Assessment of IQOS Marketing Strategies at Points-of-Sale in Israel at a Time of Regulatory Transition

Abstract

Introduction

IQOS, a tobacco heating system, and accompanying tobacco sticks (HEETS) entered the Israeli market in 2016, prior to rapid regulatory change. This study assessed IQOS marketing strategies and regulatory compliance at IQOS and/or HEETS point-of-sale (POS) in Israel in December 17, 2019 to January 7, 2020, after the ban on advertisement went into effect in March 8, 2019.

Aims and Methods

Research staff audited 80 randomly selected IQOS and/or HEETS POS in four cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data were linked to neighborhood characteristics, including socioeconomic status, ethnicity, and proximity (under 300 m) to schools.

Results

Almost half of the stores (48.7%) were convenience stores. HEETS were visible to the customers in 46.1% of POS, 35% carried at least four HEETS colors, 20.0% had IQOS and/or HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was US $8.7 (range: US $7.5–11.3), 27% more than the least expensive cigarette pack, and 39% less than the most expensive cigarette. HEETS promotions were uncommon. Compliance with the newly introduced advertisement ban was fairly high for HEETS (94.8%). Only one POS was located in a low-socioeconomic status area; 68.7% were near a school.

Conclusions

The relatively limited IQOS and/or HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher socioeconomic status populations, as indicated by pricing and POS neighborhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research.

Implications

Globally, the POS is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the POS provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS and/or HEETS marketing at POS suggests that primary marketing strategies may shift to online or other channels as regulatory contexts become more progressive and/or restrictive. Ongoing surveillance of IQOS via online marketing and POSs, specifically with regard to product placement and proximity to schools, is needed.

Introduction

Heated tobacco products (HTPs, ie, products that heat but not burn tobacco and generate inhalable nicotine aerosol)¹ are generally marketed as an alternative to combustible cigarettes, despite limited evidence of reduced harm.^1,2 The largest market share globally is held by Philip Morris International (PMI)’s product, IQOS.³ IQOS is a tobacco heating system for accompanying disposable tobacco sticks (HEETS) that are inserted into the device and heated to 350°C degrees.¹ Recently, the US Food and Drug Administration approved IQOS as a “reduced exposure” product⁴ but also indicated insufficient evidence of reduced harm or risk of tobacco-related disease.⁴ Awareness and use of HTPs—and IQOS specifically—has been growing in recent years, with studies showing greater use among current smokers, as well as men and racial and ethnic minorities in various contexts and countries.^5–9 Specifically, data from Guatemala city (May–September 2019) show that 8.4% of youth have ever tried HTP, with higher ever-use among current smokers, those using electronic cigarettes (e-cigarettes), and those with friends who use HTPs.¹⁰

In December 2016, Israel became among the first countries where IQOS was introduced into the market. IQOS is currently the only HTP in the Israeli tobacco market¹¹ and has shown some market growth in recent years.¹² Data from a 2018–2019 national survey in Israel found that 1.8% of the population reported currently using IQOS and/or an e-cigarettes, an increase from 0.8% in 2017.¹² Moreover, there were gender differences in prevalence (3.1% of men, 0.5% of women) and across ethnic groups (3.0% of the Arab minority, 1.3% of the Jewish population).¹² Surveys of Israeli youth from 2017 to 2019 show that 2% of those aged 15–19 years old had ever used IQOS.¹³ IQOS went through a period of rapid tobacco regulatory change, from first being sold as a regular consumer product, to being regulated as all other tobacco products, to being subject to recent progressive tobacco control policies.^11,14 Regarding the latter, in December 2018, Israel passed extensive tobacco control legislation that also applied to HTPs and includes a complete ban on advertisement (excluding print media, effective March 8, 2019), the introduction of plain packaging with 65% textual warnings (effective January 8, 2020), and point-of-sale (POS) display bans (effective January 8, 2020).^15,16 Exposure to POS tobacco promotion has been linked consistently with higher risk of tobacco use and susceptibility among both youth and adults.^17,18 These mechanisms might also apply to the use of other products, such as HTPs, underscoring its importance in tobacco control efforts.

