco Products among Current and Former Smokers in South Korea: Findings from the 2020 ITC Korea Survey.

South Korea is the world's second-largest heated tobacco product (HTP) market after Japan. HTP sales in South Korea have increased rapidly since May 2017, accounting for 10.6% of the total tobacco market in 2020. Despite this, little is known as to why HTP consumers who were current and former smokers started using HTPs and used them regularly. We analyzed cross-sectional data for 1815 adults (aged 19+) who participated in the 2020 International Tobacco Control (ITC) Korea Survey, of whom 1650 were HTP-cigarette consumers (those who reported smoking cigarettes and using HTPs ≥ weekly) and 165 were exclusive HTP consumers (using HTPs ≥ weekly) who were former or occasional smokers (smoking cigarette < weekly). Respondents were asked to report the reason(s) they used HTPs, with 25 possible reasons for HTP-cigarette consumers and 22 for exclusive HTP consumers. The most common reasons for initiating HTP use among all HTP consumers were out of curiosity (58.9%), family and friends use HTPs (45.5%), and they like the HTP technology (35.9%). The most common reasons for regularly using HTPs among all HTP consumers were that they were less smelly than cigarettes (71.3%), HTPs are less harmful to own health than cigarettes (48.6%), and stress reduction (47.4%). Overall, 35.4% of HTP-cigarette consumers reported using HTPs to quit smoking, 14.7% to reduce smoking but not to quit, and 49.7% for other reasons besides quitting or reducing smoking. In conclusion, several common reasons for initiating and regularly using HTPs were endorsed by all HTP consumers who were smoking, had quit smoking completely, or occasionally smoked. Notably, only about one-third of HTP-cigarette consumers said they were using HTPs to quit smoking, suggesting that most had no intention of using HTPs as an aid to quit smoking in South Korea.

Factors Associated with Quit Intentions among Adult Smokers in South Korea: Findings from the 2020 ITC Korea Survey.

Background: South Korea has made substantial progress on tobacco control, but cigarette smoking prevalence is still high. Previous studies were conducted before the use of nicotine vaping products (NVPs) or heated tobacco products (HTPs) became popular. Thus, whether the concurrent use of NVPs or HTPs affects quit intentions among Korean smokers remains a question that needs to be explored. This study aims to identify predictors of quit intentions among cigarette-only smokers and concurrent users of cigarettes and NVPs or HTPs. Methods: Data were from the 2020 International Tobacco Control Korea Survey. Included in the analysis were 3778 adult cigarette smokers: 1900 at-least-weekly exclusive smokers and 1878 at-least-weekly concurrent smokers and HTP or NVP users. Bivariate and multivariable logistic regression analyses were conducted. Results: Quit intentions were reported by 66.4% of respondents. Factors significantly associated with quit intentions included younger age, having a spouse/partner, lower nicotine dependence, reporting a past quit attempt, regretting starting smoking, believing that smoking had damaged health, worrying that smoking will damage future health, and perceiving health benefits of quitting. Current use of NVPs or HTPs was not significantly associated with quit intentions. Conclusions: This study contributes the following to current literature: intrinsic health-related beliefs were more important than societal norms in shaping quit intentions. These findings should be considered in shaping future smoking cessation policies, such as reinforcing education programs that emphasize the benefits of quitting for personal health reasons, lowering nicotine dependence, and encouraging multiple quit attempts and successful quitting.

Local Brand Smoking Among Adult Smokers: Findings from the Wave 5 International Tobacco Control China Survey - China, 2015.

What is already known about this topic?: Branding of cigarettes may play a role in shaping the smoking behaviors of Chinese smokers, and local brand (LB) cigarettes may reflect this influence because of greater tax and non-tax incentives compared to non-LB. Some of these brands are regional flagships that market to smokers using local landmarks or icons. What is added by this report?: LB brands were significantly more likely to be the usual brand of smokers residing in provincial-level administrative divisions (PLADs) that produced their own LB cigarettes [adjusted odds ratio (AOR): 30.95; 95% confidence interval (CI): 26.36-36.49] compared to those residing in PLADs that had non-local ventures with non-LB cigarettes. Further, smokers residing in urban areas were found to be less likely to smoke LB cigarettes (AOR: 0.79; 95% CI: 0.67-0.93) compared to those in rural areas. What are the implications for public health practice?: These findings suggest that LB smoking may be a result of industry-driven incentives to boost LB sales, fueled by such as supply-side strategies to boost LB sales or targeted cultural/social marketing that appeals to certain demographic groups. Although addressing these incentives to support LBs would be challenging given the nature of China's tobacco industry, doing so would have potential to reduce cigarette smoking and ultimately the health burden of smoking in China.

Assessing use of inhalable nicotine products within complex markets: the dilemma of heated tobacco products.

