Abstract
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.
Introduction
The nicotine and tobacco product marketplace has evolved rapidly with the emergence of new products, such as heated tobacco products (HTPs) which heat rather than burn tobacco.1 IQOS, a HTP manufactured by Philip Morris International, launched in 2014 and is aggressively marketed in more than 60 countries.1 Although evidence indicates that HTPs expose consumers to lower levels of toxic chemicals than combustible cigarettes,2 the potential public health impacts of HTPs are uncertain.1 Nonetheless, IQOS’ market expansion and increasing availability have impacted consumers’ awareness, perceptions, use behaviors, and intention to use.3
In the United States, the 2016 Deeming rule extended regulatory authority of the Food and Drug Administration (FDA) to emerging tobacco products, including HTPs.4 This rule requires that new tobacco products file a Premarket Tobacco Product Application and receive FDA authorization.5 Additionally, manufacturers can apply for FDA’s modified risk tobacco product authorization (MRTPA), which permits certain products to market with explicit “reduced exposure” or “reduced risk” claims.6
In April 2019, FDA authorized Philip Morris (PM) USA’s premarket application for IQOS7; in October 2019, IQOS was launched in the United States in Georgia, followed by three other states (ie, North Carolina, South Carolina, and Virginia). In July 2020, FDA authorized the use of “reduced exposure,” but not “reduced risk,” claims in IQOS marketing.8 In May 2021, a U.S. International Trade Commission court decision regarding a patent-infringement lawsuit initiated by British American Tobacco against PM required PM to discontinue IQOS sales in the United States in November 2021.9 Regardless, PM and other tobacco companies will likely pursue HTP sales in the United States,9 and their marketing will continue to impact consumers’ perceptions and use.10 Moreover, surveillance of HTPs and other products granted FDA MRTPA (ie, General Snus, VLN cigarettes) will be critical to inform related regulatory efforts in the United States in the future.11
A prior study examining IQOS advertising in the United States from August 2019 to April 2021 suggested the importance of the MRTPA to PM, as reflected by significant increases in advertising expenditures post-authorization and their use of authorized language as soon as PM was allowed.12 There are several concerns related to IQOS’ MRTPA. First, consumers may misinterpret claims indicating reduced exposure to mean reduced risk.11 Second, PM has exploited FDA’s MRTPA in its marketing efforts globally.13 Third, the aforementioned study indicated that certain ad characteristics (eg, media channels used, imagery in ads) suggested potential targeting of young people and women.12 This literature underscores concerns about the potential negative population impact of IQOS and its marketing, both domestically and globally.
Despite what is known about IQOS’ marketing,12 little research has investigated PM’s IQOS marketing throughout its duration in the United States. The aforementioned study included less than a year after IQOS’ MRTPA and excluded when PM faced the lawsuit’s uncertain outcomes.12 This is important, given that the remainder of 2021 could have increased its visibility due to the lawsuit, which could have increased its penetration among U.S. consumers if the court decision had not required its removal. As it turned out, however, the court decision required IQOS’ removal from the U.S. market before it gained notable market share. Therefore, to expand on the earlier study,12 the current study examined the full duration of IQOS’ marketing presence in the United States, from 2019 to the end of 2021. In doing so, we examined characteristics of IQOS ads (ie, headlines, visuals, media types, and media channels) before and after the FDA MRTPA; exploratory analyses characterized ads during the final period—after the lawsuit until IQOS’ removal from the U.S. market in November 2021.
Methods
Data and Procedures
We analyzed data from Numerator, a media tracking company that monitors more than 2600 English language media outlets across various marketing channels, including print ads (in newspapers, magazines, and inserts), TV, radio, cinema, mobile, online displays or videos, outdoor, and social media in the United States.12 This study covered all IQOS advertising data from August 2019 to the end of 2021. Each ad occurrence represented a unique occurrence of an ad circulated via a specific media outlet14 and was attached to metadata regarding run date, headline, visual, media type (ie, mobile, online display, online video, print, radio, and TV), media channel (eg, specific magazines, website, etc.), and unadjusted advertising expenditures.