From a global perspective, POS is the least regulated channel for advertising and marketing,¹⁹ and research is needed to understand the impact of tobacco control policies that focus on the retail environment, such as advertisement and display bans.¹⁹ The unique circumstances in Israel—specifically the relatively long-standing presence of IQOS in its market and the recent implementation of progressive advertising restrictions—make this an ideal setting to examine how the tobacco industry in general responds to such policies,¹⁵ as well as how the marketing of novel products such as IQOS adapt to such policies. We aimed to assess IQOS and HEETS marketing strategies (ie, placement, pricing, and promotional strategies) and regulatory compliance among IQOS and/or HEETS POS in Israel at a time of regulatory transition (ie, December 17, 2019 to January 7, 2020).

Materials and Methods

Study Setting and Sample Selection

We used publicly available data on PMI IQOS Israel Web site to identify IQOS and/or HEETS POS locations across Israel in June, 2019 (n = 3267). Our sampling frame for this study was defined as POS within the limits of 4 of Israel’s largest cities (Haifa, Tel-Aviv, Jerusalem, and Beer-Sheva), for a sample size of approximately 20 POS per city that carry IQOS and/or HEETS. Audits were conducted by research assistants (RAs) in person between December 17, 2019 to January 7, 2020, when POSs were banned from all advertisements, but prior to the POS display ban and plain packaging requirement (effective January 8, 2020). Using simple randomization, a numbered list of POS was generated for each city. As the audit was conducted 6 months after the POS list was extracted from the IQOS Web site, RAs were first instructed to assess whether POS carries either HEETS or the IQOS device. POSs were excluded if they did not carry either HEETS or the IQOS device, if the store was closed, did not exist, or address was not correct, if a membership or fee was required to enter, if the environment was deemed unsafe, or if the RA was not allowed to enter or asked to leave. POSs were included if they usually carry HEETS but were temporally out of stock because of the changes in plain packaging requirements soon to be implemented. This was assessed through a direct question to the merchant. In Beer-Sheva, initial attempts to conduct in-person audits indicated that many of stores did not carry HEETS. Thus, to inform in-person research staff visits (and reduce travel burden), a subsample of POS (n = 50) were first called via phone to determine whether they carry HEETS.

Data Collection

Protocol and Training

Adapting a previously used protocol,²⁰ RAs were trained by the lead author (YB-Z) and research coordinator (MR), which included field training for each RA in two separate POSs not included in the study sample. RAs were instructed to conduct a concealed audit, unless directly asked by the merchant regarding their presence. In this case, they were instructed to acknowledge that they were collecting data for a study assessing tobacco retailers and comply with merchant requests to leave or delete data collected.

IQOS POS Assessment Tool

Drawing from the Standardized Tobacco Assessment for Retail Settings,²¹ we developed the assessment tool to include HTPs, specifically IQOS. The tool was developed by three of the authors (CJB, YB-Z, and HL), with input from the study’s External Advisory Board, and was piloted in 15 POSs in Jerusalem and Beer-Sheva.²² The final assessment tool (Supplementary File 1) assessed the following: (1) store characteristics (ie, type of store, recategorized into convenience store or kiosk; convenience store within a gas station; and grocery shop or supermarket); (2) products sold (ie, cigarettes, little cigars or cigarillos, large cigars, smokeless tobacco [eg, chew, dip, and snus], e-cigarettes, HTPs, and specifically IQOS); (3) placement, including IQOS displays, placement near youth-oriented merchandise (ie, within 30 cm of toys and confectionary), and whether products were displayed within 1 m of the floor (ie, the field of vision of youth); (4) price (ie, least expensive price of a cigarette pack and HEETS in New Israeli Shekels [NIS]; 1 NIS = $0.29 at the time of the study) and any price promotions across products; (5) promotional strategies, including product advertisements outside or inside the store, ability to sample products, and special promotions for populations (eg, military, college students) or loyalty club memberships; and (6) compliance with legislation that is currently in effect, specifically minimum age signage, “no tobacco use” signage, and advertisement ban compliance (defined as the presence of any branded advertisement). The assessment tool did not assess compliance with legislation soon to be in effect (ie, display ban and plain packaging). Advertisements were defined as any item that was branded with the intent to sell the product, not limited to signage, and can include branded displays and other functional items.

