Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults

Abstract

The marketing of heated tobacco products (HTPs), like IQOS, influences consumers’ perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. ‘Go smoke-free…’) across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.

Introduction

The global tobacco market has expanded to include new products like heated tobacco products (HTPs) [1, 2]. Philip Morris International’s (PMI’s) IQOS, the global HTP leader [2], has unique histories in Israel and the United States. In Israel, IQOS was introduced without regulation in 2016 and then faced weak regulation from 2017 to 2018 when classified as a tobacco product. In 2019–20, Israel passed progressive tobacco control legislation, including advertising restrictions (2019) and plain packaging requirements (2020) that applied to IQOS [3]. In the United States, IQOS was launched in 2019 [4, 5] and received authorization from the US Food and Drug Administration (FDA) in 2020 to use advertising messages regarding reduced exposure to harmful chemicals, but ‘not’ claims that it is safer or less harmful than other tobacco [6]. IQOS sales ceased in the United States in November 2021 due to a patent-infringement lawsuit [7] but are expected to resume in 2024 [8, 9]. Perhaps due to IQOS’ longstanding history in Israel, 2021 estimates indicated that 16% of Israeli adults had ever used IQOS, with 8% currently using [10], while 3% of US adults had ever used IQOS, with 1% currently using [10].

HTP-related consumer behavior may be influenced by marketing elements like product design, distribution and promotion [10, 11]. Regarding product design and distribution, IQOS is available in different colors and designs, allowing consumers to personalize the device [3], and the devices, heatsticks and accessories (e.g. cleaning sticks) are available via select traditional retailers (e.g. convenience stores), IQOS specialty stores and online [3].

IQOS uses aggressive promotional activities (e.g. social events, membership programs, price promotions, point-of-sale displays, and online promotion via social media) [9, 12–18]. Advertising messages often indicate reduced risk [3, 18, 19], which may appeal to [20–25] and/or mislead consumers [21, 26–31]. For example, consumers misperceive FDA-authorized statements regarding ‘reduced exposure’ claims to mean lower risk [21, 26–30] and may even misinterpret smoking health warnings as endorsements for IQOS [27, 31]. Other advertising messages emphasize IQOS as a clean, chic and pure product, more acceptable to non-smokers, and a satisfactory alternative to cigarettes (despite mixed findings [32–34]) [9, 14, 18, 34].

PMI asserts that IQOS’ target market is current cigarette smokers [35–37]—and ‘not’ young people [35–37]. While research from the United States [38, 39] and other countries (e.g. Israel [10], Italy [40] and Korea [41]) indicates that those using IQOS also more likely smoke cigarettes and/or e-cigarettes, those who never smoked (versus currently smoke) are equally or more likely to have tried or intend to try IQOS [40], and IQOS marketing targets youth and young adults [9, 18, 42], who also show relatively high use and interest in use [38, 43]. Additionally, HTP use is more prevalent among men and racial/ethnic minorities [38, 39, 44].

Given the importance of marketing and its influences on perceptions of HTPs and other newer tobacco products among different consumer subgroups, this mixed-methods study aimed to provide insights regarding perceptions of IQOS and its marketing among US and Israeli adults. Despite these countries’ distinct IQOS regulatory histories and use rates, IQOS has been marketed using similar advertising content and marketing channels in these countries [9, 18, 44–46], and PMI has used IQOS’ US FDA reduced exposure authorization in its Israel-based marketing [44]. We hypothesized that IQOS and its marketing would be perceived more favorably among certain subgroups, including those who currently use other tobacco products (particularly cigarettes and/or e-cigarettes) and those aware of or who have used HTPs (including those in Israel where IQOS has a longer history and higher use rates [10]).

Materials and Methods

We analyzed data from a tobacco-related study among US and Israeli adults, particularly pertaining to HTPs given their distinct histories but similar marketing in the US and Israel [10]. This study used a sequential explanatory mixed-methods design (i.e. quantitative data collection, followed by qualitative data to explain quantitative findings); such designs are strategic when quantitative findings can be better understood through such qualitative approaches [47]. The study received ethical approvals from George Washington University (NCR213416) and Hebrew University (27062021). The current study analyzed (i) cross-sectional survey data (collected in October–December 2021) and (ii) semi-structured interviews (conducted in Spring 2022). This study adhered to STrengthening the Reporting of OBservational studies in Epidemiology guidelines for cross-sectional quantitative research and Consolidated Criteria for Reporting Qualitative Research guidelines for qualitative research.

Quantitative data

Participants

Eligibility criteria included respective country citizenship, age 18–45 years (because alternative tobacco product use is most prevalent among those ≤45 years [48–50]) and able to speak English (United States) or Hebrew or Arabic (Israel). In each country, we aimed for sufficient numbers reporting current tobacco use (40–50%) and representing the sexes (∼50% each) and country-specific racial/ethnic targets.

In the United States, racial/ethnic quotas were ∼45% White, ∼25% Black, ∼15% Asian, and ∼15% Hispanic. The US survey was conducted primarily using KnowledgePanel^®, a probability-based web panel designed to be representative (recruited via random-digit dialing and address-based sampling), supplemented with off-panel recruitment (via banner ads and web pages) to meet subgroup recruitment targets (i.e. Asian reporting tobacco use). Of 4960 panelists recruited, 2397 (48.3%) completed eligibility screening and 1095 (45.7%) completed the survey; of 353 off-panel individuals screened, 33 (9.3%) were eligible and completed the survey.

The Israeli survey was conducted using opt-in sampling and ethnic targets of ∼85% Jewish and ∼15% Arab. Ipsos recruited the opt-in sample through a blend of sources, primarily by using banner ads, web pages and e-mail invitations. Those who clicked online ads were sent to a study landing page. Ipsos used a pre-screening process to ensure eligibility (age, citizenship and language) and reach subgroup quotas (sex, ethnicity and tobacco use). Of 2970 individuals screened, eligible and allowed to advance to the survey (i.e. target enrollment not yet reached), 1094 (36.8%) completed the survey.

Measures

Supplementary Table S1 provides specific assessments administered.

IQOS product and marketing assessment

Participants were presented with a photo of IQOS (Fig. 1a) and its description (i.e. ‘…heats but doesn’t burn tobacco and consists of the device, charger, and heatstick’). They were then asked, ‘Before beginning this survey, had you heard of heated tobacco products, like IQOS?’ Then, participants were asked to rate the appeal of its overall design, technology, device colors (Fig. 1b), accessories/customization (Fig. 1b), flavors (e.g. amber, bronze, purple, sienna, turquoise and yellow; see Fig. 2 for flavor descriptions), maintenance and specialty stores (Fig. 1c); response options were 1 = not at all, 2 = a little, 3 = neutral/unsure, 4 = somewhat and 5 = very. Participants were also asked to rank in order the three flavors they (i) would be most likely to try and (ii) perceived as least harmful. They were also provided the average cost of the device and heatsticks and assessed cost (1 = much too cheap to 5 = much too expensive). Participants were also asked, ‘For each of the following slogans, indicate the extent to which each might persuade you to try IQOS?’ (see Table II for full list; 1 = not at all to 5 = very). Responses to marketing messages were averaged to create a ‘marketing message persuasiveness index score’ (Cronbach’s α = 0.96). An overall product/marketing ‘appeal index score’ was created by taking an average of each product attribute score (e.g. design, technology and colors) and message persuasiveness score (Cronbach’s α = 0.79).

Fig. 1.

IQOS product design, colors, accessories and retailers.

Fig. 2.

IQOS flavors.

Table II.