Each ad occurrence’s run date was categorized as pre- versus post-MRTPA periods (ie, first run either before or after July 7, 2020); we further dichotomized post-MRTPA as pre- versus post-court decision (ie, before or after May 15, 2021). Ad characteristics were operationalized using a mixed-methods approach. For each unique ad, we recorded the headline (see Table 1 for headlines). Then, two team members (ie, ZD, LG) assigned headline themes (eg, “real tobacco,” “innovation or technology”) and visual themes (eg, product-only, person) for each ad, and media channel themes (eg, news or weather, business) for each channel associated with an ad occurrence. Themes were drawn from those in the previous study12 augmented with any new themes that emerged from April to December 2021 (see Table 2 for full list of headline, visual, and media channel themes). Initial interrater reliability exceeded 85% for each theme; discordantly coded headlines were discussed and resolved. Advertising expenditures were adjusted to the 2019 Q3 dollars to account for the inflation across the study period.15
Table 1.
IQOS Ad Headlines and Example Content Pre- and Post-MRTPA (Modified Risk Tobacco Product Authorization)
| Occurrences | |
|---|---|
| Ad Headline | (of 685 total) |
| N (%) | |
| Pre-MRTPA (n = 269) | |
| The future of tobacco is here. | 89 (13.0) |
| Get IQOS. | 73 (10.7) |
| Real tobacco meets innovative technology. | 43 (6.3) |
| The future of real tobacco has arrived. | 19 (2.8) |
| Get IQOS: real tobacco less odor. | 16 (2.3) |
| Meet IQOS: real tobacco no ash less odor. | 11 (1.6) |
| Get IQOS: real heated tobacco is here with less odor to worry about. There’s no need to step away. | 6 (0.9) |
| IQOS uses heatsticks made with real tobacco. | 6 (0.9) |
| With heat control technology real tobacco is heated never burned. IQOS: be one of the first to switch. | 3 (0.4) |
| We built a new way to enjoy tobacco with heat control technology. Real tobacco is heated never burned. IQOS: Be one of the first to switch. | 2 (0.3) |
| Real, heated tobacco is here with less odor to worry about. There’s no need to step away. Real tobacco, no interruptions. | 1 (0.2) |
| Post-MRTPA (n = 416) | |
| Get IQOS: real heated tobacco is here with less odor to worry about. There’s no need to step away. | 56 (8.2) |
| Get IQOS. | 55 (8.0) |
| IQOS uses heatsticks made with real tobacco. | 55 (8.0) |
| Reduce your body’s exposure to harmful chemicals by switching completely from cigarettes to IQOS. | 41 (6.0)a |
| With heat control technology real tobacco is heated never burned. IQOS: be one of the first to switch. | 36 (5.3) |
| Why make the switch from cigarettes to IQOS? The IQOS system heats tobacco but does not burn it. | 16 (2.3) |
| Real, heated tobacco is here with less odor to worry about. There’s no need to step away. Real tobacco, no interruptions. | 13 (1.9) |
| Purchase an IQOS bundle with same-day delivery in select cities. | 11 (1.6) |
| We built a new way to enjoy tobacco with heat control technology. Real tobacco is heated never burned. IQOS: be one of the first to switch. | 11 (1.6) |
| IQOS is the only tobacco product of its kind that can say this. The IQOS system heats tobacco but does not burn it. | 12 (1.8)b |
| Too busy to make an appointment? Experience IQOS at home. Order an IQOS bundle with same-day delivery in select cities. | 10 (1.5) |
| It’s not a vape. It’s not an e-vape. It’s real tobacco with less odor and no ash. | 54 (7.9)c |
| Order an IQOS bundle with same-day delivery in select cities. Experience less lingering odor from the comfort of your couch. | 6 (0.9) |
| Half off! Use promo code device50 at getIQOS.com. | 3 (0.4) |
| Experience heated tobacco sooner than ever. Purchase an IQOS bundle with same-day delivery in select cities. | 2 (0.3) |
| We built a new way to enjoy tobacco with heat control technology. Real tobacco is heated, never burned. | 3 (0.5)d |
| Only post-court decision (n = 33) | |
| No lighters. No ashtrays. Just real tobacco with less lingering odor. | 14 (2.0) |
| Cigarettes burn tobacco. IQOS heats it. There’s a reason why. | 9 (1.3) |
| See why our heat-not-burn technology matters. | 8 (1.2) |
| Stay ready. | 1 (0.2) |
a1 (0.2%) was post-court decision;
b2 (0.3%) were post-court;
c46 (6.7%) were post-court;
d1 (0.2%) was post-court.