Neighborhood Data

Data describing the population characteristics for each POS location were provided by Points Location Intelligence, a private Israeli mapping and data company, using the Central Bureau of Statistics 2017 National Population Statistics Survey, which divides Israel into small homogenous statistical areas with an average of 3000 people per statistical area.²³ Population characteristics included (1) socioeconomic status (SES) ranking on an ordinal scale from 0 to 10, recategorized into industrial unpopulated area (0), low SES (1–3), medium (4–7), and high SES (8–10). The SES rank is calculated by the Israeli Central Bureau of Statistics and is based on 14 different sociodemographic and economic factors such as the proportion of 27–54 years old who have an academic degree and average monthly income per person²³ and (2) population ethnicity (>50% Israeli Arabs or >50% ultra-Orthodox Jews or general population). Proximity (defined as <300 m from the center of the school) to elementary, middle, high schools, and any type of school was calculated from coordinates that were provided by The Israeli Ministry of Education.

Data Analysis

Analysis was performed using SPSS version 26. Descriptive analysis was conducted using frequencies (%) for categorial variables and mean (standard deviation [SD]) for continuous variables (products price). Bivariate analysis was conducted using the chi-square test (with Yates Continuity correction or Fishers Exact test when appropriate), Kruskal–Wallis test, and Mann–Whitney test, as appropriate, to assess differences: (1) across stores types and (2) between POS with or without the special IQOS and/or HEETS display (a hypothesized indicator of IQOS marketing importance of the POS location).

Ethics Approval

This study was approved by the Hebrew University, Faculty of Health Ethics Committee (approval #13122019).

Results

Overall, out of 232 stores visited in person, an audit was not possible in 23.7% (n = 55) because the store was closed, the address was not found, or the environment was deemed unsafe by the RA. An additional 41.8% (n = 97) did not sell HEETS or IQOS at the time of the audit. Therefore, a complete audit was not conducted on these, and they were removed from our sample. Eighty stores remained in our sample and received the full audit. Out of the 80 stores, 7 that generally carried the product did not have the product in the store at the time (5 were out of stock [3 in Beer-Sheva, 2 in Jerusalem] and 2 unique outlets only sold it by special order [coffee shop in Beer-Sheva, fast food outlet in Jerusalem]).

We examined neighborhood characteristics of the 97 POSs that were excluded because they did not carry HEETS versus the 80 POSs that were included in the study sample. Stores that did not carry HEETS were more likely to be in a low-SES area (16.7% [16/96, missing n = 1] vs. 1.2% [1/80] in those that did carry HEETS, p < .001) and in areas with predominantly ultra-orthodox Jews (12.5% [12/96, missing n = 1] vs. 2.5% [2/79, missing n = 1], respectively, p = .022); no differences were found in relation to Arab population areas or proximity to schools.

Store Characteristics

Table 1 summarizes the POS characteristics and HEETS marketing strategies across the entire sample and comparing across the different store types. Almost half of the stores (48.7% [39/80]) were convenience stores or kiosks, 27.5% [22/80] were convenience stores within gas stations, 18.8% (15/80) grocery stores or supermarkets, and 5% (4/80) other unique outlets (eg, coffee shop). Only one POS was located in a low-SES area. Few stores were located in predominantly Arab neighborhoods (7.6% [6/79], missing n = 1) or ultra-orthodox Jewish neighborhoods (2.5% [2/79]). Almost 70% (55/80) were proximal to schools.

Table 1.

Point-of-Sale Characteristics, Regulatory Compliance, and Marketing, Total and Across Store Types