Bivariate comparisons regarding sociodemographics, tobacco use characteristics and appeal of IQOS product and marketing across cigarette and e-cigarette use groups of adults in the United States and Israel

Variables	Total N = 2222 (100%)	No cigarette or e-cigarette use n = 1396 (62.8%)	Cigarette/ no e-cigarette n = 381 (17.1%)	E-cigarette/ no cigarette n = 145 (6.5%)	Dual cigarette/ e-cigarette use n = 300 (13.5%)	P
Sociodemographics
Israel (versus United States) resident, n (%)	1094 (49.2)	601 (43.1)	218 (57.2)	65 (44.8)	210 (70.0)	<0.001
Age, M (SD)	32.19 (7.74)	32.32 (7.81)	33.28 (7.46)	30.04 (7.42)	31.22 (7.67)	<0.001
Female, n (%)	1118 (50.3)	743 (53.2)	176 (46.2)	64 (44.1)	135 (45.0)	0.005
College degree or more, n (%)	953 (42.9)	635 (45.5)	139 (36.5)	53 (36.6)	126 (42.0)	0.005
Married/cohabitating, n (%)	1186 (53.4)	732 (52.4)	176 (53.8)	72 (49.7)	177 (59.0)	0.162
Children <18 years in the home, n (%)	1125 (50.6)	701 (50.2)	185 (48.6)	66 (45.5)	173 (57.7)	0.042
HTP awareness, n (%)	677 (30.5)	292 (20.9)	147 (38.6)	55 (37.9)	183 (61.0)	0.001
Past 30-day use, n (%)
Cigarettes	681 (30.6)	0 (0.0)	381 (100.0)	0 (0.0)	300 (100.0)	<0.001
Days of use in those with past 30-day use, M (SD)	15.85 (11.77)	0 (0.00)	17.09 (12.12)	0 (0.00)	14.28 (11.13)	0.002
E-cigarettes	445 (20.0)	0 (0.0)	0 (0.0)	145 (100.0)	300 (100.0)	<0.001
Days of use in those with past 30-day use, M (SD)	10.54 (10.62)	0 (0.00)	0 (0.00)	13.97 (12.45)	8.89 (9.19)	<0.001
HTPs	172 (7.7)	9 (0.6)	53 (13.9)	22 (15.2)	88 (29.3)	<0.001
Days of use in those with past 30-day use, M (SD)	5.84 (5.52)	3.11 (3.06)	5.36 (4.96)	3.64 (3.13)	6.95 (6.21)	0.020
Appeal of IQOS product and marketing, M (SD)a
IQOS design	2.69 (1.40)	2.38 (1.35)	3.00 (1.33)	3.11 (1.32)	3.53 (1.25)	<0.001
IQOS technology	2.57 (1.36)	2.24 (1.28)	2.90 (1.34)	3.08 (1.28)	3.47 (1.20)	<0.001
IQOS colors	2.99 (1.49)	2.73 (1.47)	3.29 (1.47)	3.32 (1.40)	3.66 (1.37)	<0.001
IQOS accessories, customization	2.91 (1.47)	2.67 (1.45)	3.16 (1.45)	3.26 (1.50)	3.55 (1.32)	<0.001
IQOS flavors	2.79 (1.44)	2.45 (1.38)	3.17 (1.37)	3.23 (1.37)	3.67 (1.24)	<0.001
Likelihood of entering IQOS store	2.05 (1.32)	1.60 (1.04)	2.57 (1.40)	2.62 (1.34)	3.19 (1.29)	<0.001
IQOS maintenance reduces appealc	2.86 (1.33)	2.77 (1.34)	2.98 (1.34)	3.08 (1.34)	3.03 (1.24)	<0.001
IQOS cost evaluationb,  c	3.89 (1.00)	3.93 (1.02)	3.85 (1.01)	3.89 (0.97)	3.82 (0.96)	0.264
Persuasiveness of IQOS marketing messages
Real tobacco meets innovative technology	2.22 (1.33)	1.78 (1.13)	2.73 (1.33)	2.87 (1.35)	3.27 (1.20)	<0.001
Go Smoke-free, Go IQOS	2.26 (1.33)	1.89 (1.19)	2.61 (1.29)	2.85 (1.38)	3.28 (1.23)	<0.001
True tobacco taste	2.11 (1.28)	1.69 (1.05)	2.59 (1.28)	2.68 (1.38)	3.14 (1.27)	<0.001
Meet IQOS: real tobacco, no ash, less odor	2.39 (1.41)	1.90 (1.22)	3.02 (1.33)	3.07 (1.40)	3.52 (1.17)	<0.001
Moving beyond smoking	2.26 (1.37)	1.88 (1.21)	2.62 (1.36)	2.97 (1.42)	3.22 (1.29)	<0.001
Change to tobacco without smoke and ashes	2.26 (1.38)	1.83 (1.19)	2.75 (1.37)	2.96 (1.45)	3.28 (1.24)	<0.001
The future of tobacco has arrived	2.23 (1.36)	1.83 (1.19)	2.59 (1.36)	3.28 (1.27)	2.23 (1.36)	<0.001
A cleaner way to use tobacco	2.43 (1.41)	1.97 (1.24)	2.98 (1.36)	3.24 (1.40)	3.47 (1.17)	<0.001
This changes everything	2.22 (1.36)	1.83 (1.19)	2.60 (1.37)	2.94 (1.44)	3.19 (1.27)	<0.001
Your IQOS, Your way	2.12 (1.32)	1.74 (1.12)	2.51 (1.33)	2.66 (1.41)	3.14 (1.33)	<0.001
Message persuasiveness scored	2.25 (1.14)	1.83 (0.99)	2.70 (1.03)	2.91 (1.10)	3.27 (0.91)	<0.001
Overall IQOS product and marketing appeal scorec,  e	2.93 (0.81)	2.68 (0.73)	3.11 (0.78)	3.16 (0.75)	3.47 (0.75)	<0.001
Flavor most likely to use, n (%)f						<0.001
Turquoise	518 (23.6)	353 (25.7)	75 (19.8)	33 (22.8)	57 (19.0)
Amber	472 (21.5)	296 (21.5)	95 (25.1)	27 (18.6)	54 (18.0)
Purple	473 (21.5)	268 (19.5)	97 (25.6)	33 (22.8)	75 (25.0)
Bronze	306 (13.9)	174 (12.7)	55 (18.0)	19 (13.1)	58 (19.3)
Yellow	228 (10.4)	168 (12.2)	29 (7.7)	13 (9.0)	18 (6.0)
Sienna	202 (9.2)	116 (8.4)	28 (7.4)	20 (13.8)	38 (12.7)
Flavor perceived least harmful, n (%)f						<0.001
Turquoise	852 (38.6)	557 (40.3)	144 (38.0)	56 (38.6)	95 (31.7)
Amber	410 (19.0)	281 (20.3)	57 (15.0)	27 (18.6)	55 (18.3)
Yellow	328 (14.9)	212 (15.4)	63 (16.6)	24 (16.6)	29 (9.7)
Bronze	231 (10.5)	119 (8.6)	45 (11.9)	14 (9.7)	53 (17.7)
Purple	211 (9.6)	128 (9.3)	41 (10.8)	12 (8.3)	30 (10.0)
Sienna	163 (7.4)	84 (6.1)	29 (7.7)	12 (8.3)	38 (12.7)

Notes: Bold indicates P < 0.05. ^a1 = not at all to 5 = very.

^b1 = much too cheap to 5 = much too expensive.

^cExcluded in appeal score due to low Cronbach’s α.

^dCronbach’s α = 0.96.

^eIndex score includes design, technology, color, accessories, maintenance, flavors, likelihood to enter store, cost and slogan persuasiveness score. Cronbach’s α = 0.79.

^fPresents top rank for: ‘Based on how each flavor is described and presented, please rank in order the 3 flavors: (1) you would be most likely to try; and (2) you think are the least harmful to use.’

Tobacco use

We assessed the past 30-day (current) use of cigarettes, e-cigarettes and HTPs (yes/no) [51, 52]. To determine how to operationalize tobacco use variables, exploratory analyses examined current and lifetime use of each and the overlap. Lifetime and current use (respectively) were 54.1% and 30.6% for cigarettes, 37.4% and 20.0% for e-cigarettes, and 13.8% and 7.7% for HTPs. Among those ‘currently’ using HTPs (n = 172), (i) 94.8% (n = 163) also currently used (a) cigarettes but not e-cigarettes (30.8%), (b) e-cigarettes but not cigarettes (12.8%) or (c) both (51.2%) and (ii) only 5.2% (n = 9) currently used only HTPs. Among those reporting ‘lifetime’ HTP use (n = 307), (i) 76.2% (n = 234) also currently used (a) cigarettes but not e-cigarettes (28.3%), (b) e-cigarettes but not cigarettes (11.7%) or (c) both (36.2%) and (ii) 23.8% (n = 73) reported not currently using cigarettes or e-cigarettes. In those reporting ‘lifetime HTP but not current cigarette or e-cigarette use’ (n = 73), (i) 91.8% (n = 67) reported lifetime use of (a) cigarettes but not e-cigarettes (11.0%), (b) e-cigarettes but not cigarettes (24.7%) or (c) both (56.2%) and (ii) only 8.2% (n = 6) ever used HTPs only. Given that we did not assess the extent of HTP use among those with lifetime HTP use or how HTP, cigarette and e-cigarette use levels compared, we categorized participants based on current cigarette and e-cigarette use (i.e. cigarettes/no e-cigarettes, e-cigarettes/no cigarettes and dual/both) and accounted for current HTP use separately. However, supplementary analyses also compared participants reporting never, former (lifetime but not current) and current HTP use. [Note that current use prevalence of hookah, cigars, pipe and smokeless tobacco was low (5–13%) and 80–95% overlapped with current cigarette or e-cigarette use [10]; thus, analyses did not account for these products separately.]

