In recent years, alternatives to cigarettes have begun to be introduced among multiple countries around the world. In Japan, for example, many former adult smokers are now using heated tobacco products instead of smoking. Other countries, most notably the U.K. and New Zealand, are promoting the switch to vaping as part of their national public health policy. In Sweden, the smoke-free oral tobacco product snus has already replaced cigarettes among adult males as the most widely used tobacco product. In fact, this transition in tobacco product use habits in Sweden has contributed to a decrease in the prevalence of cigarette smoking among men and, according to some literature, seems to suggest a decrease in tobacco-related mortality. On the other hand, some questions have been raised about the market introduction of cigarette alternatives.
In order for cigarette alternatives to contribute to public health in accordance with the concept of tobacco harm reduction, it is important not only to scientifically prove that the alternatives are less harmful than smoking, but also be accepted by current adult smokers (20 years or older in Japan). At the same time, the use of these alternative products by youth (under 20 years old in Japan) and nonsmokers needs to be prevented.
Successful population harm reduction can only be achieved when a large number of adult smokers switch to better, reduced-risk smoke-free alternatives.
In this interview, Dr. Karina Fischer, Manager Regulatory Consumer Research at Philip Morris International (PMI), discusses a representative 5-year study conducted by PMI on tobacco product prevalence and usage patterns in Japan. She presented the results of this study at a scientific conference held by the Japan Society of Japan Health and Medical Behavioral Sciences in Osaka. Below, Karina describes the study’s findings and her opinion on whether heated tobacco products have the potential to benefit public health.
Dr. Karina Fischer
Manager Regulatory Consumer Research
Dr. Fischer helps to lead the design, development, implementation, analysis, and reporting of post-market studies by applying existing or innovative scientifically robust theories and practices.
What are the main alternatives to cigarettes in Japan?
In order to reduce the health risks associated with cigarette smoking, new, scientifically substantiated smoke-free products such as heated tobacco products and e-cigarettes have been developed and marketed for several years based on the concept of tobacco harm reduction. By only heating and not burning tobacco, scientifically substantiated heated tobacco products generate significantly reduced emissions of harmful chemicals compared with smoking cigarettes (on average 95% lower levels of harmful chemicals, for example, in our leading heated tobacco product, THS). Therefore, heated tobacco products have the potential to present a reduced-risk option for adult smokers (over 20 years old in Japan) who otherwise would continue to smoke cigarettes.
Worldwide, e-cigarettes are the most popular alternatives to cigarette smoking while, in Japan, heated tobacco products are the most accepted alternative to cigarettes. Due to laws and regulations (Pharmaceuticals and Medical Devices Act), e-cigarettes with nicotine (i.e., products that generate vapor by heating liquid containing nicotine to inhale) are not available for consumers in Japan. An approval is required to sell liquids that contain nicotine, and there are currently no approved liquids, so e-cigarettes sold in Japan do not contain nicotine.
How can we know whether the increasing availability of heated tobacco products will indeed contribute to tobacco harm reduction and benefit to public health?
Heated tobacco products are still relatively new products and long-term prospective data are limited. Our own THS, commercialized as IQOS, was launched nationwide in Japan in 2016. Therefore, we understand that there are concerns regarding the individual and public health impact of heated tobacco products.
For example, some of the voiced concerns include:
- The advent of heated tobacco products may increase the overall tobacco product consumption in Japan.
- The use of heated tobacco products together with cigarettes may not benefit individual and public health.
- Never tobacco product users may start using heated tobacco products.
- The introduction of heated tobacco products may prevent smokers who want to quit cigarettes or all tobacco products from doing so.
These are all legitimate concerns, which need to be discussed and addressed. This is why rigorous scientific studies ― and in particular post-market studies ― need to be conducted and analyzed.
You went to Japan to present the results of a repeated study on tobacco product use in Japan at an academic conference, right?
Yes, we have now been conducting this study already over 5 years to assess the evolution of tobacco use habits, including heated tobacco products, in Japan. I had the opportunity to present our 5-year trend data at the 37th Annual Meeting of the Japan Academy for Health Behavioral Science (June 17-18, 2023 at Higashiosaka University). I believe that the results of this 5-year study can respond to some of the concerns about heated tobacco products mentioned earlier.
Learn more about PMI’s research to assess the evolution of tobacco product use habits:
Now, could you please give us an overview of the heated tobacco product research conducted in Japan.