Table 2.
IQOS Ad Occurrences (N = 685) and Expenditures ($15 451 870) Across Dimensions Pre- Versus Post-MRTPA (Modified Risk Tobacco Product Authorization)
| Ad occurrences | Inflation-adjusted expenditure (in thousands)a | |||||||
|---|---|---|---|---|---|---|---|---|
| Total | Pre-MRTPA | Post-MRTPA | Total | Pre-MRTPA | Post-MRTPA | |||
| Variable |
N = 685 (100%) |
N = 269 (39.3%) |
N = 416 (60.7%) |
p b | $15 451 870 (100%) |
$1 322 048 (8.6%) |
N = 14 129 822 (91.4%) |
pc |
| Media Type, N (%) | ||||||||
| Online display | 501 (73.1) | 253 (94.1) | 248 (59.6) | <.001 | 44.84 (0.3) | 28.91 (2.2) | 15.93 (0.1) | .994 |
| 139 (20.3) | 11 (4.1) | 128 (30.8) | 15 394.75 (99.6) | 1292.90 (97.8) | 14 101.85 (99.8) | |||
| Mobile | 45 (6.6) | 5 (1.9) | 40 (9.6) | 12.28 (0.1) | 0.24 (0) | 12.04 (0.1) | ||
| Ad headline theme, N (%)d | ||||||||
| Real tobacco | 365 (53.3) | 104 (38.7) | 261 (62.7) | <.001 | 11 643.24 (75.4) | 1301.77 (98.5) | 10 341.47 (73.2) | .623 |
| Innovation or technology | 230 (33.6) | 54 (20.1) | 176 (42.3) | <.001 | 7307.43 (47.3) | 5.79 (0.4) | 7301.65 (51.7) | .044 |
| Get IQOS | 206 (30.1) | 95 (35.3) | 111 (26.7) | .016 | 22.90 (0.1) | 8.88 (0.7) | 14.02 (0.1) | <.001 |
| Less odor or ash | 190 (27.7) | 34 (12.6) | 156 (37.5) | <.001 | 11 630.15 (75.3) | 1294.52 (97.9) | 10 335.63 (73.1) | .107 |
| Not burned or heat control | 141 (20.6) | 5 (1.9) | 136 (32.7) | <.001 | 7296.60 (47.2) | 0.14 (0) | 7296.46 (51.6) | .150 |
| Reduced exposure | 110 (16.1) | 0 (0) | 110 (26.4) | <.001 | 10 969.89 (71.0) | 0 (0) | 10 969.89 (77.6) | N/A |
| Future | 108 (15.8) | 108 (40.2) | 0 (0) | <.001 | 14.59 (0.1) | 14.59 (1.1) | 0 (0) | <.001 |
| Switch | 93 (13.6) | 5 (1.9) | 88 (21.2) | <.001 | 3935.89 (25.5) | 0.14 (0) | 3935.76 (27.9) | .495 |
| Distinct from e-cigarettes | 86 (12.6) | 0 (0) | 86 (20.7) | <.001 | 10 072.32 (65.2) | 0 (0) | 10 072.32 (71.3) | N/A |
| Convenience (eg, use indoors) | 86 (12.6) | 7 (2.6) | 79 (19.0) | <.001 | 9.85 (0.1) | 0.25 (0) | 9.60 (0.1) | .075 |
| Same-day or home delivery | 29 (4.2) | 0 (0) | 29 (7.0) | <.001 | 0.98 (0) | 0 (0) | 0.98 (0) | N/A |
| Enjoyment or satisfaction | 16 (2.3) | 2 (0.7) | 14 (3.4) | .027 | 2.43 (0) | 0.01 (0) | 2.42 (0) | .452 |
| Science or research | 10 (1.5) | 0 (0) | 10 (2.4) | .010 | 2.78 (0) | 0 (0) | 2.78 (0) | N/A |
| Ad visual theme, N (%) | ||||||||
| Product | 548 (80.2) | 233 (86.6) | 315 (76.1) | <.001 | 14 866.43 (97.6) | 1318.87 (99.8) | 13 547.56 (95.9) | .009 |
| Product with woman | 112 (16.4) | 23 (8.6) | 89 (21.5) | 362.71 (2.4) | 1.62 (0.1) | 361.09 (2.6) | ||
| Product with man and women | 13 (1.9) | 13 (4.8) | 0 (0) | 1.56 (0) | 1.56 (0.1) | 0 (0) | ||