Sociodemographic covariates

We included country, age, sex, education, relationship status and children in the home.

Data analysis

Descriptive and bivariate analyses characterized participants’ sociodemographics, tobacco use characteristics and appeal of IQOS product and marketing factors. Associations between HTP use group and appeal were as expected (i.e. never use related to least appeal and current use related to greatest appeal), and country-specific analyses showed few differences in associations of sociodemographics and tobacco use characteristics to appeal. Thus, primary analyses examined differences in appeal by cigarette/e-cigarette use group—accounting for HTP use separately—with the entire cross-country sample, allowing examination of differences between Israeli and US participants, accounting for other factors.

Then, multivariable linear regression analyses examined sociodemographic covariates, country, HTP awareness, current HTP use and cigarette/e-cigarette use subgroups in relation to the overall product/marketing appeal index score, using the ‘neither cigarette/e-cigarette use’ group as the referent group. Subsequently, a similar regression model was conducted, excluding participants reporting using neither cigarettes/e-cigarettes in order to contrast the three use subgroups with one another (using dual use as the referent group). Country-specific regression analyses were also conducted. Analyses were conducted using SPSS (v27.0) and alpha = 0.05.

Qualitative data

Participants

Participants in both countries were purposively recruited for representation by sex, race/ethnicity and tobacco use. The US participants were recruited from the online survey sample (i.e. called/emailed invitations). In Israel, the opt-in sample for the online survey precluded our ability to re-contact survey participants; instead, we promoted the study via ads on Facebook; individuals who clicked ads were provided study description, consented and screened for eligibility (i.e. ≥18 years, speak Hebrew/Arabic and current or former cigarette use) and to reach subgroup targets (i.e. sex and ethnicity).

Assessment

Each interview was conducted online via Zoom in English (United States) or Hebrew/Arabic (Israel; participant’s choice), audio-recorded, ∼45 min long, and incentivized (USD$25 or 100 New Israeli Shekels). The interview guide first described IQOS using the same description as in the survey and stated, ‘IQOS began being sold in the US in Fall 2019; however, IQOS stopped being sold in the US in November 2021 because of a lawsuit with another tobacco company.’ Participants were asked, ‘Did you: hear about IQOS before today? See IQOS ads? See articles in newspapers, magazines, or online about IQOS? Try/use IQOS?’ Participants without prior use were asked, ‘Would you try IQOS?’ Those who currently or ever used IQOS were asked about their use (i.e. frequency, when, where and why). Then, participants were asked, ‘What do you think about IQOS? What is appealing? What concerns might you have? Who do you think it is meant for? How does it compare to [cigarettes; e-cigarettes]?’

Qualitative analysis

Interviews were professionally transcribed. Data were analyzed using deductive-inductive thematic analysis [53]. Preliminary deductive codes were compiled based on the interview guide and preliminary review of US-based transcripts. Then, a subsample of eight US transcripts and eight translated Arabic and Hebrew interviews (n = 4 each) were independently reviewed by two US-based coders and two Israeli-based coders. An iterative process was used to assess inter-rater reliability, reach consensus, inform revisions, yield additional codes based on emergent themes and finalize the codebook [53]. After ensuring sufficient inter-rater reliability (>80%), the remainder of the interviews were coded. Themes were summarized, any differences across countries were noted, and quotes were selected to represent themes and different use profiles. (Note that comparing qualitative responses/themes by distinct tobacco use subgroups was complex and yielded limited insights due to overlap in current and lifetime product use.)

Results

Survey and interview participant characteristics are shown in Table I.

Table I.

Sociodemographics and tobacco use characteristics of survey participants (N = 2222) and interview participants (N = 84)

	Survey participants			Interview participants
	Total (N = 2222)	United States (n = 1128)	Israel (n = 1094)	Total (N = 84)	United States (n = 40)	Israela (n = 44)
Sociodemographics
Age, M (SD)	32.19 (7.74)	34.11 (7.23)	30.21 (7.76)	32.90 (6.27)	36.50 (6.25)	29.35 (6.20)
Female, n (%)	1118 (50.3)	562 (49.8)	556 (50.8)	40 (45.5)	17 (42.5)	23 (52.3)
US race/ethnicity, n (%)
White	493 (22.2)	493 (43.7)		13 (14.8)	13 (32.5)	–
Black	284 (12.8)	284 (25.2)	–	13 (14.8)	13 (32.5)	–
Asian	177 (8.0)	177 (15.7)	–	5 (5.7)	5 (12.5)	–
Hispanic	174 (7.8)	174 (15.4)	–	9 (10.2)	9 (22.5)	–
Israel ethnicity, n (%)
Jewish	954 (42.9)	–	954 (87.2)	39 (44.3)	–	39 (88.6)
Arab	140 (6.3)	–	140 (12.8)	5 (5.7)	–	5 (11.4)
HTP awareness, n (%)	677 (30.5)	244 (21.6)	433 (39.6)	–	–	—
Past 30-day use, n (%)						b
Cigarettes	681 (30.6)	253 (22.4)	428 (39.1)	41 (46.6)	17 (42.5)	24 (54.5)
E-cigarettes	445 (20.3)	170 (15.5)	275 (25.2)	18 (21.4)	18 (45.0)	1 (2.3)
HTPs	172 (7.8)	36 (3.2)	136 (12.5)	13 (15.5)	6 (15.0)	7 (15.9)
Past 30-day cigarette/e-cigarette use group, n (%)						c
Neither cigarette/e-cigarette use	1396 (62.8)	795 (70.5)	601 (54.9)	–	12 (30.0)	0 (0.0)
Cigarette/no e-cigarette	381 (17.1)	163 (14.5)	218 (19.9)	–	10 (25.0)	234 (52.3)
E-cigarette/no cigarette	145 (6.5)	80 (7.1)	65 (5.9)	–	11 (27.5)	0 (0.0)
Dual cigarette/e-cigarette use	300 (13.5)	90 (8.0)	210 (19.2)	–	7 (17.5)	1 (2.3)

Notes: ^aIn Israel, the opt-in sample for the online survey precluded re-contacting survey participants; instead, we promoted the study via ads on Facebook. Potential participants were provided a study description, consented and screened for eligibility (i.e. ≥18 years old, speak Hebrew or Arabic and reported current or former cigarette use); thus, not all measures/sample targets align exactly.

^bOutside of current use: n = 20 (45.5%) reported former use of cigarettes, n = 38 (86.4%) e-cigarettes and n = 12 (27.3%) HTPs.

^cCurrent neither cigarette/e-cigarette use included five reporting current HTP use; current cigarette/no e-cigarette only group included 20 former e-cigarette use (one of which reported current HTP use); one participant reporting current dual cigarette/e-cigarette use reported never HTP use.

Quantitative results

Product attributes reported as most highly appealing were colors (M = 2.99, SD = 1.49), accessories/customization (M = 2.91, SD = 1.47), flavors (M = 2.79, SD = 1.44), design (M = 2.69, SD = 1.40) and technology (M = 2.57, SD = 1.36; Table II). On average, participants were neutral regarding maintenance (M = 2.86, SD = 1.33), perceived IQOS as somewhat expensive (M = 3.89, SD = 1.00) and were a little likely to enter an IQOS store (M = 2.05, SD = 1.32).

