Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020

Abstract

Introduction

Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults.

Aims and Methods

Using 2020 cross-sectional data from 2,470 young adults (ages 18–34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively.

Results

19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (β = 0.26, 95%CI = 0.21, 0.30; β = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (β = −0.06, 95%CI = −0.10, −0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users.

Conclusions

Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims.

Implications

Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.

Introduction

In recent years, the nicotine and tobacco product marketplace has evolved rapidly with the emergence of tobacco products like heated tobacco products (HTPs). HTPs are electronic tobacco products that heat tobacco to produce an inhalable aerosol, and are distinct from e-cigarettes, which heat e-liquid into inhalable vapor.¹ Although current evidence indicates that HTPs may expose consumers to lower levels of toxic chemicals than cigarettes,^2,3 research suggests potential negative health effects (eg, cardiovascular diseases) associated with HTP use.^4,5

HTPs are available globally in >60 countries, with considerable growth rates in countries like Japan and Italy where HTPs have been available since 2014.^6,7 Some HTP brands from big tobacco companies include “Mok” of China Tobacco, “iFuse” and “glo” of British American Tobacco, “Ploom TECH” of Japan Tobacco, “lil” of Korea Tobacco, and “IQOS” of Philip Morris (PM).^7,8

In the United States, two types of HTPs, IQOS, and Eclipse, are authorized for sale by the US Food and Drug Administration (FDA).⁹ IQOS’ entry to the US market in Atlanta, Georgia in October 2019 was marked by $1.29 million in print magazine ads to promote IQOS in fall 2019 alone.¹⁰ Moreover, from August 2019 to April 2021, IQOS marketing expenditure in the United States reached $4.9 million.¹¹ Notably, in July 2020, IQOS received FDA’s Modified Risk Tobacco Product (MRTP) authorization to use claims in its marketing that indicate “reduced exposure” (ie, to harmful substances relative to cigarettes)—but not “reduced risk” (ie, less health risks than cigarettes).¹² However, growing evidence indicates that “reduced exposure” claims may be inaccurately perceived as “reduced risk” by consumers.^13–15

In the United States, HTP awareness and use are low, but increasing.^16–18 Regarding young adults, for example, a 2017 study indicated 7.6% awareness and 1.6% ever use,¹⁷ the 2016/2017 Tobacco Products and Risk Perceptions Survey documented 13.9% awareness and 3.0% ever use,¹⁸ and a 2019 study showed 9.7% awareness and 3.5% ever use.¹⁹ Thus, despite a patent dispute with a rival tobacco company that suspends IQOS sales in the US market,²⁰ HTPs are poised to represent an increasing share of the US tobacco market.

Market expansion and increasing availability of HTPs may impact consumers’ awareness, perceptions, use behaviors, and intention to use HTPs, particularly among young adults, who have historically been targeted by tobacco industry marketing.^21–23 In addition to traditional tobacco marketing approaches, IQOS was marketed using innovative strategies (eg, social influencers on social media, pop-up and mobile stores),^24,25 making them more appealing to young adults.^21,26,27 Theoretical and empirical evidence suggest that perceptions toward tobacco products are influenced by marketing and advertising and significantly associated with tobacco use or intention to use,^28,29 underscoring the need to understand consumer perceptions and their associations with HTP use and use intentions.

Notably, the FDA MRTP authorization allowing IQOS to use reduced exposure claims in their advertising may have important implications. For example, consumers may misinterpret such claims as reduced risk,^14,15 as well as statements about the benefits of “switching completely” from traditional cigarettes to IQOS.^13,15 In the United States and globally, IQOS ads often claim that IQOS (vs. cigarettes) poses “reduced risk”,^30,31 is a “cleaner” product (ie, “less ash”, “less odor”), is more acceptable to nonsmokers,³¹ and is a satisfactory alternative to cigarettes (eg, “real tobacco”), despite mixed findings regarding consumers’ perceptions of IQOS design and marketing claims.^31,32 In addition, PM has also marketed IQOS as distinct from vaping products, which have received media coverage connecting them to e-cigarette and vaping associated lung injuries.³³ For example, one IQOS ad message reads, “It’s not a vape. It’s not an e-cig. It’s real tobacco with less odor and no ash”.¹¹ Additionally, a study of IQOS marketing during its initial 2 years in the United States indicated use of marketing themes and channels indicating the targeting of young adults, as well as those interested in technology and innovation.¹¹

Despite the importance of monitoring HTPs’ early expansion among US young adults, limited research has examined the associations between individuals’ perceptions and HTP use and use intentions. Previous studies have generally been limited in the scope of correlates examined, documenting that ever use of HTPs was correlated with tobacco and cannabis use,^16–18 younger age (ie, <30 years),¹⁷ and racial/ethnic minority status.¹⁸ While these findings are important, research examining the implications of HTP-related perceptions is needed.

