The story of THS in Japan, an interview with Tomoko Iida

 

What impact has the introduction of the THS had on tobacco harm reduction in the country?

In 2000, approximately 47.4 % of men and 33% of all adults in Japan smoked cigarettes. But in 2015, during and after the introduction of the THS, sales of cigarettes began declining five times faster than in preceding years, an average annual decline of 9.5%, according to researchers of the  American Cancer Society study.  When we look at the data ourselves, we can also clearly see that even after heated tobacco products (HTPs) became available, sales of all tobacco products (including both HTPs and conventional cigarettes) continued to fall. Data from the 2019 National Health and Nutrition Survey (surveys were not conducted during the pandemic) indicates that 76% of consumers who use HTPs do so exclusively. Only 24% of HTP users continued to smoke cigarettes. HTP use in Japan has also had a minimal impact on unintended users – nonsmokers, former smokers, and adolescents.

 

Why was Japan among the first countries where the THS was launched and what made it such a good initial market?

The uniqueness of Japan comes across through societal values of hygiene, cleanliness, and courtesy as well as through interest and adoption of new technologies and innovations. Consumer preference for HTPs compared to cigarettes was shown through our consumer testing and research. HTPs were considered to have a significant advantage over cigarettes because of some of the key features that had a cultural fit with Japanese smokers, especially in the early days. For example, HTPs do not generate ash (no need for anyone to clean ashtrays), no fire (mitigates the risk of household fires), less smell, and no smoke (bothers others less). 

 

How can Japan serve as an example of successful tobacco harm reduction to other countries? 

The experience and data from Japan show that smoke-free products can play a significant role in tobacco harm reduction and public health. Sales and prevalence data from Japan continues to show that HTPs have had a positive impact on decreasing smoking prevalence by transitioning a large number of adult smokers away from smoking cigarettes. The uptake of HTPs in Japan has also been accompanied by sharp declines in cigarette sales. According to the latest industry report from the Tobacco Institute of Japan, cigarette consumption decreased by 44% in 5 years after the introduction of the THS – the highest decline that Japan has ever had.  

Of course, you must consider disposable income, users' preference, and the regulatory environment to address the need for the right product for the country at the right time, but the Japanese experience can certainly be replicated in other countries. Sweden is another example, which came before the harm reduction story in Japan. It has been reported that the use of snus played an important role in decreasing smoking prevalence in the country, especially among men, and a lower rate of lung cancer and heart attacks among men in the country was observed. You have to have the right product to help smokers who won’t quit to switch.

 

Tell us about some of the research PMI has conducted in Japan. 

The passive exposure study is one of several important research studies PMI has conducted in Japan to assess the impact of THS use in real-life settings on users and non-users of the product. 

This study exposed nonsmokers to THS aerosol in a restaurant in Tokyo. Urine samples were taken before and after to determine the presence of harmful chemicals in the body. The results showed that the use of THS didn’t generate environmental smoke and had no adverse effects on indoor air quality. Also, nonsmokers didn’t have an increase in exposure to nicotine and tobacco-specific nitrosamines (TSNA) as a result of passive exposure to the THS aerosol.

The Ministry of Health (MOH) conducted its own studies and concluded that the “results do not negate the inclusion of HTPs within a regulatory framework for indoor tolerable use from exposure to HTP aerosol, unlike cigarette smoke”. The revised Health Promotion Law imposed new regulations on smoking cigarettes in small premises. In larger establishments, smoking is allowed only in a dedicated smoking booth, in which eating and drinking are not permitted. However, HTPs may be used in dedicated HTP areas, in which eating and drinking are also allowed. 

Another important study was conducted in Tokyo and Fukuoka. This clinical study showed that scaling and root planning in periodontitis patients was beneficial to patients who smoked or who had switched to THS, but the outcomes among periodontitis patients who switched to THS were better at sites with higher initial probing depth.

There are several other studies, some of which are shown on the infographic map of Japan.

 

Tell us more about independent research. What do Japanese researchers say about heated tobacco/THS?

There are four important independent studies that I’d like to mention here that were carried out by the Ministry of Health, Labour and Welfare (MHLW) of Japan and its affiliated institutions. In a reduced emission study published in the Journal of UOEH, the National Institute of Public Health (NIPH) concluded that “The concentrations of nicotine in tobacco fillers and the mainstream smoke of IQOS were almost the same as those of conventional combustion cigarettes, while the concentration of TSNAs was one fifth and CO was one hundredth of those of conventional combustion cigarettes.”

 MHLW and the  National Cancer Center  (NCC) conducted two studies to examine the impact of HTPs on indoor air quality. They found that the “exposure to aerosol from HTPs in a designated smoking room under usual conditions is estimated to be tolerable since the lifetime cancer risk is expected to be below a VSD of 10^-5 (1/100,000), which is three orders of magnitude lower than that for cigarettes smoked under the same conditions”. 

Research by the Health Service Division, Health Service Bureau, MHLW, published in the  International Journal of Environmental Research and Public Health compared the concentration of nicotine and particulate matter  (PM_2.5, particles that are 2.5 microns or less in diameter) in the air following 50 puffs from HTPs or cigarettes in a small shower cubicle. They found that the “results do not negate the inclusion of HTPs within a regulatory framework for indoor tolerable use from exposure to HTP aerosol, unlike cigarette smoke”.

Finally, research data from Tottori University commissioned by MHLW demonstrates low levels of HTP use by young people, both in absolute and relative terms, compared to combustible cigarettes. 

 

Any last thoughts?

Even though the focus here is on Japan, it’s not the only country that is embracing tobacco harm reduction. For example, Public Health England has stated that “Alternative nicotine delivery devices, such as nicotine vaping products, could play a crucial role in reducing the enormous health burden caused by cigarette smoking.” And the U.S. FDA has established the Modified Risk Tobacco Products pathway which allows companies a way to gain authorization to provide important information about their smoke-free products. I’m looking forward to seeing what population health impacts we will see – if and when - a large number of adult smokers switch to smoke-free products in these and other countries where tobacco harm reduction is gaining more recognition.