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. 2022 Oct 25;30:102031. doi: 10.1016/j.pmedr.2022.102031

Prevalence and denial of current tobacco product use: Combustible and heated tobacco products, Japan, 2022

Satomi Odani 1,⁎, Takahiro Tabuchi 1
PMCID: PMC9747627  PMID: 36531095

Abstract

Monitoring tobacco use has become more complex with the proliferation of novel tobacco products, including heated tobacco products (HTPs). We assessed the latest prevalence and denial of tobacco product use in Japan, a major market for HTPs. 28,124 individuals aged 16–74 responded to a nationwide, internet-based, self-reported survey. Current (past-30-day) tobacco use was assessed for HTPs, cigarettes, non-cigarette combustible tobacco, and dual (combustible plus HTP) use. Denial of current tobacco use was determined when respondents reported past-30-day use of a specific tobacco product (“On how many days did you use [the respective products]?”) but denied having used any tobacco (“Do you currently use tobacco?”) in the past 30 days. Descriptive and multivariable analyses were weighted to account for the selectivity of the internet-based sample. In 2022, current tobacco use was 11.8 % (HTPs), 19.4 % (cigarettes), 3.6 % (non-cigarette combustible tobacco), and 6.8 % (dual use). Among past-30-day users of specific tobacco products (N = 6,343), 19.5 % denied current tobacco use including single-product users of HTPs (10.0 %), cigarettes (21.7 %), and non-cigarette combustible tobacco (53.3 %), and dual users (20.2 %). The likelihood of denying current tobacco use was lower among exclusive HTP users and dual users compared to exclusive cigarette smokers; the likelihood was higher among females, never/non-current drinkers, less-frequent tobacco users, and those not reporting tobacco dependence. HTP use remained high in Japan. One-fifth of past-30-day tobacco users denied having used any tobacco products in the past 30 days. Increasing the sensitivity of questions to assess tobacco use can mitigate nondisclosure of tobacco use status.

Keywords: Tobacco control, Heated tobacco product, Non-cigarette tobacco product, Smoking, Surveillance, Tobacco dependence, MPOWER

1. Introduction

Japan has been a major market for heated tobacco products (HTPs). The prevalence of HTP use jumped from 0.2 % to 11.3 % between 2015 and 2019 (Hori et al., 2020) and has remained almost unchanged during 2019–2021, (Hori, 2022, Odani and Tabuchi, 2021) as the second most used tobacco product after cigarettes in Japan.

The proliferation of novel tobacco products such as HTPs has affected tobacco use behaviors and perceptions about the tobacco-attributable health risks, social acceptance of tobacco use, and whether people even consider themselves tobacco users if they use tobacco products. (Hair et al., 2018, Tabuchi, 2021, Lau et al., 2021) In surveys and clinical settings, tobacco use is often assessed by asking people whether they smoke or use any tobacco in general without specifying the type of tobacco or the timing of use (Ministry of Health, Labour and Welfare, 2022, Canters for Disease Control and Prevention, 2022, World Health Organization, 2022) (e.g. “Do you currently smoke/use tobacco?”). Such assessments may not capture tobacco users who simply do not consider themselves tobacco users, posing challenges for monitoring tobacco use (“M” in the World Health Organization’s MPOWER) (World Health, 2021) and offering tobacco users help to quit (“O” in MPOWER). (World Health, 2021).

The available studies on denial of tobacco use or being a tobacco user are limited. The majority of previous research has either included specific populations such as students and young adults in Western industrialized countries or focused only on combustible tobacco products such as cigarettes and cigars. (Tombor et al., 2015, Choi et al., 2010, Leas et al., 2015, Guillory et al., 2017, Agaku et al., 2018, Smith et al., 2019, Berg et al., 2009, Ridner et al., 2010) Given the increasing complexity of tobacco product profiles and usage, a better understanding of tobacco-related self-reporting patterns can help inform clinical and public health practice, particularly with regard to tobacco screening, counseling, surveillance, and education programs. The objectives of the present study were 1) to provide the latest prevalence of tobacco product use in Japan for HTPs, cigarettes, and other combustible tobacco products, and 2) to estimate the percentage of current users of specific tobacco products who deny current tobacco use.