The introduction of electronic inhalable products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs), has further diversified the nicotine market landscape. This poses unique challenges in measuring self-reported nicotine use behaviours, which have been the hallmark of tobacco surveillance systems. This paper raises concerns of potential measurement error for electronic inhalable product use in surveys due to similarities in product design between NVPs and HTPs, as well as changing trends in cannabis administration. We identify several strategies for addressing this issue (eg, including descriptive preambles in surveys that differentiate product classes from one another; incorporating survey questions that probe beyond an initial question regarding product use). In the absence of comprehensive validation studies, caution is warranted when interpreting survey results that rely on self-reported HTP use.

Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey.

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005-2014, cohort 2: 2016, and cohort 3: 2020-present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

Achieving the Goals of Healthy China 2030 Depends on Increasing Smoking Cessation in China: Comparative Findings from the ITC Project in China, Japan, and the Republic of Korea.

Tobacco smoking is the number one preventable cause of disease and death in China as it is globally. Indeed, the toll of smoking in China is much greater than its status as the world's most populous country. There is a persistent and continuing need for China to implement the measures specified in the global tobacco control treaty, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), which China ratified in 2005. The theme for the 2021 WHO World No Tobacco Day focuses on the need to support smoking cessation. This article presents findings from the International Tobacco Control (ITC) Policy Evaluation Project cohort surveys in China, in comparison to ITC cohort surveys in two neighboring countries: Japan and the Republic of Korea. These findings demonstrate that smokers in China very much want to quit, but these intentions are not being translated into quit attempts, relative to smokers in Japan and the Republic of Korea. Additionally, about 80% of Chinese smokers want the Chinese government to do more to control smoking. These findings reaffirm the need for China to implement strong, evidence-based measures to reduce smoking. The objective of Healthy China 2030 to reduce deaths from non-communicable diseases by 30% can be achieved by reducing smoking prevalence from its current 26.6% to 20%, and this reduction can be achieved through strong implementation of FCTC measures.

Reasons for Regularly Using Heated Tobacco Products among Adult Current and Former Smokers in Japan: Finding from 2018 ITC Japan Survey.

The market growth of heated tobacco products (HTPs), such as IQOS, Ploom TECH, and glo, has increased dramatically in Japan since 2016. Little is known about the reasons why current and former smokers are using HTPs. The data for this cross-sectional study were from the 2018 (Wave 1) International Tobacco Control (ITC) Japan Survey, a national web-based survey of 4500 people, including 658 current HTP users, of whom 549 were concurrently smoking cigarettes and 109 were former smokers. The most common reasons for regularly using HTPs were: beliefs that HTP are less harmful than cigarettes to themselves (90.6%) or to others (86.7%), enjoyment (76.5%), and social acceptability (74.4%). About half of current smokers (55.1%) reported using HTPs because these products might help them quit smoking. However, a near-equal percentage (52.0%) of current smokers reported using HTPs to replace some of the cigarettes they smoked so that they did not have to give up smoking altogether. If smokers are using HTPs to complement rather than quit their smoking, then the harm reduction potential of HTPs suggested by the toxicity studies will be diminished.

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

Japan is one of the world's largest cigarette markets and the top heated tobacco product (HTP) market. No forms of tobacco advertising, promotion, and sponsorship (TAPS) are banned under national law, although the industry has some voluntary TAPS restrictions. This study examines Japanese tobacco users' self-reported exposure to cigarette and HTP marketing through eight channels, as well as their support for TAPS bans. Data are from the 2018 ITC Japan Survey, a cohort survey of adult exclusive cigarette smokers (n = 3288), exclusive HTP users (n = 164), HTP-cigarette dual users (n = 549), and non-users (n = 614). Measures of overall average exposure to the eight channels of cigarette and HTP advertising were constructed to examine differences in exposure across user groups and products. Dual users reported the highest exposure to cigarette and HTP advertising. Tobacco users (those who used cigarettes, HTPs, or both) reported higher average exposure to HTP compared to cigarette advertising, however non-users reported higher average exposure to cigarette compared to HTP advertising. Retail stores where tobacco or HTPs are sold were the most prevalent channel for HTP and cigarette advertising, reported by 30-43% of non-users to 66-71% of dual users. Non-users reported similar exposure to cigarette advertising via television and newspapers/magazines as cigarette smokers and dual users; however, advertising via websites/social media was lower among non-users and HTP users than among cigarette smokers and dual users (p < 0.05). Most respondents supported a ban on cigarette (54%) and HTP (60%) product displays in stores, and cigarette advertising in stores (58%).

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.

Perceptions of Harmfulness of Heated Tobacco Products Compared to Combustible Cigarettes among Adult Smokers in Japan: Findings from the 2018 ITC Japan Survey.

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers' harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Secondhand Smoke Exposure in Public Places and Support for Smoke-Free Laws in Japan: Findings from the 2018 ITC Japan Survey.