Bivariate analyses by cigarette/e-cigarette use subgroup

Across subgroups (62.8% neither cigarettes/e-cigarettes, 17.1% cigarette/no e-cigarette, 6.5% e-cigarette/no cigarette and 13.5% dual cigarette/e-cigarette), IQOS awareness and appeal of product attributes (except cost) differed (P’s < 0.001; Table II). In post hoc analyses, those using neither cigarettes/e-cigarettes (versus others) were less aware and reported less appeal, while those reporting dual (versus cigarette/no e-cigarette and e-cigarette/no cigarette) use reported greater awareness and generally greater appeal (except colors and customization versus e-cigarette/no cigarette).

Elaborating on flavors (Table II), the flavor most likely to be tried was turquoise for the neither cigarette/e-cigarette use group (25.7%) and purple for the cigarette/no e-cigarette (25.6%) and dual use groups (25.0%). The e-cigarette/no cigarette use group reported being equally likely to try turquoise and purple (22.8%). All groups reported least likely trying either sienna (9.2% overall; least likely for non-use and cigarette/no e-cigarette) or yellow (10.4% overall; least likely for e-cigarette/no cigarette and dual use). The flavor perceived as least harmful by each group was turquoise (38.6%);sienna was least often perceived as least harmful (7.4%), followed by purple (9.6%) and bronze (10.5%).

Regarding advertising messages (Table II), all four groups rated the following as most persuasive: ‘A cleaner way to use tobacco’ (M = 2.43, SD = 1.41) and ‘Meet IQOS: real tobacco, no ash, less odor’ (M = 2.39, SD = 1.41). Messages perceived least persuasive were as follows: ‘True tobacco taste’ (M = 2.11, SD = 1.28) and ‘Your IQOS, Your way’ (M = 2.12, SD = 1.32). All messages were perceived as more persuasive among those using neither cigarettes/e-cigarettes (versus others) and less persuasive among those reporting dual versus single-product use and e-cigarette/no cigarette use (except three relative to e-cigarette/no cigarette use: ‘Moving beyond smoking’, ‘A cleaner way to use tobacco’ and ‘This changes everything’). Those reporting e-cigarette/no cigarette versus cigarette/no e-cigarette use perceived three messages as more persuasive (‘Moving beyond smoking’, ‘The future of tobacco has arrived’ and ‘This changes everything’).

Supplementary bivariate analysis by HTP use

Participants never using HTPs reported the least product/marketing appeal; participants currently using HTPs reported the greatest appeal (Supplementary Table S2). Participants reporting former and current HTP use most frequently indicated purple as the flavor they would most likely use (25.6% and 30.8%, respectively); those never using HTPs most frequently indicated turquoise (25.1%). The flavor perceived as least harmful was turquoise for those reporting never and former HTP use (40.2% and 39.3%) and bronze for those currently using HTPs (21.5%).

Multivariable linear regression: overall product/marketing appeal

Compared to those using neither cigarettes/e-cigarettes (Table III, upper panel), those reporting cigarette/no e-cigarette (β = 0.60, 95% CI = 0.49, 0.72), e-cigarette/no cigarette (β = 0.75, 95% CI = 0.58, 0.92) or dual use (β = 1.00, 95% CI = 0.86, 1.13) reported greater overall appeal of IQOS attributes/marketing. In analyses excluding those using neither cigarettes/e-cigarettes (Table III, lower panel), compared to those reporting dual cigarette/e-cigarette use, those reporting cigarette/no e-cigarette (β = −0.14, 95% CI = −0.33, −0.02) or e-cigarette/no cigarette use (β = −0.27, 95% CI = −0.47, −0.07) reported lower overall appeal of IQOS attributes/marketing. Additionally, those who were aware of HTPs, those in Israel (versus United States) and men reported greater overall appeal in both models; current HTP use was not (Table III). Country-specific analyses showed similar trends; however, men reported greater appeal in Israel but not in the United States and HTP use was positively associated with appeal in the United States but not Israel (Supplementary Table S3).

Table III.

Multivariable regression analyses examining correlates of overall appeal of IQOS marketing across cigarette and e-cigarette use groups

Model including non-use group (N = 2222): referent group: neither cigarette/e-cigarette usea
Variable	B	95% CI	P-value
Constant	1.86	1.63, 2.10	<0.001
Sociodemographics
Israel (ref: United States)	0.36	0.27, 0.45	<0.001
Age	0.001	−0.005, 0.007	0.782
Male (ref: female)	0.11	0.03, 0.19	0.009
≥College degree (ref: <)	0.06	−0.03, 0.14	0.196
Children in the home (ref: no)	−0.02	−0.10, 0.06	0.632
HTP awareness (ref: no)	0.19	0.10, 0.29	<0.001
Past 30-day HTP use (ref: no)	0.14	−0.02, 0.31	0.090
Past 30-day cigarette/e-cigarette use (ref: neither cigarette/e-cigarette use)
Cigarette/no e-cigarette	0.60	0.49, 0.72	<0.001
E-cigarette/no cigarette	0.75	0.58, 0.92	<0.001
Dual cigarette/e-cigarette use	1.00	0.86, 1.13	<0.001
Adjusted R-square = 0.215
Model excluding non-use group (N = 826): referent group: dual cigarette/e-cigarette usea
Variable	B	95% CI	P-value
Constant	2.43	2.12, 2.93	<0.001
Sociodemographics
Israel (ref: United States)	0.22	0.07, 0.37	0.005
Age	0.003	−0.007, 0.01	0.551
Male (ref: female)	0.15	0.01, 0.29	0.035
≥College degree (ref: <)	0.09	−0.06, 0.23	0.226
Children in the home (ref: no)	0.002	−0.14, 0.14	0.978
HTP awareness (ref: no)	0.23	0.08, 0.37	0.002
Past 30-day HTP use (ref: no)	0.13	−0.05, 0.31	0.147
Past 30-day cigarette/e-cigarette use (ref: dual cigarette/e-cigarette use)
Cigarette/no e-cigarette	−0.14	−0.33, −0.02	0.040
E-cigarette/no cigarette	−0.27	−0.47, −0.07	0.009
Adjusted R-square = 0.078

Notes: Bold indicates P < 0.05. ^aAlso represents those with past 30-day HTP use (n = 172): (i) neither cigarette/e-cigarette (i.e. HTP use only, n = 9, 5.2%); (ii) cigarette/no e-cigarette (n = 53, 30.8%); (iii) e-cigarette/no cigarette (n = 22, 12.8%); and (iv) dual cigarette/e-cigarette (n = 88, 51.2%). In models comparing cigarette/no e-cigarette and e-cigarette/no cigarette, no differences were found.

Qualitative results

Qualitative data (Table IV) indicated similar themes across countries.

Table IV.

Qualitative findings regarding IQOS awareness, exposure, perceptions and use among US and Israeli adults, N = 84^a

