Heated Tobacco Products (HTPs) are rapidly expanding into new markets around the world, and in Japan and South Korea, they have gained a substantial share of the tobacco market. Unlike e-cigarettes, which contain a liquid nicotine solution called e-liquid, HTPs contain heat sticks or pellets made from a tobacco leaf paste that is treated with a mix of chemicals that includes propylene glycol, a e-cigarette liquid solvent. The IQOS HTP device made by Philip Morris International consists of a paper tube tipped with a foam filter. Instead of being lit on fire like a cigarette, however, a battery powered heating device heats the tobacco paste to a point before it burns, called pyrolysis. With this heat, the tobacco then releases nicotine and other chemicals into an aerosol that is inhaled by the user.

Unlike the e-cigarette market, the HTP market has been the exclusive domain of tobacco cigarette manufacturers. As a result, the HTP products are branded in a similar manner to tobacco cigarettes. Unquestionably, we can see that declines in per-capita cigarette sales have accelerated as HTP sales have increased. In terms of tobacco control policy progress, Japan has lagged behind other very-high-HDI countries. For example, they have been unable to pass a smoke-free policy for the 2020 Summer Olympic Games in Tokyo, something that most host countries or cities going back decades have been able to accomplish. Despite this, since Japan has seen its rate of decline in cigarette sales quintuple from a 2% decline per year from 2011 through 2015 to a 10% decline per year from 2015 through 2018, all without a major change in national tobacco control policy. Can all or part of this acceleration in the decline of tobacco sales be attributed to the introduction of IQOS? A team of American Cancer Society researchers, who are also Tobacco Atlas authors, examined this question using market data from Japan.

In 2014, Philip Morris International introduced the IQOS heated tobacco system into Nagoya, Japan. Then the product was given a phased introduction to 12 of Japan’s 47 prefectures in September of 2015, and the remaining 35 in April of 2016. The IQOS system’s Marlboro Heatsticks rapidly grew, comprising a 17.4 percent share of the combined cigarette/heated-tobacco-stick market by 2019.

Above: An unusual marketing tactic used to sell IQOS in Japan.

The ACS researchers exploited the externally manipulated introduction dates across prefectures to assess the likely impact of IQOS introduction. Comparing the timing of IQOS introduction with the timing of decline in per-capita smoking, they found that cigarettes sales tended to decline in the months after IQOS introduction. The decline in cigarette sales happened later in the regions where IQOS was introduced later. The researchers further determined that this pattern was not explicable by a national-level factor other than IQOS and that it was unlikely to be attributable to random chance.

The piece fits into a narrative that is developing around HTPs and the business case that is being made for them by their proponents. Tobacco companies are pressing regulatory agencies, treasuries, and legislatures for favorable tax treatment as a concession to their purportedly lower health hazards. In some cases, they are being granted tax rate concessions, but overall, the products seem to be more profitable per unit than the cigarettes they are replacing. They are also consistently more expensive to use than cigarettes in every market except those with the highest cigarette prices. This new article makes the case that HTPs are likely to be replacing cigarette sales. If the products do have higher profit margins than cigarettes and have the potential to replace declining cigarette sales, then it is little wonder that tobacco companies are so eager to get into this product category.

We want to add two notes for further consideration before we conclude.  First, dropping cigarettes sales might not necessarily translate to dropping cigarette smoking prevalence. From what we see in other data sources, many smokers are now dual users of both cigarettes and HTPs and the number of exclusive HTP users is relatively low. Dual use is not desired from the public health perspective because continuing to smoke cigarettes, even at a low intensity, will cause a level of harm to the smoker that is far out of proportion to the amount smoked. Second, it is not currently possible to reach confident conclusions about the level of direct harm users will experience from HTP use, and how this compares to the harms of smoking. Therefore, unless smokers are successfully using HTPs as a short-term cessation device, there are uncertain and potentially substantial risks associated with prolonged use of HTPs.

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Read full article: Michal Stoklosa, Zachary Cahn, Alex C. Liber, Nigar Nargis, Jeffrey Drope (2019) “The effect of IQOS introduction on cigarette sales: evidence of decline and replacementTobacco Control Published online first on 17 June 2019.

By Alex Liber