Thus, this study used data from a large, diverse sample of US young adults (aged 18–34 years) to examine: (1) perceptions of HTPs (specifically IQOS), for example their utility or appeal, as well as their correlates; and (2) these perceptions in relation to one’s lifetime HTP use and HTP use intentions (as well as past-month cigarette and e-cigarette use status). We also conducted subgroup analyses to examine these perceptions in relation to lifetime HTP use and use intentions among past-month cigarette, e-cigarette, and any tobacco users, respectively. We hypothesized that: (1) young adults who endorsed positive IQOS perceptions would be more likely to report lifetime HTP use and greater use intentions; (2) certain perceptions (eg, social appeal) may also be related to cigarette and e-cigarette use; and (3) specific perceptions (eg, favorable comparisons to cigarettes or e-cigarettes) would show positive correlations with HTP use and use intentions among subgroups of young adults representing different other tobacco/nicotine product use status.

Methods

Study Design

This study analyzed 2020 survey data from the Vape shop Advertising, Place characteristics and Effects Surveillance (VAPES) study, a 2-year, 5-wave cohort study involving US young adults (ages 18–34) across six metropolitan statistical areas (MSAs; ie, geographical regions with relatively high core population density and close social/economic ties in adjacent communities).³⁴ The VAPES study, which launched in 2018, examines vaping products’ retail environment and estimating its impacts on tobacco use among US young adults. The six MSAs (ie, Atlanta, Georgia; Boston, Massachusetts; Minneapolis, Minnesota; Oklahoma City, Oklahoma; San Diego, California; Seattle, Washington) were selected for their variation in state tobacco control contexts (ie, Massachusetts and California being most restrictive; Oklahoma and Georgia being least).³⁵ The detailed study design and data collection procedures are published elsewhere³⁶ but summarized here. This study was approved by the Emory University and George Washington University Institutional Review Boards.

Advertisements posted on Facebook and Reddit targeted eligible individuals (ie, 18–34 years old, living in one of the six MSAs as indicated by residential zip code, English speaking). Individuals who clicked on ads were directed to a webpage with a study description, consent form, and eligibility screener. Purposive, quota-based sampling was used to ensure sufficient representation of e-cigarette and cigarette users (~1/3 each), sexes, and racial/ethnic minorities.

Overall, 65,843 Facebook/Reddit users viewed study ads, 10,433 clicked ads, and 9,847 consented. Of the 9,847 individuals, 2,751 were not allowed to advance to the baseline survey (1,472 ineligible; 1,279 excluded to reach recruitment targets). Of the 7,096 allowed to advance to the baseline survey, 3,460 (48.8%) completed the full survey, and 3,636 (51.2%) partially completed it (not enrolled; see Supplementary Figure 1). (Note that 2,469 [67.9%] of partial completers only completed the initial sociodemographic section of the survey; see prior publication for comparisons between full and partial completers.³⁶) Participants were required to confirm their participation 7 days post-baseline to be enrolled and emailed their first incentive ($10 e-gift card); 3,006 (86.9%) confirmed participation. Of 2,476 participants who completed the Wave 5 (fall 2020) survey (after FDA’s MRTP authorization of IQOS), 2,470 (99.8%) provided complete information on awareness and ever use of HTPs and were thus included in current analyses.

Measures

Primary Outcomes

HTP Awareness, Use, and Use Intentions. Participants were presented with images of HTPs and a brief description (i.e., “…new category of tobacco products sometimes referred to as heat-not-burn tobacco, called this because they heat tobacco but do not actually burn it. Two common brands are IQOS and Eclipse”). They were then asked, “Have you heard of heat-not-burn products, like IQOS or Eclipse, which heat sticks of tobacco instead of burning it?” and “In your lifetime, have you ever tried a heat-not-burn product like IQOS or Eclipse?”, with response options of: No; Yes, IQOS only; Yes, Eclipse only; Yes, both IQOS and Eclipse.^19,37 Those who had ever heard of or tried either product were coded as ever heard and ever used HTPs, respectively. Participants who were aware of HTPs were asked, “How many days in the past 6 months did you use a heat-not-burn product?”^19,37 Past 6-month HTP users were asked, “How many days of the past 30 days did you use a heat-not-burn product?”^19,37 All participants were asked, “How likely are you to use HTPs in the next year?” with response options of “1 = not at all” to “7 = extremely”.^19,37