| Product with man | 6 (0.9) | 0 (0) | 6 (1.5) | 0.25 (0) | 0 (0) | 0.25 (0) | ||
| Text only | 4 (0.6) | 0 (0) | 4 (1.0) | 0.31 (0) | 0 (0) | 0.31 (0) | ||
| Media channel theme, N (%) | ||||||||
| Women's fashion | 116 (16.9) | 31 (11.5) | 85 (20.4) | <.001 | 2177.35 (14.1) | 413.37 (31.3) | 1763.98 (12.5) | <.001 |
| Technology | 114 (16.6) | 53 (19.7) | 61 (14.7) | 515.42 (3.3) | 382.66 (28.9) | 132.76 (0.9) | ||
| News or weather | 88 (12.9) | 36 (13.4) | 50 (12.0) | 4805.23 (31.1) | 17.14 (1.3) | 4,788.14 (33.9) | ||
| Entertainment or pop culture/gaming | 83 (12.1) | 4 (1.5) | 79 (19.0) | 5360.97 (34.7) | 0.20 (0) | 5360.78 (37.9) | ||
| Home | 56 (8.2) | 17 (6.3) | 39 (9.4) | 2.57 (0) | 0.54 (0) | 2.02 (0) | ||
| Men's fashion | 38 (5.6) | 10 (3.7) | 28 (6.7) | 2131.81 (13.8) | 498.97 (37.7) | 1632.84 (11.6) | ||
| Sports | 35 (5.1) | 29 (10.8) | 6 (1.4) | 5.22 (0) | 3.10 (0.2) | 2.12 (0) | ||
| Business | 30 (4.4) | 24 (8.9) | 6 (1.4) | 313.46 (2.0) | 1.32 (0.1) | 312.14 (2.2) | ||
| Travel | 22 (3.2) | 4 (1.5) | 18 (4.3) | 125.51 (0.8) | 0.05 (0) | 125.46 (0.9) | ||
| Yahoo | 20 (2.9) | 19 (7.1) | 1 (0.2) | 0.86 (0) | 0.78 (0.1) | 0.08 (0) | ||
| Other | 83 (12.1) | 42 (15.6) | 41 (9.9) | 13.41 (0.1) | 3.90 (0.3) | 9.52 (0.1) | ||
aAdjusted by consumer price index (2019 Q3, U.S. Bureau of Labor Statistics).
bPer Chi-square tests.
cPer ANOVAs.
dHeadline themes not discrete. N/A: ANOVAs not applicable due to empty cells.
Data Analysis
We conducted descriptive and bivariate analyses of ad occurrences (using Chi-square tests) and expenditures (using t-tests and ANOVAs) by media type, headline and visual theme, and theme of media channels to characterize IQOS advertising overall, as well as by period in the U.S. market—pre- versus post-MRTPA. Exploratory analyses also examined post-court IQOS advertising, from the time of the court decision to IQOS’ withdrawal from the U.S. market. All data management and analyses were conducted using Stata 15.1 (StataCorp LLC, College Station, TX).
Results
Primary Analyses: Pre- Versus Post-MRTPA
There were 685 total ad occurrences: 39.3% (n = 269) pre-MRTPA and 60.7% (n = 416) post-MRTPA (Table 2). Inflation-adjusted ad expenditures totaled $15 451 870: 8.6% ($1 322 048) pre-MRTPA and 91.4% ($14 129 822) post-MRTPA. Average ad expenditure per occurrence was $22 590: $4910 pre-MRTPA and $34 050 post-MRTPA (p < .001). Print accounted for most expenditures (99.6%); online display accounted for most occurrences (73.1%). From pre- and post-MRTPA, the proportion of ad occurrences via online display decreased (94.1% vs. 59.6%), but the proportions via print and mobile increased (4.1% vs. 30.8% and 1.9% vs. 9.6%, respectively, p < .001).