	Representative quotes
Themes	United States	Israel
IQOS awareness, exposure and perceived target market
Awareness	– I haven’t heard of [IQOS]. But I’ve heard of a similar technology that brings some kind of tobacco up to a certain temperature below the burning point, but enough to extract whatever the nicotine or whatever is from the product. So, I’ve heard of similar things, but not that particular one. (#368; 45-year-old NH White male, no current cigarette use, current e-cigarette use, United States) – I hadn’t heard of [IQOS] until I did a survey where they asked me about them. That’s all I know—they use heat to heat the tobacco. (#450; 44-year-old NH White female, current cigarette and e-cigarette use, United States)	– I didn’t hear about IQOS specifically, but when I looked up a similar product I recently saw on the Internet, then I understood the idea. (#23; [age not provided] Jewish female, current cigarette use, no current e-cigarette use, Israel) – I heard about it [IQOS] in Japan. There it is very common. I saw it with many smokers. (#44; 24-year-old Jewish male, no current cigarette or e-cigarette use, Israel)
Source of exposure
Social network	– I had tried [IQOS] while I was at some party, like a happy hour with my colleagues in my office. It was the first time that I used it. (#729; 40-year-old Asian Non-Hispanic male, current cigarette and HTP use, no current e-cigarette use, United States) – Classmates were my first source of IQOS exposure, and then I saw the advertisements. They just were talking about their experience using the product. (#626; 27-year-old Hispanic male, current cigarette, e-cigarette, and HTP use, United States)	– I was smoking a cigarette and I ran into a friend that was using it, so I asked him about it, and I tried it. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – I think I might have seen it once, but I didn’t know it was called that… (I was) with a friend. (#49; 35-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – [I learned about it] through a friend from work who started smoking it. Several people followed her. (#46; 31-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
Advertisements (via retailers, online and social media)	– I’ll be looking at the cigarette board [at convenience stores], and I see it in advertisements. So, IQOS looks familiar. I’ve just seen the ad basically. (#758; 44-year-old NH White male, current cigarette use, no current e-cigarette use, United States) – I remember seeing [IQOS ads] online a few times. I remember clicking one of the links to understand how it works, because the charger, the USB port, and the push button are new. I was a little curious. It looks like a device, rather than a traditional cigarette. As a technical person, I thought of looking at it more and how it would actually work, but the ad was not very clear in showing the features, but it was trying to explain how safe it is. (#729; 40-year-old Asian Non-Hispanic male, current cigarette and HTP use, no current e-cigarette use, United States) – Social media, that’s where I first started seeing it…. At least once a day as I’m going through Instagram, I’ll see something for IQOS, someone young and attractive on the go and using it…. I don’t know what psychological effect it has, but seeing it on multiple platforms makes me say, ‘Wow. They’re out there. I should try.’ (#626; 27-year-old Hispanic male, current cigarette, e-cigarette, and HTP use, United States)	– I remember a girl was standing there [in a stall in a smoke shop] holding [IQOS], and they were displaying it in a plastic case. She was showcasing, and a few people seemed interested. I stood there for a couple of minutes, but it didn’t speak to me, I just went on my way. (#2; 27-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – I remember seeing a stand made of plastic or glass… Something transparent, and they had stored [IQOS] underneath it. (#5; 32-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – I remember seeing an advertisement on the internet, but I don’t remember it being called IQOS. Also, through Facebook, I think. (#8; 30-year-old Jewish female, no current cigarette or e-cigarette use, Israel) – Since I bought IQOS, I get ads and discounts…. And there’s the friend brings a friend, so if your friend buys through you, you get a discount. (#46; 31-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
Perceived target market
Young people	– I have teenagers. I think it [IQOS] is targeting immediately my kids’ age group. I know [IQOS] is trying to target all age groups, but they are targeting those younger generation…. So, [tobacco companies] had to come up with something the same level to attract those young people. It’s just brainwashing. It’s like another toy, and it’s not an old people thing anymore. It’s hip and fun. So, for me, it’s scary. (#803; 45-year-old NH Asian female, current cigarette use, no current e-cigarette use, United States) – IQOS is probably targeting the young professionals that are out and about who would rather use a vape over a cigarette because it leaves smell and then it’s the whole visual dynamic of smoking cigarettes. They feel like [IQOS] is a bit cooler and more acceptable than cigarettes. (#720; 28-year-old NH Black female, no current cigarette use, current e-cigarette and HTP use, United States)	– I think it’s more appealing to youth and not people who smoke or are heavy smokers, because it’s all-electric, and that design, [youth] see it as not a real cigarette. (#2; 27-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – I imagine that [IQOS] is intended mainly for younger crowds—those who want to smoke but don’t want to smoke. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
People looking for an alternative to cigarettes	– IQOS targets somebody has to go into office buildings or be around the public a lot, where they can’t smoke a cigarette, someone who is trying to either quit or cut down cigarette smoking, or more mindful of the people around them for second-hand smoke. (#458; 44-year-old Hispanic female, current cigarette use, no current e-cigarette use, United States) – [IQOS targets] somebody who smokes, somebody who wants more variety in terms of flavors, or somebody who is working in an office or high-rise buildings, because it’s not always convenient for them to go outside, especially in the city. (#74; 28-year-old Hispanic male, no current cigarette or e-cigarette use, United States)	– Maybe people who smoke and are interested in quitting, or really want an alternative with health advantages, if they really exist in the product. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel) – Maybe there are people who are looking for a different experience, something other than smoking, than the cigarette. (#8; 30-year-old Jewish female, no current cigarette or e-cigarette use, Israel)
Females	– [IQOS] looks very female-driven. It also looks kind of young and I won’t say it’s marketed to the teenage crowd but it is definitely marketed towards early 20s. (#833; 42-year-old NH White male, current cigarette, e-cigarette, and HTP use, United States) – [IQOS] is more oriented towards females than males. I’d say the target audience of IQOS is mid middle-aged females in the workforce, in a professional job or something like that. (#358; 39-year-old NH Black male, no current cigarette use, current e-cigarette use, United States)	– I would go for it because it looks like a feminine product like. It doesn’t look like a masculine product. I’m a woman, I would be drawn to it. I would like this pink one. (#8; 30-year-old Jewish female, no current cigarette or e-cigarette use, Israel)
IQOS product perceptions
General perceptions	– [IQOS] looks pretty slick and it would feel good in your hand. It looks pretty easy to use and aesthetically pleasing. It also comes in a bunch of different colors, which is cool. (#360; 30-year-old NH White male, no current cigarette or e-cigarette use, United States) – [IQOS] looks like a little cigarette with a charger connector. It looks like a cell phone. It looks expensive to purchase at first. The design itself doesn’t really appeal to me. (#758; 44-year-old NH White male, current cigarette use, no current e-cigarette use, United States) – [IQOS] looks kind of complicated for nicotine consumption. But I know vaping products are the direction that tobacco is going. (#139; 39-year-old NH Asian female, current cigarette and e-cigarette use, United States) – IQOS is not easily available everywhere. So that’s a problem if you don’t find them in every local shop, or they are not more reachable. (#729; 40-year-old Asian Non-Hispanic male, current cigarette and HTP use, no current e-cigarette use, United States)	– [IQOS] is nice, they look fancy… its shape [is appealing]. But I didn’t like it, it’s not the same sensation as smoking a cigarette, it’s a different experience. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – It didn’t seem appealing when I saw it inside the shop, but I was interested when I saw people using it, the device and those small cigarettes. (#5; 32-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – IQOS, cigarettes and e-cigarettes are all the same. I think most people will stop [IQOS] because it is too much work, charging it, turning it on, the whole process. (#13; 34-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel) – I think it’s elegant… and the effect of the poisonous chemicals that is less, the smell is less offensive to those around you, so there are advantages. (#44; 24-year-old Jewish male, no current cigarette or e-cigarette use, Israel)
Comparisons to cigarettes
Harm to health
-Less harmful	– I don’t think IQOS causes second-hand smoke at all because it disappears quickly, vs. a cigarette where it lingers and causes huge smoke clouds and bad smell, bad for asthmatics. (#992; 31-year-old Hispanic female, no current cigarette use, current e-cigarette use, United States) – I feel like [IQOS] dissipates a lot quicker than cigarettes smoke that really hangs in the air for a long time around people. (#450; 44-year-old NH White female, current cigarette and e-cigarette use, United States)	– Maybe [IQOS] is less risky [than cigarettes] because there is less smoke, less passive smoking. I don’t remember if there’s smoke or not but if there is, I imagine there’s less.(#5; 32-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – From what I understand IQOS is not good, because none of these things are good but it’s less terrible than regular cigarettes. (#46; 31-year-old Jewish female, current cigarette and HTP use, no current e-cigarette use, Israel) – There’s also poison in IQOS but I feel that there’s no comparison. It doesn’t approach even ten percent of the damage of a regular cigarette does to me. (#47; 43-year-old Arab male, current cigarette and HTP use, no current e-cigarette use, Israel)
-Same harm	– It would be the same effect [IQOS vs cigarette]. I know smoke comes [from IQOS] so that’s not good. There are chemicals you inhale from that device. It’d be safer to step away or go outside. (#762; 31-year-old NH Black male, current cigarette, e-cigarette, and HTP use, United States) – [IQOS] still has nicotine in it, and it’s still burning tobacco. So, the secondhand smoke would be the same [harm] as a cigarette. (#758; 44-year-old NH White male, current cigarette use, no current e-cigarette use, United States)	– [IQOS and cigarettes] are pretty much the same. Regular cigarettes are burnt. Maybe it’s a little different with IQOS, but in the end, both products contain nicotine. (#5; 32-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – [IQOS and cigarettes] are both harmful… The harms of their second-hand smoke are the same as well. (#2; 27-year-old Arab female, current cigarette use, no current e-cigarette use, Israel)
Addictiveness
-Same addictiveness	– It’s probably on par with cigarettes, if there’s nicotine. (#139; 39-year-old NH Asian female, current cigarette and e-cigarette use, United States) – I started using vaping to get off cigarettes, but then I just started doing both, which made no sense. Think the similarity to [IQOS] vs. vaping is probably closer to tobacco use. The addiction is going to probably be there for just about anybody. (#833; 42-year-old NH White male, current cigarette, e-cigarette, and HTP use, United States)	– I think it’s the same because the addictive substance, which is nicotine, exists here and there. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel) – I don’t think [IQOS] helps [in terms of addiction]. It still contains nicotine, so I don’t think it means you’d smoke less or more. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel)
-Less addictive	– [IQOS] isn’t really a product you would necessarily get addicted to. It’s more sort of like a helping aid, so I don’t think there’d be any problems there. (#992; 31-year-old Hispanic female, no current cigarette use, current e-cigarette use, United States) – I think that the real cigarettes are probably more addictive. It’s the real thing. It’s smoke as opposed to vapor, which I’m not positive how true that statement is. (#552; 27-year-old Hispanic male, no current cigarette use, current e-cigarette use, United States)	– It would be easier [to quit IQOS] since cigarette addiction is beyond tobacco. It’s more about the experience, lighting it when you’re with friends, etc. IQOS doesn’t give you those things. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – I don’t think a product like this will cause addiction. A person who is addicted seeks the hardcore thing. A person who has an addiction will go back to regular cigarettes. (#8; 30-year-old Jewish female, no current cigarette or e-cigarette use, Israel)
-More addictive	– It seems more addictive, especially if there’s flavoring, like menthol and other flavors, I think it would be probably a little more difficult. (#840; 23-year-old NH White female, no current cigarette use, current e-cigarette use, United States) – I suppose [quitting IQOS] will be harder because it gives you the idea of being able to smoke without hurting yourself. (#986; 38-year-old Hispanic female, current cigarette use, no current e-cigarette use, United States)	– Since it comes with flavors and it’s easier to use, it is also more tempting to use, and so overall, it’s harmful. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