2. Methods

2.1. Data source

The study was a cross-sectional analysis of the 2022 wave from the Japan Society and New Tobacco Internet Survey (JASTIS), a nationwide, internet-based, self-reported survey. Respondents were randomly drawn from more than two million panelists of a private vendor, Rakuten Insight Inc., (Rakuten Insight, 2022) by considering wide-ranging demographic and socioeconomic variables including education, housing, and marital status as defined by the Japan census (Tabuchi et al., 2019). For the present study, data were collected during February 1–28, 2022. We excluded individuals who provided unreasonable answers (N = 2,870) using a set of questions incorporated in the questionnaire (Tabuchi et al., 2019). For example, individuals who answered with the same number over an entire set of questions, those who checked all multiple-choice items of questions asking about illegal substance use (seven items) or presence of chronic conditions (15 items), or those who chose a wrong answer to the question “Choose the second item from the bottom” were excluded. Individuals aged 75 + years (N = 2,006) were also excluded to keep consistency with our previous report (Odani and Tabuchi, 2021), which resulted in 28,124 individuals to be included in the analysis. In-depth details of the sampling methods have been described elsewhere (Tabuchi et al., 2019). The study was reviewed and approved by the Research Ethics Committee of the Osaka International Cancer Institute (approval number 20094–2).

2.2. Prevalence of current tobacco product use

Current tobacco product use was assessed as past-30-day use of HTPs, cigarettes (manufactured and roll-your-own), non-cigarette combustible tobacco products (little cigars/pipes/water pipes), and dual use of combustible tobacco and HTPs. Respondents were asked product-specific questions (“During the past 30 days, on how many days did you use [the respective products]?”), and those who reported having used the product on ≥ 1 day in the past 30 days were classified as current users. (Hori et al., 2020, Odani and Tabuchi, 2021) A list of product names and separate answer spaces were provided for each tobacco product, as well as specific brand examples for HTPs (Ploom Tech/Ploom S/Ploom X/IQOS/glo/lil) to reduce confusion and increase the accuracy of respondents to survey questions. These product-specific questions are considered to have a high degree of face and construct validity for correctly identifying current tobacco product users. (National Center for Biotechnology, 2010).

2.3. Denial of current tobacco use

Preceding the product-specific questions, respondents were asked “Do you currently use tobacco? Think about the past 30 days.” Response categories included “every day”, “some days”, “I have used tobacco, but do not currently use it”, and “I have never used tobacco”. Given the validity of the product-specific questions, we assumed that respondents who answered in the affirmative to the product-specific questions (having used the respective products on ≥ 1 day in the past 30 days) but not to the question about general tobacco use (reporting “not currently” or “never” used tobacco) denied current tobacco use.

2.4. Statistical analysis

Prevalence of tobacco product use was computed for respondents overall and by gender, age, education (less than high school/high school [including current students]), and alcohol use. The percentage of respondents who denied current tobacco use was calculated for past-30-day users of at least one specific tobacco product (N = 6,343) and exclusive users of HTPs (N = 1,246), cigarettes (N = 3,048), and non-combustible tobacco products (N = 196), and dual users (N = 1,853). Along with the population characteristics listed above, the estimates were stratified by the number of days on which the respondent used tobacco products during the past 30 days (1–5/6–10/11–20/21–30) and tobacco dependence determined by the Tobacco Dependence Screener. (Kawakami et al., 1999) Between-group differences were assessed with chi-squared tests with the statistical significance level set at p < 0.05. Multivariable Poisson regression was used to examine the associated factors for denial of current tobacco use. Adjusted prevalence ratios (APRs) and 95 % confidence intervals (CIs) were estimated by controlling for all the aforementioned characteristics. All analyses were weighted by applying the inverse probability weight (IPW) to account for the selectivity of the internet-based sample. (Tabuchi et al., 2019, Tabuchi et al., 2016) To obtain the IPW, we calculated propensity scores for “being an internet survey respondent” by fitting logistic regression models adjusted for basic demographic, socioeconomic, health-related, and tobacco-use-related factors between the 2022 JASTIS sample and a nationally representative sample. (Ministry of Health, Labour and Welfare, 2022) Further details regarding weighting have been reported elsewhere. (Tabuchi et al., 2019, Tabuchi et al., 2016) Statistical analyses were performed using R version 4.1.3.