The ad headline representing the most occurrences pre-MRTPA was “The future of tobacco is here” (13.0%), followed by “Get IQOS” (10.7%) and “Real tobacco meets innovative technology” (6.3%; Table 1). Post-MRTPA, the most prominent ad headlines included “Get IQOS: Real heated tobacco is here with less odor to worry about; there’s no need to step away” (8.2%), “Get IQOS” (8.0%), and “IQOS uses heat sticks made with real tobacco” (8.0%).
Shown in Table 2, across ad occurrences and expenditures, prominent pre-MRTPA headline themes included “real tobacco” (38.7% of occurrences, 98.5% of expenditures), “less odor or ash” (12.6%, 97.9%), “Get IQOS” (35.3%, 0.7%), “future” (40.2%, 1.1%), and “innovation or technology” (20.1%, 0.4%). Post-MRTPA, 3 new headline themes emerged: “reduced exposure” (26.4% of post-MRTPA ad occurrences, 77.6% of post-MRTPA expenditures), “distinct from e-cigarettes” (20.7%, 71.3%), and “science or research” (2.4%, <1%). Other prominent post-MRTPA headline themes included “not burned or heat control” (32.7%, 51.6%), “innovation or technology” (42.3%, 51.7%), and “less odor or ash” (37.5%, 73.1%). From pre- to post-MRTPA, there were significant increases (p < .05) in the proportion of ad occurrences focused on “real tobacco” (38.7% pre-MRTPA vs. 62.7% post-MRTPA), “innovation or technology” (20.1% vs. 42.3%), “less odor or ash” (12.6% vs. 37.5%), “not burned or heat control” (1.9% vs. 32.7%), “switch” (1.9% vs. 21.2%), and “convenience” (2.6% vs. 19.0%). There were decreases in the proportions of occurrences themed “get IQOS” (35.3% vs. 26.7%) and “future” (40.2% vs. 0%).
From pre- to post-MRTPA, there were increases in the proportion of ad occurrences and expenditures allocated to ads featuring women with the product (from 8.6% to 21.5% per ad occurrences and 0.1% to 2.6% per ad expenditures), but decreases in ads featuring the product alone (from 86.6% to 76.1% per occurrences and 99.8% to 95.9% per expenditures; Table 2).
The most prominent pre-MRTPA media channel theme was “technology” (19.7% of occurrences, 28.9% of expenditures; Table 2). The most prominent post-MRTPA media channel themes post-MRTPA were “women's fashion” (20.4% of occurrences, 12.5% of expenditures) and “entertainment or pop culture/gaming” (19.0%, 37.9%).
Exploratory Analyses: Pre-MRTPA, MRTPA to Court Decision, and Post-court
The proportions of ad occurrences across the three periods were 39.3%, 48.8%, and 12.0%, respectively (p < .001; Supplementary Table), the proportions of ad expenditures were 8.6%, 30.0%, and 61.5%, and the average expenditures per occurrence were $4910, $13 860, and $117 310 (p < .001). There were few new headlines post-court decision, most commonly aiming to distinguish IQOS from cigarettes (eg, “No lighters. No ashtrays. Just real tobacco with less lingering odor”; Table 1). Post-court, ad occurrences, and expenditures indicated the prominence of print media (97.6% of post-court occurrences, nearly all of post-court expenditures); headline themes indicating “real tobacco” (97.6%, 99.0%), “less odor or ash” (96.3%, 99.0%), “distinct from e-cigarettes” (95.1%, 96.3%), “not burned or heat control” (72.0%, 73.6%), “innovation or technology” (72.0%, 73.6%), and “reduced exposure” (70.7%, 73.6%); ad imagery focused on the “product” (96.3%, 96.2%); and media channels thematically focused on “entertainment or pop culture/gaming” (40.2%, 43.2%) and “news or weather” (35.4%, 39.6%).
Discussion
This study expanded on previous research12 by examining the full duration of IQOS’ presence in the U.S. market, including after being the court order requiring its removal from the United States. Findings suggest that IQOS was aggressively marketed in the United States after receiving MRTPA, and such marketing remained aggressive after the court decision. This may potentially account for the recently growing awareness of IQOS in the United States16,17 and may lay the foundation for IQOS to reenter the U.S. market, which is likely.9
Post-MRTPA, new headline themes emerged (ie, “reduced exposure,” “science or research”), and some existing headline themes increased in prominence (ie, “switch,” “not burned or heat control”). Additionally, the theme “distinct from e-cigarettes” emerged, perhaps reflecting efforts to distinguish IQOS from e-cigarettes due to the attention focused on e-cigarette and vaping-associated lung injury.18 Visual themes and marketing channel themes suggest increased targeting of women post-MRTPA, with media channels (ie, entertainment or pop culture/gaming) potentially targeting young and/or technology-savvy people; these findings align with findings from prior research12 and provide more comprehensive data throughout IQOS’ presence in the U.S. market.