Technology	– [IQOS] is almost a vape pen. But they also say that it has a cleaner pull with traditional vape pens or traditional tobacco products, etc. (#626; 27-year-old Hispanic male, current cigarette, e-cigarette, and HTP use, United States) – [IQOS] is more sophisticated than cigarettes because you have to learn the technology. But I’m sure the curve isn’t that much steeper. Cigarettes, like Marlboro, are more of an analogue form of smoking vs. this technological device. (#131; 36-year-old NH White male, no current cigarette or e-cigarette use, current HTP use, United States)	– It is attractive. It has a charger, a button to turn it on, and a button to clean the heating element. It is very attractive to the eye. (#13; 34-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
Complexity
-Less complex	– [IQOS] looks easier to use because it looks like there’s an all-in-one device and there’s no lighter that’s necessary. (#358; 39-year-old NH Black male, no current cigarette use, current e-cigarette use, United States) – If you have everything charged and you have cartridges ready to go, then [IQOS] could be more convenient because you wouldn’t necessarily have to smoke regular cigarette, by which you have to go to a designated spot that allows it while most public places do not have one at this point in this country anyway. (#139; 39-year-old NH Asian female, current cigarette and e-cigarette use, United States)	– I think it’s much easier. I don’t really know how you use it, but I assume that there’s a button to press and then you inhale or something like that. So, it seems much easier than a cigarette. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
-More complex	– [Using IQOS] would be a little more difficult than regular cigarettes. You have multiple pieces, make sure it’s charged, and have full cartridges. IQOS is a little more work than a cigarette. (#139; 39-year-old NH Asian female, current cigarette and e-cigarette use, United States)	– Regular cigarettes are more convenient. You don’t have to charge it and it’s more accessible, just pull it out and light it (#49; 35-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – You need to charge it, so that’s less convenient than a regular cigarette. You’ve got to calculate your usage in advance. It isn’t spontaneous. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
Cost	– All depends on pricing. Like in some places, the brand of cigarettes I smoke is way cheaper than where I’m at. If I travelled out of state while I was having to get these here and go back home, but you can’t. So, it definitely has to be pricing and distribution, if anything that I can see [IQOS] compared to. (#739; 39-year-old NH Black male, current cigarette use, no current e-cigarette use, United States)	– [IQOS] would be costlier than the traditional tobacco. I was a little hesitant how costly it would be. (#46; 31-year-old Jewish female, current cigarette and HTP use, no current e-cigarette use, Israel)
Smell	– [IQOS] is for somebody who wants to be able to do use it without smelling like smoke, and those who still want the flavors and the buzz of nicotine without having the smoke smell. (#360; 30-year-old NH White male, non-current cigarette use, current e-cigarette use, United States)	– The smell of [IQOS] smoke doesn’t stick to you. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
Environmental harms	– In terms of the environment, with cigarettes, people chuck the butts on the ground and they don’t biodegrade. In that sense, [IQOS] could be better although I don’t know what happens to the heatsticks once they’re used. They probably also go in landfills, but the rechargeable piece is nice. Anything that’s reusable is a bonus. (#139; 39-year-old NH Asian female, current cigarette and e-cigarette use, United States)	– Ecologically, people who really want to be more ecological would try it. They maybe pollute the environment less—less gross cigarette butts on the floor. (#44; 24-year-old Jewish male, no current cigarette or e-cigarette use, Israel)
Comparisons to e-cigarettes
Harm to health
-Same harmfulness	– [IQOS and e-cigarettes] have their consequences and negative impact. All of them are very similar. (#986; 38-year-old Hispanic female, current cigarette use, no current e-cigarette use, United States) – In the second-hand exposure, they both [IQOS and e-cigarettes] give out little vapors. So, I don’t think one will be more harmful than the other. (#115; 32-year-old NH Black male, current cigarette use, no current e-cigarette use, United States)	– The similarity [between e-cigarettes and IQOS] is that because nicotine enters the body in vapor form, so it seems to me it’s the same issue. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
-Less harmful	– A difference is one [e-cigarettes] burns a liquid, one [IQOS] burns tobacco. IQOS wouldn’t leave the condensation in your lungs. It’s actual tobacco that’s burnt, so it would be a little bit safer. (#758; 44-year-old NH White male, current cigarette use, no current e-cigarette use, United States) – With IQOS’ technology, [IQOS] is way better and more advanced than e-cigarettes. It’s like have a healthier alternative and experience vs. other ones where you’re blowing in random stuff. (#992; 31-year-old Hispanic female, no current cigarette use, current e-cigarette use, United States)	– I’m not sure if I understand correctly but as far as I know, electronic cigarettes are far more harmful [than IQOS], or at least they used to be. Each time a new product is released, we think it’s better than regular cigarettes, but these products are always more harmful. (#2; 27-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – The vape is much more harmful. From what I understand, vaping is based on evaporation, and in the end, can cause Oedema. IQOS heats tobacco, and doesn’t cause oedema… (#46; 31-year-old Jewish female, current cigarette and HTP use, no current e-cigarette use, Israel)
-More harmful	– [IQOS] is much more significant in terms of potential harm to other people, because there’s smoke that’s expelled from this device rather than vapor that’s expelled from e-cigarettes. (#784; 38-year-old NH White female, no current cigarette use, current e-cigarette and HTP use, United States)	– I would assume it is more harmful than electronic cigarettes with liquid. Feels as if the liquid is less harmful. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
-Uncertain	– There should be case studies and trials done to have a better understanding of what [IQOS] is and what it can do, especially with children. (#131; 36-year-old NH White male, no current cigarette or e-cigarette use, current HTP use, United States)	– [IQOS] would be kind of a newer device. So, if you’re into vaping, it might be a good option, but I would want to know more. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
Addictiveness
-Same addictiveness	– Sickness wise, could be the same depending on a person’s tolerance. I want to say addiction to it was the same and that’s part of your tolerance too. Having that addiction to something, you want to do it more or you need more of it. So, they (IQOS and e-cigarettes) are about the same. (#758; 44-year-old NH White male, current cigarette use, no current e-cigarette use, United States) – I think they (IQOS and e-cigarettes) probably still all have the ingredients and the nicotine, even though they say e-cigarettes are not as addictive. (#545; 45-year-old Hispanic female, no current cigarette or e-cigarette use, current HTP use, United States)	– I think the addiction would be the same, but perhaps quitting IQOS could be more difficult since I think it contains more nicotine. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel)
-Less addictive	– Probably the e-cigarettes are more addictive, just because I feel like juice would be more concentrated and these sticks (IQOS) aren’t even burned. (#552; 27-year-old Hispanic male, no current cigarette use, current e-cigarette use, United States) – IQOS would be less addictive because it has the natural ingredient in it vs. something processed. The liquid and the tobacco, that’s totally two different things. Give me the tobacco plant. (#739; 39-year-old NH Black male, current cigarette use, no current e-cigarette use, United States)	– I assume [IQOS] is less addictive [than e-cigarettes] because liquid is a bit more tempting. You can go around with a little bottle, simply fill up all the time. But with tobacco sticks, it’s a little less tempting to constantly replace them. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel) – I think it would be the same, or perhaps quitting IQOS could be more difficult since I think it contains more nicotine. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel)
Technology	– Its technology is not as useful as e-cigarettes. (#4; 45-year-old NH Black female, no current cigarette or e-cigarette use, current HTP use, United States)	– IQOS is kind of just another one of those electronic cigarettes. It seems like there’s so many different ones out there. There are so many different brands of cigarettes. And now it just seems like there’s so many different brands of e-cigarettes or whatever you want to call them. (#23; [age not provided] Jewish female, current cigarette use, no current e-cigarette use, Israel)
Complexity
-Equal complexity	– You use both of them [IQOS and e-cigarettes] the same way. It’s just your preference that you want the liquid or you prefer the actual product with the nicotine in [IQOS]. (#739; 39-year-old NH Black male, current cigarette use and non-current e-cigarette use, United States) – I think [IQOS] is just as easy [e-cigarettes]. You can get different levels of nicotine. So, if this product offered that same option, I think they are equal in terms of ease of vaping. (#368; 45-year-old NH White male, no current cigarette use, current e-cigarette use, United States)	– It’s the same thing if we’re talking about those that are rechargeable. Both of them have this issue of charging [IQOS and e-cigarettes]. (#14; 38-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)
-Less complex	– I feel like this (IQOS) would be way easier to use [vs. e-cigarettes] having to unscrew like tops and pour liquid down. So, I would definitely prefer this. (#992; 31-year-old Hispanic female, no current cigarette use, current e-cigarette use, United States) – It looks like [IQOS] is more portable [than e-cigarettes]. It doesn’t look like as big and bulky like the other ones that’s out. (#739; 39-year-old NH Black male, current cigarette use, no current e-cigarette use, United States)	– I think it’s a bit easier to use, this device, because here you just insert the tobacco stick, turn the device on, and it heats. It doesn’t seem too hard to operate. (#8; 30-year-old Jewish female, no current cigarette or e-cigarette use, Israel)
-More complex	– [IQOS] just seems too complicated. That wouldn’t be something I would be interested in. (#538; 33-year-old NH White female, current cigarette and e-cigarette use, United States)	– E-cigarettes are easier [to use than IQOS] because you have to charge the IQOS when the battery runs out. You don’t have to do that with e-cigarettes. You just get a new one when it runs out. (#49; 35-year-old Arab female, current cigarette use, no current e-cigarette use, Israel) – Regular e-cigarettes are easier [to use than IQOS]. It’s easier to fill with liquid by simply attaching the bottle to the vape rather than replacing a tobacco stick. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
Willingness to try IQOS
Willing	I like the look, the design, the little charger, the pack, and everything. It looks cool and neat. I would definitely try it if given an opportunity. (#833; 42-year-old NH White male, current cigarette, e-cigarette, and HTP use, United States)   – [IQOS] looks modern. I like the different colors. It’s portable. You can carry it and people wouldn’t know what it is. I would be curious about it if I saw it in real life. (#626; 27-year-old Hispanic male, current cigarette, e-cigarette, and HTP use, US) – With the look and design, I would want to try it and see if it has a better pull, try the flavors, or things like that, to see how it works. That piqued my curiosity. (#635; 24-year-old Hispanic male, no current cigarette use, current e-cigarette use, United States)	– I would try it to see if it could be something to replace cigarettes for me, or I would try to see what it is like, how it feels, heating the tobacco. (#17; 24-year-old Jewish female, no current cigarette or e-cigarette use, Israel) – I considered buying [IQOS] and trying it because I thought it might be less harmful so I thought I could transition to IQOS… I’d be open to trying it. (#9; 30-year-old Arab female, current cigarette use, no current e-cigarette use, Israel)
Conditionally willing	– It sounds a little bit different [than other tobacco products]. I’d need to hold it, see it, and try it to understand how it works. I would try it if it was affordable. (#395; 39-year-old NH White female no current cigarette use, current e-cigarette use, United States) – It’s it really depends on it depends on the flavors. And obviously the nicotine content and the heatstick. (#358; 39-year-old NH Black male, no current cigarette use, current e-cigarette use, United States) – I am not sure that I would buy [IQOS]. But if a friend had one, I would definitely want to try it. (#450; 44-year-old NH White female, current cigarette and e-cigarette use, United States)	– I would try if I see it at a friend’s but I wouldn’t buy one specially. But I’ve taken a draw here and there from vaping and that’s nice. It has a pleasant flavor and I would be interested to know how it feels compared with vape. (#19; 21-year-old Jewish male, current cigarette use, no current e-cigarette use, Israel)
Unwilling	– [IQOS] just seems too complicated. It wouldn’t be something I would be interested in. (#358; 39-year-old NH Black male, no current cigarette use, current e-cigarette use, United States) – If [IQOS] has nicotine, it’s still dangerous. So, I don’t know what they trying to do and it wouldn’t be something I want to try. (#334; 39-year-old NH Black male, current cigarette use, no current e-cigarette use, United States)	– [I will not try it] because the exhausting and oppressive part is the financial expense, so I’m not going to give up cigarettes to take on another expense on another product. (#23; [age not provided] Jewish female, current cigarette use, no current e-cigarette use, Israel) – No, even though [IQOS] was recommended for me, but I personally didn’t connect to it. So, I won’t try it. (#10; 25-year-old Jewish female, current cigarette use, no current e-cigarette use, Israel)