3. Results

In 2022, current (past-30-day) tobacco product use was 11.8 % for HTPs, 19.4 % for cigarettes, 3.6 % for non-cigarette combustible tobacco, and 6.8 % for dual use (Table 1). 24.5 % of all respondents reported having used at least one specific product in the past 30 days. Among the assessed non-cigarette combustible tobacco products, little cigars were most commonly reported by 2.5 % of all respondents, followed by pipes (1.7 %) and water pipes (1.5 %) (data not shown). When stratified by population characteristics, the prevalence was higher among males (vs females) and current drinkers (vs never/non-current drinkers), and lower among young (aged 16–19 years) and old (aged 60 + years) individuals for all tobacco products assessed (all p < 0.05). By education, although not statistically significant, less-educated individuals had higher prevalence for cigarette smoking (22.4 % vs 19.2 %; those with less than high school education vs high school education, hereinafter) and non-cigarette combustible tobacco use (4.7 % vs 3.5 %) while the reverse pattern was seen for HTP use (10.2 % vs 12.2 %). For dual use of combustible tobacco and HTPs, less educated individuals had lower prevalence than those with high school or higher education (5.0 % vs 7.1 %) (p < 0.05).

Table 1.

Prevalence of current (past-30-day) tobacco product use in Japan, Japan Society and New Tobacco Internet Survey (JASTIS), 2022.

 Distribution
 Prevalence - by product
 Prevalence - total
Cigarettes1 Non-cigarette combustible tobacco products2 Heated tobacco products3 Dual (combustible + heated tobacco) use Any (≥1) product use
Characteristics N % % (95 % CI) % (95 % CI) % (95 % CI) % (95 % CI) % (95 % CI)
Overall 28,124 100.0 19.4 (18.6–20.3) 3.6 (3.2–4.0) 11.8 (11.2–12.5) 6.8 (6.3–7.4) 24.5 (23.6–25.5)
Sex
Female 14,404 51.0 10.5 (9.6–11.4) 1.4 (1.1–1.6) 6.0 (5.2–6.7) 2.9 (2.4–3.4) 13.6 (12.6–14.6)
Male 13,720 49.0 28.7 (27.3–30.1) 6.0 (5.2–6.7) 17.9 (16.8–19.1) 11.0 (10.0–11.9) 35.9 (34.4–37.4)
Age, years
16–19 693 6.8 4.2 (2.1–6.3) 2.4 (0.8–4.0) 3.8 (1.7–5.8) 3.2 (1.3–5.1) 5.0 (2.8–7.3)
20–29 6061 12.2 20.1 (18.4–21.8) 7.8 (6.7–8.9) 16.0 (14.4–17.5) 12.1 (10.7–13.4) 24.1 (22.3–25.8)
30–39 4068 16.0 23.1 (20.6–25.6) 3.8 (3.0–4.6) 17.7 (15.5–20.0) 10.2 (8.4–12.1) 30.9 (28.2–33.6)
40–49 5324 21.0 22.6 (20.7–24.4) 3.4 (2.7–4.1) 14.8 (13.4–16.3) 7.7 (6.6–8.8) 29.5 (27.5–31.4)
50–59 4617 19.1 22.4 (20.1–24.7) 3.3 (2.0–4.6) 11.6 (10.0–13.1) 5.9 (4.7–7.1) 28.1 (25.8–30.5)
60–74 7361 25.0 16.0 (14.5–17.5) 2.3 (1.7–2.9) 5.9 (4.9–6.9) 3.1 (2.5–3.7) 19.1 (17.4–20.7)
Education
Less than high school 569 6.4 22.4 (17.6–27.2) 4.7 (2.5–6.9) 10.2 (6.7–13.7) 5.0 (3.0–7.0) 28.6 (23.1–34.1)
High school or higher (including current students) 27,386 93.6 19.2 (18.4–19.9) 3.5 (3.2–3.9) 12.2 (11.6–12.8) 7.1 (6.6–7.6) 24.4 (23.6–25.2)
Alcohol use
Non-current/never 13,664 51.8 15.0 (13.9–16.0) 3.1 (2.7–3.5) 9.4 (8.5–10.2) 5.4 (4.8–6.0) 19.2 (18.0–20.4)
Current 14,460 48.2 24.2 (22.9–25.5) 4.2 (3.5–4.9) 14.5 (13.4–15.5) 8.4 (7.5–9.2) 30.3 (28.9–31.6)
Open in a new tab
Note: Data were adjusted for “being a respondent in an internet survey” using a nationally representative sample of Japanese population. Within-group differences were assessed by chi-squared tests. Bold type indicates statistical significance (p < 0.05).
  • 1.
    Cigarettes assessed in this study included manufactured cigarettes and roll-your-own cigarettes.
  • 2.
    Non-cigarette combustible tobacco products assessed in this study included little cigars, pipes, and water pipes.
  • 3.
    Heated tobacco products assessed in this study included Ploom Tech, Ploom S, Ploom X, IQOS, glo, and lil.