Notably, the pre-MRTPA period showed no evidence of paid IQOS ads using reduced exposure (or risk) claims. However, these data do not include content not clearly paid for by PM (eg, third-party promotion). Furthermore, certain ad headlines that did not require MRTPA (eg, “Meet IQOS: Real tobacco no ash less odor”) may impact consumers’ risk perceptions.11 This latter point may also explain why only ~26% of post-MRTPA ads used MRTPA language; perhaps industry research found that advertising language not requiring MRTPA had similar impact—or different consumer segments are impacted by advertising language unrelated to exposure or risk.
Also notable is the large proportion of ad expenditures for print versus online, which contrasts the large proportion of ad occurrences online relative to print. Advertising in traditional media like print is more expensive but perhaps a necessary part of a marketing strategy.19 However, digital media provides a low-cost alternative with high reach that is increasingly used by industries,19 including the tobacco industry.20
Limitations
Study limitations include potential underestimates of ad expenditures, due to possible missing data and unassessed marketing activities, like event sponsorship or social media promotions—either directly or indirectly traceable to industry financial support. Additionally, the relatively small number of ad occurrences limited statistical power, and ad expenditures were heavily influenced by print-related expenditures. Finally, coronavirus disease 2019 and other regulatory and societal events likely impacted IQOS marketing activities during this timeframe.
Conclusions
IQOS was increasingly marketed post-MRTPA, despite its court-required removal from the U.S. market. Given IQOS’ potential reentry to the United States, surveillance of its marketing strategies in the United States if or when it does—and in other countries—is crucial, particularly given PM’s exploitation of the FDA authorization to promote IQOS in other countries.12,13 Additionally, as the nicotine market in the United States expands, further population studies are needed to evaluate the impact of marketing, particularly marketing using reduced risk or exposure language, on consumer understanding, perceptions, and behaviors, including among specific subpopulations.
Supplementary Material
A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.
Acknowledgments
Institutional Review Board approvals were obtained from George Washington University (IRB# NCR213416) and Hebrew University (27062021).
Contributor Information
Zongshuan Duan, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
Hagai Levine, Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem and Hadassah Medical Center, Jerusalem, Israel.
Katelyn F Romm, Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; TSET Health Promotion Research Center, Stephenson Cancer Center, Univeristy of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
Yael Bar-Zeev, Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem and Hadassah Medical Center, Jerusalem, Israel.
Lorien C Abroms, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; George Washington Cancer Center, George Washington University, Washington, DC, USA.
Lynniah Griffith, Wellesley College, Wellesley, M, A, USA.
Yan Wang, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; George Washington Cancer Center, George Washington University, Washington, DC, USA.
Amal Khayat, Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem and Hadassah Medical Center, Jerusalem, Israel.
Yuxian Cui, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA.
Carla J Berg, Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; George Washington Cancer Center, George Washington University, Washington, DC, USA.
Funding
This work was supported by the U.S. National Cancer Institute (R01CA239178-01A1, MPIs: Berg, Levine). Dr. Berg is also supported by other U.S. National Institutes of Health funding, including the National Cancer Institute (R01CA215155-01A1; PI: Berg; R21CA261884-01A1, MPIs: Berg, Arem), the Fogarty International Center (R01TW010664-01, MPIs: Berg, Kegler), the National Institute of Environmental Health Sciences/Fogarty (D43ES030927-01, MPIs: Berg, Caudle, Sturua), and the National Institute on Drug Abuse (R01DA054751-01A1, MPIs: Berg, Cavazos-Rehg). Dr. Romm is supported by the National Institute on Drug Abuse (R25DA054015, MPIs: Obasi, Reitzel), the Oklahoma Tobacco Settlement Endowment Trust (TSET) contract #R22-03, and the National Cancer Institute grant awarded to the Stephenson Cancer Center (P30CA225520).