Note: ^aNo current HTP use unless noted. NH = non-Hispanic.

IQOS awareness, exposure and perceived target market

Some participants were aware of IQOS; notably, some were unable to clearly discern IQOS from other electronic tobacco/nicotine products. Across countries, major sources of IQOS exposures were social networks (e.g. friends and colleagues), particularly for those who had tried IQOS, and advertisements at retailers (e.g. convenience stores) or online, particularly social media.

The majority perceived that IQOS targeted young people because of its technology, sleek design, less smell and social acceptability, and some expressed concerns about targeting youth. The majority also identified people seeking cigarette alternatives as a target market, given the potential benefits over cigarettes promoted in IQOS marketing (e.g. secondhand smoke reduction and convenience) as well as some unique attributes like the flavor and technology that distinguish IQOS from cigarettes. Some also perceived IQOS and its marketing as ‘female-driven’ due to its design, colors and flavor descriptions.

Perceptions of IQOS

Participants perceived IQOS to have some appealing attributes, particularly its design (e.g. ‘elegant’ and ‘aesthetically pleasing’), technology, various colors and flavors and potentially less byproduct exposure. However, some commented on IQOS complexity (e.g. ‘looks complicated’), cost and limited retail accessibility (e.g. ‘not available everywhere’), which posed barriers to adopting use.

Relative advantage of IQOS versus cigarettes

About half believed that IQOS and cigarettes were equally harmful and addictive, as they both heat or burn tobacco and contain nicotine. However, about half perceived IQOS use and its byproducts as less harmful (e.g. ‘less smoke’ and ‘dissipates quicker’) and believed that IQOS was less addictive, often suggesting that IQOS was not the ‘real’ or ‘hardcore thing’ but could help reduce cigarette use. Others perceived IQOS as more addictive, commenting that its flavors or underestimating IQOS harms could lead to more frequent use and addiction.

Most perceived that IQOS technology was more advanced than cigarettes. However, perceived complexity was mixed: some perceived IQOS as less complex (e.g. due to the all-in-one nature, chargeability and ability to use discretely) and others as more complex (e.g. charging and distinct components needed). IQOS was often perceived as more expensive than cigarettes but to have environmental benefits over cigarettes (i.e. less potential for litter).