Of all current (past-30-day) tobacco users, 19.5 % denied current tobacco use (Table 2). The percentage was highest among exclusive users of non-cigarette combustible tobacco (53.3 %), followed by exclusive cigarette smokers (21.7 %), dual users (20.2 %), and exclusive HTP users (10.0 %). Among former and never tobacco users combined (N = 21,781), 99.4 % denied current tobacco use (data not shown). In the multivariable analysis, exclusive users of HTPs and dual users had significantly lower likelihoods of denying current tobacco use (APR = 0.39 [95 %CI = 0.31–0.50] and APR = 0.71 [95 %CI = 0.61–0.82], respectively) compared to exclusive cigarette smokers. The likelihood was higher among females (APR = 1.33 [95 %CI = 1.17–1.51]) than males, non-current or never alcohol drinkers (APR = 1.20 [95 %CI = 1.05–1.36]) than current drinkers, less-frequent users of tobacco products (APR = 4.58 [ 95 %CI = 3.82–5.49], APR = 2.45 [95 %CI = 1.95–3.08], and APR = 2.22 [95 %CI = 1.76–2.79] for those who used tobacco products on 1–5 days; 6–10 days; and 11–20 days during the past 30 days, respectively) compared to frequent tobacco users (21 + days), and those not reporting tobacco dependence (APR = 2.31 [95 %CI = 1.91–2.81]).

Table 2.

Percentage and likelihood of denying current tobacco use among past-30-day users of any tobacco products, Japan Society and New Tobacco Internet Survey (JASTIS), 2022.