Variables	Totaln = 80	Convenience store and Kiosk (n = 39)	Convenience within a gas station (n = 22)	Grocery and supermarket (n = 15)	p
Place characteristics
SES of the neighborhood, n (%)
Nonresidence (SES 0)	10 (12.5)	2 (5.1)	7 (31.8)	1 (6.7)	N/Aa
Low (SES 1–3)	1 (1.3)	0 (0)	1 (4.5)	0 (0)
Medium (SES 4–7)	52 (65.0)	29 (74.4)	11 (50)	9 (60)
High (SES 8–10)	17 (21.3)	8 (20.5)	3 (13.6)	5 (33.3)
Proximity (300 m) to schools, n (%)
Elementary schools	33 (41.3)	18 (46.2)	7 (31.8)	6 (40)	0.548
Middle schools	18 (22.5)	8 (20.5)	6 (27.3)	1 (6.7)	N/A
High schools	33 (41.3)	17 (43.6)	6 (27.3)	7 (46.7)	0.373
Any schoolb	55 (68.8)	30 (76.9)	10 (45.5)	12 (80)	0.022
Marketing
Product availability and visibilityc, n (%)
HEETS
Visibility	37 (46.8)	22 (56.4)	9 (40.9)	4 (28.6)	0.163
Carried at least 4 flavors	28 (35.0)	19 (48.7)	3 (13.6)	6 (40)	0.023
Cigarettes
Availability	80 (100)	39 (100)	22 (100)	15 (100)	1.0
Visibility	40 (51.3)	23 (59)	6 (27.3)	8 (61.5)	0.039
Menthol cigarettes
Availability	76 (95.0)	38 (97.4)	20 (90.9)	15 (100)	N/A
Visibility	36 (48.6)	22 (57.9)	4 (21.2)	8 (57.1)	0.024
Roll-your-own tobacco
Availability	75 (94.9)	39 (100)	21 (100)	1 (93.3)	N/A
Visibility	54 (72.0)	32 (82)	10 (47.6)	11 (78.6)	0.015
E-cigarettes
Availability	41 (51.2)	27 (69.2)	9 (40.9)	4 (26.7)	0.008
Visibility	23 (65.7)	15 (68.2)	5 (55.6)	2 (66.7)	N/A
Waterpipe
Availability	15 (19.0)	9 (23.1)	2 (9.1)	4 (28.6)	N/A
Visibility	7 (50.0)	0 (0)	7 (77.8)	0 (0)	N/A
Chew, snuff, dip, or snus
Availability	32 (41.0)	18 (47.4)	8 (36.4)	6 (42.9)	0.709
Visibility	18 (60.0)	10 (58.8)	4 (50)	4 (80)	N/A
Cigarillos or little cigars
Availability	36 (45.6)	24 (61.5)	7 (31.8)	5 (35.7)	0.049
Visibility	25 (69.4)	19 (79.2)	3 (42.9)	3 (60)	N/A
Large cigars
Availability	33 (42.3)	21 (55.3)	7 (31.8)	5 (35.7)	0.161
Visibility	21 (63.6)	15 (71.4)	3 (49.2)	3 (60)	N/A
Placement, n (%)
Within 30 cm of youth-oriented merchandise
IQOS and/or HEETS	11 (13.8)	6 (15.4)	3 (13.6)	2 (13.3)	N/A
Other tobacco products	20 (25.0)	11 (14.5)	1 (4.5)	7 (9.2)	0.012
Within 1 m of the floor
IQOS and/or HEETS	4 (5.0)	1 (2.6)	0 (0)	3 (20)	N/A
Other tobacco products	6 (7.5)	4 (10.3)	0 (0)	2 (13.3)	N/A
Price in NIS, mean (SD) (range)d
HEETS pack	30.09 (2.40)	29.72 (1.77)	30.15 (3.20)	30.53 (1.71)	0.252
	(25.9–39.0)	(25.9–35)	(25.9–39)	(28–33)
Cheapest cigarette pack	23.56 (2.60)	22.82 (1.91)	24.73 (3.67)	23.69 (1.55)	0.197
	(14.0–37.8)	(14–25)	(22.0–37.8)	(21–26)
Most expensive cigarette pack	38.74 (1.10)	38.54 (1.17)	39.30 (1.00)	38.12 (1.35)	0.017
	(34.0–41.0)	(34.0–41.0)	(37.0–40.6)	(36.0–40.0)
Internal ads, n (%)
IQOS or HEETS, special stand	16 (20.0)	8 (20.5)	5 (22.7)	1 (6.7)	N/A
E-cigarette, any ad	23/41 (56.1)	11 (40.7)	7 (77.8)	2 (50)	N/A
Cigarettes, any ad	37 (46.3)	17 (43.6)	11 (50)	8 (53.3)	0.779
Regulatory compliance
Minimum age signage, n (%)	40 (50.0)	21 (53.8)	14 (63.6)	5 (33.3)	0.189
No smoking signage, n (%)	18 (22.5)	1 (2.6)	16 (72.7)	1 (6.7)	<0.001

p-Values per chi-square tests, unless otherwise noted. NIS = New Israeli Shekel, SD = standard deviation, and SES = socioeconomic status. Comparison across store types excludes four point-of-sales that were unique outlets (such as a coffee shop), therefore n = 76 for all comparisons. Analyses excluded missing data for some variables: visibility for HEETS (n = 1), cigarettes, menthol cigarettes, and roll-your-own (n = 2, respectively), availability for roll-your-own (n = 1), e-cigarette visibility (n = 6), waterpipe availability or visibility (n = 1), chew availability or visibility (n = 6), cigarillos or little cigars (n = 1), large cigars availability or visibility (n = 2), prices for HEETS (n = 3), and cheapest and most expensive cigarettes (n = 10 and 14, respectively).