Relative advantage of IQOS versus e-cigarettes

Some participants perceived IQOS and e-cigarettes as equally harmful and addictive, due to similar technology and containing nicotine. Some perceived IQOS as less harmful (e.g. does not involve vapor and related lung damage) and less addictive (e.g. e-cigarette e-liquids with high nicotine concentrations). Others perceived IQOS as more harmful given that its byproducts were similar to smoke. However, many were uncertain (e.g. due to IQOS newness, more research needed).

Participants generally perceived IQOS and e-cigarette technology as similar. Further, many perceived IQOS and e-cigarettes as equally complex, while some perceived IQOS as less complex (e.g. small, no need for e-liquids and all-in-one) or more complex (e.g. too many components).

Willingness to try IQOS

Willingness varied. Those willing to try IQOS commented on its attractive design, technology and flavors. Some mentioned that their willingness depended on cost and ability to try it, for example, its flavors, nicotine content and holding it. Some expressed their unwillingness to try IQOS, due to its complexity or nicotine content.

Discussion

This study aimed to advance the evidence-base informing tobacco regulations by assessing reactions to industry marketing elements, specifically IQOS product characteristics and advertising messages [54, 55]. Notably, 82.0% of participants currently using HTPs also currently used cigarettes, with 62.4% of these also using e-cigarettes; an additional 12.8% of those currently using HTPs used e-cigarettes but not cigarettes. These findings undermine the notion that those who use cigarettes will switch completely to IQOS and reinforce concerns about dual use of IQOS with other tobacco products, particularly cigarettes, and related health effects [56].

Survey participants not using cigarettes/e-cigarettes, versus using either or both, perceived IQOS and its marketing as less appealing; those with dual cigarette/e-cigarette use reported the greatest appeal. Further, interview participants perceived target markets to include those using cigarettes but looking for an alternative. These findings corroborate PMI’s assertion that IQOS targets adults using cigarettes [35–37]. However, those reporting dual cigarette/e-cigarette use or e-cigarette/no cigarette use, who rated IQOS attributes and messaging as most favorable, were among the youngest subgroups; these findings also suggest that dual use groups might be unable or unwilling to entirely switch from cigarettes to another product, and/or IQOS technology might attract those using e-cigarettes. Furthermore, participants perceived IQOS’ target markets include youth and young adults, those not using cigarettes and females, which highlight concerns regarding IQOS’ impact on the nicotine-naïve and potential targeting of these and other groups who might be disproportionately impacted, as corroborated in other IQOS use and marketing surveillance research [9, 18, 35–40, 42–44].

Interview participants noted advertising as an influential source of IQOS exposure, as previously documented [3, 16, 39, 57], and noted the appeal of IQOS design, colors, flavors, technology and potentially less byproduct exposure, also previously shown [3, 19, 34, 39, 58]. Among survey participants, attributes perceived most appealing were colors, followed by accessories/customization, flavors, design and technology. The most persuasive advertising messages focused on cleanliness (i.e. ‘A cleaner way to use tobacco’), while the least persuasive were vague. Furthermore, survey and interview participants indicated key barriers to trial or use, including IQOS expense, complexity and limited retail accessibility.

Interview participants generally perceived IQOS to have lower risks (i.e. harm and addictiveness) compared to cigarettes, as shown previously [20–25]. However, some perceived IQOS and cigarettes to have similar risks and findings regarding IQOS risks relative to e-cigarettes were mixed. Perceived risks were often tied to containing nicotine (relevant to all three products), nicotine concentrations, amount of emissions produced (less from IQOS and e-cigarettes) and the role of flavors in use (relevant to IQOS and e-cigarettes). While participants generally perceived IQOS technology more favorably than cigarettes’, views on its ease of use relative to cigarettes and e-cigarettes diverged. For example, IQOS was perceived as more complex than disposable e-cigarettes but less complex and more discrete than other types of e-cigarettes.

The flavor perceived as least harmful among each tobacco use group was turquoise (described as ‘Refreshing & Cooling’), while sienna was reportedly perceived as more harmful and least likely to be tried. Furthermore, those using neither cigarettes/e-cigarettes were participants reported being most likely to try turquoise in neither cigarette/e-cigarette and e-cigarette/no cigarette use groups and purple (‘Cooling menthol sensation…’) for both single-product use groups and the dual use groups. These findings reflect cigarette-related research indicating that cool colors (i.e. turquoise and purple) and the terms ‘cooling’ and ‘menthol’ may reduce perceived harm and increase appeal, while bold red colors convey greater harms [58–62].

Limitations

Despite study strengths (e.g. cross-country and mixed-methods design), findings have limited generalizability, as this study faced methodological challenges similar to many international studies [51, 52, 63]—differences in available resources (e.g. panels and census data) for sampling across countries. Survey participants were primarily recruited via a panel in the United States and opt-in sampling in Israel, requiring caution in terms of how the data are used. For example, rather than attempting to generate prevalence estimates, this study examined associations between participant characteristics (including those used to determine subgroup quotas) and IQOS perceptions—within the cross-country sample and within the country-specific samples, using multivariable analyses. Additionally, as with all qualitative samples, our interview samples have limited generalizability and were recruited to provide diverse, in-depth perspectives across key sociodemographic and tobacco use groups [64]—albeit using different approaches (i.e. recruited from the survey sample in the United States and via Facebook in Israel) which could have impacted the perspectives portrayed among US versus Israeli participants. Other limitations include the cross-sectional design (limiting causal inferences) and self-reported assessments (i.e. potential recall and social desirability biases).

Conclusions

Participants reporting dual cigarette/e-cigarette use (versus non-use or single-product use) indicated greater overall appeal of IQOS and its marketing; yet, qualitative data indicated mixed perceptions regarding IQOS advantages (e.g. harm, addiction and complexity) compared to cigarettes and e-cigarettes. Participants perceived that IQOS targets those seeking alternatives to cigarettes but also young people, people not using cigarettes and females. Notably, the product attributes rated most appealing were IQOS colors, accessories/customization and flavors—attributes likely targeting younger consumers. Given the perceived target markets, IQOS youth-oriented product attributes and particular appeal to dual cigarette/e-cigarette use groups, ongoing monitoring of IQOS marketing is key to assessing its population impact.

Supplementary data

Supplementary data are available at HEAL online.

Author contributions

Yuxian Cui (Conceptualization, Data curation, Formal analysis, Writing—original draft, Writing—review & editing), Yael Bar-Zeev (Conceptualization, Data curation, Formal analysis, Funding acquisition, Writing—review & editing), Hagai Levine (Conceptualization, Data curation, Formal analysis, Funding acquisition, Writing—review & editing), Cassidy R. LoParco (Conceptualization, Writing—review & editing), Zongshuan Duan (Conceptualization, Data curation, Formal analysis, Writing—review & editing), Yan Wang (Conceptualization, Writing—review & editing), Lorien C. Abroms (Conceptualization, Writing—review & editing), Amal Khayat (Conceptualization, Writing—review & editing) and Carla J. Berg (Conceptualization, Data curation, Formal analysis, Funding acquisition, Writing—original draft, Writing—review & editing).

Funding

US National Cancer Institute (R01CA239178, MPIs: Berg, Levine); National Cancer Institute (R01CA215155, PI: Berg; R01CA278229, MPIs: Berg, Kegler; R01CA275066, MPIs: Yang, Berg; R21CA261884, MPIs: Berg, Arem) to C.J.B.; Fogarty International Center (R01TW010664, MPIs: Berg, Kegler; D43TW012456, MPIs: Berg, Paichadze, Petrosyan); National Institute of Environmental Health Sciences/Fogarty (D43ES030927, MPIs: Berg, Caudle, Sturua); National Institute on Drug Abuse (R01DA054751, MPIs: Berg, Cavazos-Rehg).

Conflict of interest statement

H.L. had received fees for lectures from Pfizer Israel Ltd (distributor of a smoking cessation pharmacotherapy in Israel) in 2017. L.C.A. receives royalties for the sale of Text2Quit. No other conflicts of interest are declared. Y.B.-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).

Data availability

Data are available upon reasonable request but are not publicly available for ethical reasons.