 Distribution
 Percentage – denying current tobacco use
 Likelihood – denying current tobacco use
Characteristics N % % (95 % CI) APR (95 % CI)
Overall 6343 100.0 19.5 (17.9–21.1) –
Tobacco use status
Cigarette1 only 3048 49.8 21.7 (19.4–23.9) Ref.
Non-cigarette combustible tobacco product2 only 196 2.0 53.3 (41.1–65.5) 1.17 (0.93–1.46)
Heated tobacco product3 only 1246 20.3 10.0 (7.0–13.1) 0.39 (0.31–0.50)
Dual (combustible + heated tobacco) use 1853 27.9 20.2 (16.9–23.5) 0.71 (0.61–0.82)
Sex
Female 1928 28.3 26.0 (22.9–29.0) 1.33 (1.17–1.51)
Male 4415 71.7 17.0 (15.1–18.9) Ref.
Age, years
16–19 45 1.4 56.8 (34.1–79.5) 1.27 (0.90–1.80)
20–29 1093 12.0 30.6 (26.8–34.4) 0.99 (0.81–1.22)
30–39 943 20.1 18.0 (14.7–21.3) 0.97 (0.78–1.21)
40–49 1499 25.3 18.0 (15.1–20.9) 1.01 (0.81–1.25)
50–59 1312 21.9 16.2 (12.0–20.4) 0.97 (0.76–1.23)
60–74 1451 19.4 17.4 (14.3–20.6) Ref.
Education
Less than high school 219 7.5 16.8 (9.2–24.3) 1.03 (0.67–1.57)
High school or higher (including current students) 6080 92.5 20.0 (18.5–21.4) Ref.
Alcohol use
Non-current/never 2463 40.6 24.0 (21.3–26.7) 1.20 (1.05–1.36)
Current 3880 59.4 16.5 (14.5–18.4) Ref.
Number days on which respondents used tobacco products (past 30 days) (Hair et al., 2018)
1–5 days 1106 13.4 59.3 (54.6–64.1) 4.58 (3.82–5.49)
6–10 days 522 7.8 27.5 (21.6–33.3) 2.45 (1.95–3.08)
11–20 days 665 10.9 26.1 (20.3–32.0) 2.22 (1.76–2.79)
21–30 days 4050 67.9 9.7 (8.1–11.4) Ref.
Tobacco dependence screening5
Not dependent 3701 54.3 29.1 (26.6–31.6) 2.31 (1.91–2.81)
Dependent 2642 45.7 8.2 (6.8–9.6) Ref.
Open in a new tab
Note: Data were adjusted for “being a respondent in an internet survey” using a nationally representative sample of Japanese population. Within-group differences were assessed by chi-squared tests. Adjusted prevalence ratios (APRs) and 95 % confidence intervals (CIs) were estimated through multivariable Poisson regression (adjusted for all the listed variables). Bold type indicates statistical significance (p < 0.05).
  • 1.
    Cigarettes assessed in this study included manufactured cigarettes and roll-your-own cigarettes.
  • 2.
    Non-cigarette combustible tobacco products assessed in this study included little cigars, pipes, and water pipes.
  • 3.
    Heated tobacco products assessed in this study included Ploom Tech, Ploom S, Ploom X, IQOS, glo, and lil.
  • 4.
    Defined as a higher number of days reported by respondents when they used multiple tobacco products.
  • 5.
    Determined by the Tobacco Dependence Screener.

4. Discussion

In 2022, HTP use remained high at 11.8 % and unchanged since 2019. (Odani and Tabuchi, 2021, Hori, 2022) The use of other tobacco products was 19.4 % for cigarettes and 3.6 % for non-cigarette combustible tobacco products, resulting in 24.5 % of all respondents currently using any (at least one) tobacco product. We also found that nearly one-fifth of current users of any tobacco product denied current tobacco use, and this proportion varied depending on the type of tobacco product they used, frequency of use, and whether they were dependent on tobacco. Assessing tobacco use without specifying these details in surveys or clinical settings may result in underreporting or nondisclosure of tobacco use, posing challenges in implementing MPOWER, including monitoring tobacco use (M) and offering smoking cessation support to tobacco users (O).

In this study, current users of HTPs were, regardless of whether they were exclusive or dual users, less likely to deny current tobacco use than exclusive cigarette smokers. This could be due to the social norms surrounding HTP use and smoking. Denormalization of smoking has become an important component of tobacco control strategies as seen in the 2020 revised Health Promotion Law, (Japan Ministry of Health, Labour and Welfare, 2018) which allows people to use HTPs in designated rooms while smoking is, in principle, banned in all indoor public places. This strategy of reinforcing non-smoking social norms may have inadvertently marginalized smokers with little advantage for them to disclose they are smokers or tobacco users. On the other hand, HTPs have often been marketed as a “cleaner alternative to cigarettes” or “reduced risk product”. (Bialous and Glantz, 2018, Philip Morris International, 2021) The health-conscious image of HTPs formed by the tobacco industry may have contributed to higher social acceptance towards HTP use than that for smoking and more comfortable disclosure of HTP use status as a current tobacco user.