Declaration of Interests
YB-Z has received fees for lectures from Pfizer, Novartis NCH, and GSK Consume Health (distributors of pharmacotherapy in Israel) in the past (2012–July 2019). LCA receives royalties for the sale of Text2Quit. No other conflicts of interest are declared. The authors declare no other conflicts of interest.
Data Availability
Data not publicly available.
References
- 1. World Health Organization. Tobacco Free Initiative (TFI): Heat-Not-Burn tobacco products information sheet. Accessed October 13, 2022. https://www.who.int/publications/i/item/WHO-HEP-HPR-2020.2
- 2. Gale N, McEwan M, Camacho OM, Hardy G, Murphy J, Proctor CJ. Changes in biomarkers of exposure on switching from a conventional cigarette to the glo tobacco heating product: a randomized, controlled ambulatory study. Nicotine Tob Res. 2021;23(3):584–591. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Ling PM, Glantz SA.. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. Am J Public Health. 2002;92(6):908–916. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. U.S. Department of Health and Human Services, Food and Drug Administration. Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Accessed October 13, 2022. https://www.federalregister.gov/d/2016-10685 [PubMed]
- 5. U.S. Department of Health and Human Services, Food and Drug Administration. Submit Tobacco Product Applications for Deemed Tobacco Products. Accessed October 13, 2022. https://www.fda.gov/tobacco-products/manufacturing/submit-tobacco-product-applications-deemed-tobacco-products
- 6. U.S. Food and Drug Administration. Premarket Tobacco Product Marketing Granted Orders. Accessed October 13, 2022. https://www.fda.gov/tobacco-products/premarket-tobacco-product-applications/premarket-tobacco-product-marketing-granted-orders
- 7. U.S. Centers for Disease Control and Prevention. Heated Tobacco Products. Accessed October 13, 2022. https://www.cdc.gov/tobacco/basic_information/heated-tobacco-products/index.html#what-are-htp
- 8. U.S. Food & Drug Administration. Modified Risk Granted Orders - Exposure Modification.2022. Accessed June 23, 2023. https://www.fda.gov/media/139797/download
- 9. Corinne Gretler SD. Philip Morris IQOS Imports Barred From U.S.; Deadline Passes. October 13, 2022. Accessed June 23, 2023. https://www.bloomberg.com/news/articles/2021-11-29/philip-morris-iqos-imports-barred-from-u-s-as-deadline-passes?leadSource=uverify%20wall
- 10. Berg CJ, Duan Z, Wang Y, et al. Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults. Tob Control. 2022. Published Online First: 25 November 2022. doi: 10.1136/tc-2022-057639. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Yang B, Massey ZB, Popova L.. Effects of modified risk tobacco product claims on consumer comprehension and risk perceptions of IQOS. Tob Control. 2021;31:e41–e49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Berg CJ, Romm KF, Bar-Zeev Y, et al. IQOS marketing strategies in the USA before and after US FDA modified risk tobacco product authorisation. Tob Control. 2021;32(4):418–427. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Berg CJ, Abroms LC, Levine H, et al. IQOS marketing in the US: The Need to Study the Impact of FDA modified exposure authorization, marketing distribution channels, and potential targeting of consumers. Int J Env Res Public Health. 2021;18(19):10551. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Huber V. Occurrence Level Data Dictionary, Quick guide to occurrence data field definitions. Accessed June 22, 2023. https://www.vivvix.com/vivvix-resources
- 15. US Bureau of Labor Statistics. Consumer Price Index. Accessed October 13, 2022. https://www.bls.gov/cpi/
- 16. Duan Z, Wysota CN, Romm KF, et al. Correlates of perceptions, use, and intention to use heated tobacco products among US young adults in 2020. Nicotine Tob Res. 2022;24(12):1968–1977. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Duan Z, Le D, Ciceron AC, et al. “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. Health Ed Res. 2022;37(5):364–377. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Resp Med. 2019;7(12):1017–1026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Krishen AS, Dwivedi YK, Bindu N, Kumar KS.. A broad overview of interactive digital marketing: A bibliometric network analysis. J Bus Res. 2021;131(2):183–195. [Google Scholar]
- 20. Ali FRM, Marynak KL, Kim Y, et al. E-cigarette advertising expenditures in the USA, 2014–2018. Tob Control. 2020;29(e1):e124–e126. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data not publicly available.