Comprehensive smoke-free policies such as those called for by the WHO FCTC are the only way to protect the public effectively from the harms of secondhand smoke (SHS), yet Japan has been slow to implement this important health measure. This study examines baseline levels of smoking and SHS exposure in public places and support for smoking bans in Japan prior to the implementation of the 2018 national smoke-free law. Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb-Mar 2018), a web survey of adult cigarette smokers, heated tobacco product users, dual users, and non-users (total N = 4684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants and bars at their last visit, and workplaces in the last month), and support for complete smoking bans in these venues. Smoking prevalence in each venue was high overall in 2018 (49% of workplaces, 55% of restaurants, and 83% of bars), even higher than in China, the country with the greatest toll of SHS. Support for complete smoking bans was very high overall (81% for workplaces, 78% for restaurants, and 65% for bars). Non-users were less likely to be exposed to SHS and had higher support for smoking bans than tobacco users. These findings point to the ineffectiveness of partial smoke-free laws in Japan and reinforce the call for comprehensive smoke-free laws, which even smokers would support at higher levels than in many other ITC countries.

Secondhand smoke exposure and support for smoke-free policies in cities and rural areas of China from 2009 to 2015: a population-based cohort study (the ITC China Survey).

OBJECTIVES: To examine trends in smoking prevalence in key venues (workplaces, restaurants, bars) and in public support for comprehensive smoke-free laws, with comparisons between cities and rural areas in China. DESIGN: Data are from Waves 3-5 (2009-2015) of the International Tobacco Control (ITC) China Survey, a cohort survey of smokers and non-smokers. Logistic regression analyses employing generalised estimating equations assessed changes in smoking prevalence and support for smoke-free laws over time; specific tests assessed whether partial smoking bans implemented in three cities between Waves 3 and 4 had greater impact. SETTING: Face-to-face surveys were conducted in seven cities (Beijing, Changsha, Guangzhou, Kunming, Shanghai, Shenyang and Yinchuan) and five rural areas (Changzhi, Huzhou, Tongren, Yichun and Xining). PARTICIPANTS: In each survey location at each wave, a representative sample of approximately 800 smokers and 200 non-smokers (aged 18+) were selected using a multistage cluster sampling design. MAIN OUTCOME MEASURES: Prevalence of smoking (whether respondents noticed smoking inside restaurants, bars and workplaces); smoking rules inside these venues; and support for complete smoking bans in these venues. RESULTS: Although smoking prevalence decreased and support increased over time, neither trend was greater in cities that implemented partial smoke-free laws. Smoking was higher in rural than urban workplaces (62% vs 44%, p<0.01), but was equally high in all restaurants and bars. There were generally no differences in secondhand smoke (SHS) exposure between smokers and non-smokers except in rural workplaces (74% vs 58%, p<0.05). Support for comprehensive bans was equally high across locations. CONCLUSIONS: Partial laws have had no effect on reducing SHS in China. There is an urgent need for comprehensive smoke-free laws to protect the public from exposure to deadly tobacco smoke in both urban and rural areas. The high support among Chinese smokers for such a law demonstrates that public support is not a barrier for action.

Use of Heated Tobacco Products within Indoor Spaces: Findings from the 2018 ITC Japan Survey.

Although heated tobacco products (HTPs) have become increasingly popular in Japan, little is known about whether these emerging tobacco products are being used within indoor public spaces. Nationally representative data were obtained prior to implementation of a comprehensive smoke-free law in Japan as part of Wave 1 of the International Tobacco Control Japan Survey (February-March 2018). We estimated the weighted prevalence of HTP use within indoor public spaces among tobacco users and compared these to estimates for combustible cigarettes (CCs). Overall, 15.6% of current tobacco users in Japan declared that they used HTPs within indoor public spaces. Any HTP use within indoor public spaces was significantly lower than any CC use (80.1% vs. 96.7%). Dual HTP + CC users reported using CCs more frequently than using HTPs within indoor public spaces (97.7% vs. 76.0%). In conclusion, HTP use is less common than CC use within indoor public spaces. Findings of this study can inform the development of targeted smoke-free policies to benefit public health.

Prevalence, Use Behaviors, and Preferences among Users of Heated Tobacco Products: Findings from the 2018 ITC Japan Survey.

Heated tobacco products (HTPs), such as IQOS, glo, and Ploom TECH, with a variety of flavored tobacco-containing inserts, have reportedly achieved a significant market share in Japan. We analyzed data from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted in February to March 2018 among 4684 adult participants to estimate the prevalence of HTP use, describe characteristics of HTP users, and explore user preferences for HTP device and flavor. The overall prevalence of monthly HTP use was 2.7% (1.7% daily use). Virtually all HTP users were current cigarette smokers (67.8%) or former smokers (25.0%); only 1.0% of HTP users were never smokers. Among HTP users, IQOS was the most frequently reported brand used (64.5%), and menthol was the most common flavor reported (41.5%). IQOS was used more by younger respondents and those who reported daily use, while Ploom TECH was more popular among older respondents and non-daily HTP users. This is one of the first non-industry funded studies to explore the use of HTPs in Japan.