We also found demographic differences in denial of current tobacco use with higher likelihoods among females, never or non-current drinkers, less-frequent tobacco users, and those not dependent on tobacco. Our findings were largely consistent with those from previous studies suggesting that tobacco use frequency and dependence are the most influential factors for denial of tobacco use or self-identity as being a tobacco user. (Choi et al., 2010, Leas et al., 2015, Guillory et al., 2017, Agaku et al., 2018) Policymakers and healthcare providers should be aware that those “light tobacco users” can be overlooked unless appropriate methods are used to monitor or screen for tobacco use. ”Light tobacco users” may include individuals who think they have quit tobacco even though they only attempted to stop using tobacco for a short period of time and continue to use tobacco intermittently. Simply asking “Do you currently smoke/use tobacco?” or asking people to identify themselves as current, former, or never users may not fully capture sporadic or social use of tobacco which can cause harms comparable to daily smoking. (Services USDoHaH, 2012, Schane et al., 2010, Bjartveit and Tverdal, 2005) Previous studies have documented that tobacco users who do not consider themselves tobacco users are less motivated to attempt cessation and tend to formulate only vague plans to stop using tobacco. (Tombor et al., 2015) Furthermore, tobacco user identity is often multifaceted; tobacco users may identify themselves, for example, as “social”, “casual”, “occasional”, or “performative” users, not just classify themselves into binary categories of users versus non-users. (Tombor et al., 2015, Berg et al., 2009, Ridner et al., 2010) Future tobacco control efforts need targeted messages toward less-frequent, non-dependent tobacco users with more focus on social and environmental triggers for tobacco use. The public also needs to be informed that no tobacco is free from harm (USDHHS, 2014, US Food and Drug Administration, 2022), and there is no safe level of tobacco use (Services USDoHaH, 2012, Schane et al., 2010, Bjartveit and Tverdal, 2005).

The present study had several limitations. First, as the study sample was collected through internet-based recruitment, our findings may not be generalizable to the population with limited access or literacy to the internet. However, over 90 % of the Japanese population had access to the internet as of 2021 (Statistica, 2022), and we used weighted data to address the differences in socioeconomic and demographic characteristics between respondents of the current internet survey and a nationally representative sample. Thus, the selection bias in this study is not likely to be large. Second, the self-reported measures may be subject to misreporting. Product-specific past-30-day use status was used as a “gold standard” when respondents gave discordant answers to the question about current use of any tobacco use on the grounds of the cited previous evidence (National Center for Biotechnology, 2010, Services USDoHaH, 2012). We interpreted that the discordant results reflected users denying current tobacco use, but other reasons may in part account for the discordance such as respondents misunderstanding the questions or answering the specific-product questions inaccurately. However, such misreports were considered to be minimized by excluding individuals who provided unreasonable responses from the analysis. Furthermore, nearly all (99.4 %) former/never tobacco users accurately denied current use of any tobacco product, supporting the validity of the definition of denial in this study.

5. Conclusion

In 2022, HTP use remained high in Japan (11.8 %) as the second most used tobacco product after cigarettes (19.4 %). One in five current (past 30-day) tobacco product users denied current tobacco use. Given the complex tobacco product use patterns and changing tobacco-related social norms, increasing the sensitivity of questions to screen for tobacco use is important to reduce underreporting and nondisclosure of true tobacco use status.

Funding

This study was supported by KAKENHI Grant (#21H04856) from the Japan Society for the Promotion of Science (JSPS); and Health Labour Sciences Research Grant (#19FA1005, 19FA1012, 19FA1011, and 20FA1005) from the Ministry of Health, Labour and Welfare, Japan.

CRediT authorship contribution statement

Satomi Odani: Conceptualization, Methodology, Validation, Formal analysis, Data curation, Writing – original draft, Visualization. Takahiro Tabuchi: Conceptualization, Methodology, Validation, Investigation, Resources, Writing – review & editing, Supervision, Project administration, Funding acquisition.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.

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