The impact of IQOS modified risk messaging on physicians’ product perceptions and recommendations

INTRODUCTION

The US Food & Drug Administration (FDA) has developed a pathway by which tobacco companies can request products be authorized as “modified risk tobacco products” (MRTPs) and make claims about reduced risks or constituent exposures.[1] MRTP claims have been authorized for only four products including IQOS.[1,2] While IQOS ads with authorized MRTP claims are targeted at people who smoke cigarettes, we examined whether such ads and claims may also impact physicians, who are an important source of patient information regarding tobacco harms.[3,4]

METHODS

Data come from a broader US survey of a national sample of board-certified physicians about their tobacco-related beliefs and practices.[5] An IQOS experiment was embedded in the online survey version. Data were collected (May-October 2021) before US IQOS sales were halted in November 2021 because of a patent infringement ruling.[6]

Subjects were randomly assigned to one of three groups in which they viewed a manipulated IQOS ad that either included no MRTP message (control) or FDA authorized MRTP message about reduced chemicals (Experimental Groups 1 and 2; EG1, EG2, Table 1). A brief introduction appeared above the ad image, with a basic description of IQOS. For participants in EG2 only, this included the statement that “The product and messages in this ad were authorized by the FDA.”

Table 1.

Impact of Message Version on Physician’s IQOS Harm Perceptions and Recommendation Willingness, 2021 (n= 543)

	Harm of IQOS vs Regular Cigarettesa				Would recommend switching to IQOSb
	Mean	SD	p-value		%	OR	95% CI	p-value
Control Ad (n= 181)	−0.60	1.27	ref		30.2	1.00	ref
Experimental Group 1 (modified exposure claim) (n= 180)	−0.79	1.15	0.491		38.4	1.44	0.92–2.25	0.113
Experimental Group 2 (modified exposure claim + FDA Authorization) (n= 182)	−0.82	1.24	0.368		42.2	1.69	1.08–2.63	0.0213
Exp Group 1 vs. Exp. Group 2c			0.978			1.17	0.76–1.80	0.469

^a“Do you think that using IQOS would be less harmful, about the same, or more harmful to a person’s health than smoking regular cigarettes?” Response options consisted of a scale ranging from −3 (less harmful) to 3 (more harmful). A score of 0 indicated the respondent believed the two products to be “about the same.”

^b“For a patient who smokes cigarettes and is not willing to quit, but open to switching products, please indicate whether you would recommend switching to IQOS” (“yes”/“no”).

^cCompares the means of Exp Group 1 versus 2 on perceived harm outcome; compares the odds ratios of the same groups for recommendation outcomes, treating Exp. Group 1 as the reference

Note: Ads in all three conditions included an image of the product, a nicotine warning label, a standard cigarette warning label, and the following ad text: “Meet IQOS. Real Tobacco. No ash. Less Odor.” An image of the control version of this ad can be found at: http://www.trinketsandtrash.org/detail.php?artifactid=14821&page=1

The ads for Experimental Groups 1 and 2 were manipulated to additionally contain the following modified exposure claims, statements previously authorized by the FDA and used in real-world IQOS ads. This text was included on the ad underneath the image of the product, on the left and right hand sides. (Left side): “Reduce your body’s exposure to harmful chemicals by switching completely to IQOS. The IQOS system heats tobacco but does not burn it”. (Right side): “This significantly reduces the production of harmful and potentially harmful chemicals. Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.”

In all conditions the ad image was preceded by the following brief statement in the survey: “IQOS is a new “heat-not-burn” product that heats sticks of tobacco (creating an aerosol), but does not burn them. It may appeal to smokers looking for an alternative to cigarettes, but who don’t like e-cigarettes. Please take a moment to look at the IQOS ad below.” In Experimental Group 2, this introduction included one additional sentence at the end referring to FDA Authorization: “The product and messages in this ad were authorized by the FDA.” This additional statement was the only difference between Experimental Groups 1 and 2.

Participant demographics did not significantly differ by experimental condition and are available in Supplemental Table 1.

Primary outcomes included perceived harm of IQOS compared to cigarettes and willingness to recommend switching to IQOS for a patient who smokes that is unwilling to quit but open to switching products (Table 1).

Data were analyzed using SAS 9.4 with ANOVA tests to compare mean harm perception ratings and logistic regression to examine group effects on odds of patient recommendation.

RESULTS

Of the 543 respondents, only 5.4% had heard of IQOS before, seen an IQOS ad (2.1%) or been asked by a patient about IQOS (0.6%), indicating participants were generally naïve to IQOS.

There was no effect of experimental condition on perceived harm of IQOS relative to cigarettes. However, physicians in EG2 (MRTP message + FDA authorization reference) had significantly higher odds (OR=1.69, 95% CI 1.08–2.63) of willingness to recommend switching to IQOS relative to those in the control group. There was no significant difference between EG1 and control.

DISCUSSION

Previous research with consumers, including adults who smoke, have found effects of IQOS ads with modified exposure claims on reduced product harm perceptions and/or increased use intentions.[2,7] This study finds that exposure to such claims may also influence physicians’ willingness to recommend IQOS to their smoking patients, which could indirectly influence consumer product use. However, our findings also suggest that being informed that novel products or reduced risk claims have been authorized by the FDA may be important in physicians’ willingness to recommend them. Overall, study findings are important given that US IQOS sales and marketing are expected to resume in 2024[6], and that physicians are a trusted source of tobacco information/advice, but are not well informed about novel tobacco/nicotine products.[3–5] Future research examining effects of other MRTP ads or interventions should also consider physicians as a relevant audience group.

Data Availability Statement

Experimental stimuli images and data reported in this study are available upon reasonable request to the corresponding author.