^aN/A: comparison not applicable because of small numbers in some of the cells.

^bAny school refers to either elementary or middle or high school.

^cVisibility for each product is calculated from the number of stores that sell that product (N availability).

^dKruskal–Wallis test comparing ranks.

Product Availability and Visibility

All of the POSs carried cigarettes, 95.0% (76/80) carried menthol cigarettes, 94.9% (75/80) roll-your-own tobacco, and 51.3% (41/80) sold e-cigarettes (Table 1).

In 46.3% (37/80), HEETS were visible to the costumers, similar to the visibility of cigarettes (51.3%, 40/78) and menthol cigarettes (48.6%, 36/74). More than a third of stores (35%, 28/80) carried at least four HEETS colors. The IQOS device was sold in only one store in Tel-Aviv in an industrial area, with many high-tech companies, and which was close to Israel’s PMI headquarters (130 m).

Placement

Overall, 13.8% of stores (11/80) placed IQOS within 30 cm from youth-oriented merchandise (vs. 25% [20/80] for other tobacco products), and 5% (4/80) placed the products within 1 m from the floor (vs. 7.5% [6/80] for other tobacco products).

Price

Mean HEETS pack price was 30.1 NIS (US $8.7) (SD = 2.4; range: 25.9–39 NIS [US $7.5–11.3]); 43.8% (35/80) sold it for 30 NIS (US $8.7). The price of HEETS (32 NIS [US $9.2]) was lower than the cheapest cigarette pack price (37.8 NIS [US $10.9]) in only one store. Excluding this store, HEETS price was on average higher than the cheapest cigarette pack by 6.5 NIS (US $1.8) (SD = 2.68, range 0.3–16 NIS [US $0.08–4.6]), and for all stores, lower than the most expensive cigarette pack by on average 8.9 NIS (US $2.5) (SD = 2.6; range: 0–15.1 [US $0–4.3]). There was no association of HEETS price to neighborhood SES (p = .19).

Price Promotions

Only two stores had a price promotion for HEETS (both in Tel-Aviv)—one offered a discount (32 NIS [US $9.2] instead of 33 NIS [US $9.5]) and one store (which also sold the device) offered the device as a package with HEETS (either one or three HEETS packs). There were no cross-promotions with cigarettes, no promotions for specific subpopulations (such as soldiers), and no customer loyalty programs for IQOS and/or HEETS. Only four had any price promotions for other products (specifically cigarettes).

Promotions

External Ads

Only four stores had any external ads, none of which were IQOS or HEETS-branded. One store had a large neon sign saying we sell cigarettes on the outside (Tel-Aviv), and three stores had either a sign regarding JUUL (Jerusalem) or placed an e-cigarette stand visible on the outside (one store in Jerusalem and one store in Tel-Aviv).

Internal Ads

The most prominent ad featured for IQOS or HEETS was a special display, found within 20% of stores (16/80), 81.3% of which (13/16) carried the same cardboard box (Figure 1). In the remaining three stores, one store in Jerusalem had a metal stand in which HEETS packs were stacked on the side according to the different colors; one store in Tel-Aviv had a see-through glass display with a sign that read “heated tobacco,” with the HEETS packs stacked on the side; and one store in Tel-Aviv (which also carried the IQOS device) had a glass display with purple lights. No store had cartoon imagery, signage suggesting IQOS is safer than cigarettes, promotion of IQOS for smoking cessation, promotion of IQOS as a cheaper alternative to cigarettes, or promotion of IQOS for use in places where smoking is prohibited.

Figure 1.

Points-of-sale with a HEETS special display cardboard box. Note: The HEETS special display box (red circle), with a white sticker covering the top area (concealing the brand name to comply with the advertisement ban). Also note proximity to youth-oriented merchandise.

Overall, 46.3% of stores (37/80) had interior ads regarding cigarettes, and 56.1% (23/41) had interior ads regarding e-cigarettes. For cigarettes, the most common form of ad was a sign (either regular or digital) reading “We sell tobacco products here” or “For tobacco products ask the merchant.” For e-cigarettes, the most common form of ads was a white covered box with a sign reading “vaping products” which had two compartments—one with a sign reading 18 mg/pod and one reading 9 mg/pod (compatible with JUUL pods sold in Israel at the time).