This study is an ongoing, yearly repeated, representative cross-sectional study that examined the usage prevalence and usage patterns of tobacco products among the general adult population (aged 20 and older) in Japan since 2016. From 2016 to 2022, we sampled and surveyed 4,000 to 7,000 participants every year. We have also surveyed adult users of THS over the same period of time. To ensure the ethical conduct and research integrity of the study, including an independent assessment and objectivity of the research, the research protocol was reviewed and approved by the Hakata Clinic Institutional Review Board in Fukuoka, Japan. Regarding the design of the study, both the sampling method (stratified multi-stage random sampling) and the separate measurement of cigarette smoking and heated tobacco product usage follow those of the Japan National Health and Nutrition Survey conducted each year by the Ministry of Health, Labour and Welfare.
Here are some of the main results.
Heated tobacco products seem to have replaced cigarettes and other combustible tobacco products in Japan without increasing the overall prevalence of tobacco product use
When looking at the usage of tobacco products, we can see that the prevalence of smoking cigarettes and other combustible products has decreased over the years, while the prevalence of heated tobacco product use has increased. Regarding the overall prevalence of tobacco product use over time, the introduction of heated tobacco products has not increased the overall tobacco product consumption, suggesting a transition of existing tobacco users to heated tobacco products, rather than an uptake of heated tobacco products in addition to cigarettes. This shift from cigarettes to alternative heated tobacco products over time seems to be consistent with the results of the Japan National Health and Nutrition Survey.
The following graphs show the annual prevalence of the use of cigarettes & other combustible tobacco products, heated tobacco products, and overall tobacco products in the Japanese adult population over 5 years (2016-2022).
The shift from combustible to heated tobacco product use is in line with the Japan National Health and Nutrition Survey data and suggests that the introduction of heated tobacco products in Japan has not increased overall tobacco product use but appears to have increasingly replaced combustible tobacco products.
Combined usage of cigarettes and heated tobacco products has decreased over time and thus does not seem to be a predominant use pattern in Japan
Looking at the patterns of tobacco product use among adult (aged 20 and older) users of THS over time, the majority of THS users have completely switched away from combustible products to exclusive THS use, or THS use together with other heated tobacco products or other smoke-free products. Five years after the start of the study, the proportion of THS users who used THS exclusively or together with other smoke-free products has meanwhile increased to over 80%. In other words, only around 20% of THS users continued smoking cigarettes, indicating that the combined use of cigarettes and heated tobacco products is not a predominant use pattern in Japan.
Combined use of THS together with combustible tobacco products markedly decreased over time and thus has not become a major product use pattern or reason for concern in Japan. TNP is an abbreviation for tobacco and nicotine product.
Never tobacco product users are very unlikely to start using THS
The rate of tobacco initiation with THS among adult never tobacco users (aged 20 and older) remained stable and low (0.1% or less) over the 5 study years and was much lower than the rate of tobacco initiation with cigarettes. This also means that nearly all THS users were cigarette smokers when they started using THS.
Tobacco initiation with THS among adult never tobacco users was stable and very low (less than or equal to 0.1%), suggesting that nearly all THS users were cigarette smokers when they started using THS.
The uptake of heated tobacco products in Japan does not seem to impede smoking cessation
Among adult tobacco product users (aged 20 and older), both the rate for stopping cigarette use and the rate of quitting tobacco and nicotine altogether are available for the past 3 years, and they have been stable over that time. This potentially indicates that the introduction of THS in Japan has not changed the quit rates among tobacco users.
Quitting rates among smokers remained stable over time, suggesting that the introduction of THS in Japan has not prevented adult smokers who wanted to quit smoking cigarettes or all tobacco products from doing so.
All these findings show that heated tobacco products, including THS, are predominantly used by current adult smokers to completely transition away from smoking, and this transition can have a beneficial impact on individual and public health.
What do you feel about this study? Also, what is the current state of Japan regarding tobacco use from a worldwide perspective?
It should be highlighted that the trend data of this 5-year study are representative for the Japanese adult population and can therefore be regarded as additional evidence to the data collected annually by the Japan National Health and Nutrition Survey. Both studies show that the introduction of heated tobacco products in Japan has the potential to reduce smoking prevalence and to positively impact public health.
In this respect, Japan is a leader from a world perspective.
What kind of research do you plan to conduct on heated tobacco products in the future?
We have a roadmap in place for future scientific studies, including post-market studies with harmonized research protocols and methods to be able to compare data, trends, and findings also across different countries. This is one of the strengths that only a global company can do. We plan to continue the repeated cross-sectional study in Japan in the future.
Do you want to add anything else?
There is no such thing as a safe tobacco product, and heated tobacco products are not without risks. At the same time, the totality of evidence collected to date suggests that encouraging adult smokers who would otherwise continue smoking to switch to heated tobacco products or other scientifically substantiated smoke-free products, can be a powerful complementary tool in addition to the existing tobacco control strategies aimed at reducing smoking.
We hope that the results of our study will contribute to the available evidence on the potential impact of smoke-free products on public health.