Compliance With Legislation Currently in Effect (Minimum Age Signage, No Smoking Signage, and Ban on Advertisement)

Minimum age signage was present in 50% of stores. Only one store in Jerusalem had a “no vaping sign” on the exterior, and no stores had any sign regarding the use of HEETS or IQOS or other HTPs.

Of the 16 stores with internal IQOS and/or HEETS ads, noncompliance was evident in 4 stores (30.7% [4/13], missing n = 3; 5.2% [4/80] of the entire sample), all in Beer-Sheva: 3 stores had the cardboard box with the name HEETS in large letters on the top, and 1 store had the words “IQOS: This changes everything” written on the top of the display. The other stores with the cardboard box complied with the advertisement ban by covering the name HEETS with a white sticker. Noncompliance was also identified with regard to cigarette and e-cigarette advertising, with 13.3% (4/30, missing n = 7; 5.5% [4/73] of the entire sample) of stores having internal ads for cigarettes and 31.6% (6/19, missing n = 4; 7.9% [6/76] of the entire sample) internal ads for e-cigarettes.

Bivariate Analyses

Type of Store Comparisons

As can be seen from Table 1, a lower proportion of stores that were located within gas stations were near schools, compared to convenience stores or kiosks, or to grocery shops or supermarkets (45.5% vs. 76.9% and 90%, respectively, p = .022). In addition, a lower proportion of these stores carried at least four HEETS colors compared to other store types (13.6% in stores within gas stations compared to 48.7% in convenience stores or kiosks and 40% in grocery shops or supermarkets, p = .023).

Stores With Versus Without IQOS or HEETS Displays

Almost half of the stores with the HEETS display (43.8% [7/16]) placed the products within 30 cm of youth-oriented merchandise, compared to only four stores without the HEETS display (6.3% [4/64]) (p = .001) Stores with the HEETS display also had a higher proportion of visibility of both HEETS and cigarettes (93.8% [15/16] and 75% [12/16]) compared to stores without the HEETS display (34.9% [22/64], p < .001; and 45.2% [28/64], p = .049], respectively. A higher proportion of stores with internal ads for cigarettes or e-cigarettes also had the HEETS display (29.3% [11/37] and 34.8% [8/23], respectively), compared to stores without internal ads for cigarettes (11.6% [5/43], p = .08) or e-cigarettes (14% [8/57], p = .06). Other variables (eg, neighborhood SES or ethnicity, proximity to schools, and marketing) were not different between POS with the special display compared to those without (Supplementary File 2).

Discussion

During a time of regulatory transition, data from this sample of IQOS and/or HEETS POS indicated limited POS marketing (ie, few advertisements and/or price promotions). Compliance with legislation was fairly high for the newly introduced advertisement ban, and approximately 50% of stores complied with the display ban that was soon to be in effect. HEETS were highlighted via special displays in 20% of POS. Notably, 14% of POSs placed HEETS near youth-oriented merchandise, and almost 70% of HEETS POSs were proximal to schools.

Only two studies have been published on HTP POS marketing^24,25: one in Canada where a POS display ban has already been implemented,²⁴ and one in Guatemala where currently there are no restrictions on POS marketing.²⁵ In our study, approximately a third of POSs circumvented the advertisement ban by including large signs indicating that they sold cigarettes and e-cigarettes (without mentioning specific branding).¹⁵ This is similar to the Canadian study findings where retailers used signage displaying the price of “heated tobacco” to inform consumers of the products presence.²⁴

The findings that few marketing strategies were employed might suggest that regulatory changes like those in Israel may cause a shift from prioritizing POS advertising toward prioritizing online (such as social influencer marketing on social media) or other forms of marketing, such as print media (which was exempt from the advertisement ban in Israel^15,16). One study from the Czech Republic, exploring specific IQOS hashtags on Instagram (January 2018 to April 2019), has suggested that PMI might be paying influencers indirectly to promote IQOS on social media and may also be targeting specifically youth and young adults.²⁶ Future research assessing ad spend data in different media channels across the different regulatory timeframes could provide insight to this question, as well as studies of other forms of online marketing, including social media.

One marketing strategy used was categorizing the different HEETS flavors through colors, such as yellow (“roasted tobacco blend with balanced tobacco flavor”) or turquoise (“a tobacco blend containing menthol”).²⁷ Tobacco companies have used color as part of their product branding to influence perceptions of the taste, strength, and health impacts of cigarettes, particularly in response to policy restricting language allowed in advertising and labeling.²⁸ Countries implementing tobacco control legislation on HTPs should take this into account when designing regulations.

At the time of the study, HEETS were also sold on the online Web site for 140 NIS (US $40.6) for five packs. Despite being 7% less expensive for each pack than the POS price, the Web site only offered the possibility of buying five packs together (either all in one color or a mix of colors), making POS purchasing more affordable. However, the fact that the number and spread of POS that sell HEETS is still quite low compared to regular cigarettes (as evident by the high proportion of POSs that were found not to carry the product) suggests that online purchasing might still be a main source for consumers. The recent COVID-19 pandemic might have also led to a preference for online purchasing, as people practiced social distancing and were required to remain inside their homes for long periods of time.

The high price of HEETS, coupled with the finding that only one POS was located in a low-SES area, suggests that this product is aimed at a higher SES population. Similarly, findings do not suggest targeting of minority groups in Israel such as Arabs or Ultra-orthodox Jews. This is similar to a US study which found that a higher proportion of tobacco retailers that advertise e-cigarette were located in higher SES areas and areas that had a higher proportion of non-Hispanic Whites.²⁹ This is also in line with reports on the IQOS launch in the United States³⁰ and South Korea³¹ that describe the IQOS specialty stores as attracting “upscale tech-savvy users” and with results of a Hong Kong study showing that awareness and use were associated with higher SES.³² A potential negative implication of these findings is that limited marketing to lower SES groups could widen tobacco-related disparities by limiting use of potential modified exposure products among lower SES groups who commonly have higher-rates of combusted tobacco use.

Despite current low levels of IQOS use among youth in Israel,¹³ the frequent proximity to schools among HEETS POS might suggest potential targeted marketing to young people who should avoid tobacco altogether.³³ This is particularly important given the literature that young people are most likely to see e-cigarette advertisements at retail stores (68%).³⁴ Such advertising has been shown to impact young adults’ perceptions and use of e-cigarettes.^35,36 Exposure to HEETS POS advertising could have similar effects. Thus, further research is needed to examine these phenomena and inform potential zoning regulations in Israel.

Limitations and Strengths

Our sample was derived from the PMI IQOS Web site and might not have included all IQOS or HEETS POS. Additionally, more than 50% of HEETS POS identified on the PMI Web site in June 2019 were not carrying them 6 months later, potentially suggesting shifts in PMI marketing plans, that merchants discontinued carrying IQOS and/or HEETS, implications of pending legislation, etc. These factors were not addressed in the current study, underscoring the need for caution in interpreting findings. In addition, our sample included only predominantly Jewish or mixed Jewish and Arab cities; thus, we did not capture other marketing strategies potentially employed in POS located in Arab cities. Our sample did not include IQOS specialty stores, which sell only IQOS products and might employ more extensive marketing strategies. At the time of the study, only one IQOS specialty store existed in Israel at the center of Tel-Aviv, limiting the extent to which Israel’s population was exposed in this setting.

Conclusions

The POS is an important tobacco marketing channel, thus warranting surveillance particularly during regulatory changes. This study is one of the first to directly assess IQOS marketing strategies at the POS, providing valuable findings that can inform regulatory efforts in Israel and other countries as well. The recently implemented advertisement ban may have shifted marketing strategies from the POS to other avenues such as online marketing which may necessitate surveillance and regulation. This study provides baseline data for surveillance of marketing activities over time as the tobacco market in Israel evolves and as the tobacco regulations are more fully implemented and enforced.

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.

Funding

This research was supported by the National Cancer Institute (R01CA239178-01A1; MPIs: Berg, Levine) and by the Israel Lung and Tuberculosis Association (MPIs: Bar-Zeev, Levine).

Declaration of Interests

YB-Z has received fees for lectures from Pfizer Israel Ltd, Novartis NCH, and GSK Consumer Health (distributors of smoking cessation pharmacotherapy in Israel) in the past (2012 to July 2019). HL had received fees for lectures from Pfizer Israel Ltd (distributor of a smoking cessation pharmacotherapy in Israel) in 2017. LCA receives royalties for the sale of Text2Quit and is a shareholder in Welltok, Inc.