Primary Correlates of Interest

Perceptions of IQOS. To examine perceptions of IQOS, we developed an assessment of product features promoted in IQOS advertising.^11,24,25,38 All participants (who were presented with a description and images of IQOS as noted above) were asked, “To what extent do you think the following describe IQOS?” in relation to 22 descriptors (eg, innovative, natural, fashionable, better than cigarettes, better than e-cigarettes—complete list in Table 2). Response options were “1 = not at all” to “7 = extremely”.

Table 1.

Participant Characteristics and Bivariate Analyses Examining Correlates of Having Heard of and Having Ever Used HTPs, N = 2,470.

		Heard of HTPs			Ever Used HTPs
	All participants	Yes	No		Yes	No
Variable	N = 2,470	n = 471	n = 1,999	p value	n = 101	n = 370	p value
	100.0%	19.1%	80.9%		21.4%	78.6%
MSA, N (%)
Atlanta	383 (15.5)	93 (19.8)	290 (14.5)	.026	16 (15.8)	77 (20.8)	.079
Boston	327 (13.2)	53 (11.3)	274 (13.7)		7 (6.9)	46 (12.4)
Minneapolis	343 (13.9)	54 (11.5)	289 (14.5)		9 (8.9)	45 (12.2)
Oklahoma City	153 (6.2)	26 (5.5)	127 (6.4)		3 (3.0)	23 (6.2)
San Diego	367 (14.9)	69 (14.7)	298 (14.9)		22 (21.8)	47 (12.7)
Seattle	313 (12.7)	52 (11.0)	261 (13.1)		14 (13.9)	38 (10.3)
Other£	584 (23.6)	124 (26.3)	460 (23.0)		30 (29.7)	94 (25.4)
Sociodemographics
Age, M (SD)	24.67 (4.7)	25.83 (4.7)	24.39 (4.7)	<.001	26.41 (4.6)	25.68 (4.5)	.154
Sex, N (%)
Male	1,023 (41.4)	250 (53.1)	773 (38.7)	<.001	60 (59.4)	190 (51.4)	.325
Female	1,378 (55.8)	213 (45.2)	1,165 (58.3)		40 (39.6)	173 (46.8)
Other	69 (2.8)	8 (1.7)	61 (3.1)		1 (1.0)	7 (2.0)
Sexual minority, N (%)	769 (31.3)	125 (26.5)	644 (32.2)	.017	23 (22.8)	102 (25.6)	.333
Race, N (%)
White	1,761 (71.3)	327 (69.4)	1,434 (71.7)	.724	69 (68.3)	258 (69.7)	.021
Black	133 (5.4)	28 (5.9)	105 (5.3)		9 (8.9)	19 (5.1)
Asian	315 (12.8)	61 (13.0)	254 (12.7)		6 (5.9)	55 (10.3)
Other	261 (10.6)	55 (11.7)	206 (10.3)		17 (16.8)	38 (10.3)
Hispanic, N (%)	272 (11.0)	63 (13.4)	209 (10.5)	.062	29 (28.7)	34 (9.2)	<.001
Education > College degree, N (%)	1,866 (75.6)	354 (75.2)	1,512 (75.6)	.828	60 (59.4)	294 (79.5)	<.001
Other tobacco use, past 30 days, N (%)
Cigarettes	481 (19.5)	127 (27.0)	354 (17.7)	<.001	64 (63.4)	63 (17.0)	<.001
E-cigarettes	622 (25.2)	170 (36.1)	452 (22.6)	<.001	64 (63.4)	106 (28.7)	<.001
Little cigars/cigarillos	211 (8.5)	77 (16.4)	134 (6.7)	<.001	32 (31.7)	45 (12.2)	<.001
Hookah	105 (4.3)	38 (8.1)	67 (3.4)	<.001	22 (21.8)	16 (4.3)	<.001
Smokeless tobacco	67 (2.7)	18 (3.8)	49 (2.5)	.100	7 (6.9)	11 (3.0)	.066
Other tobacco use*	307 (12.4)	99 (21.0)	208 (10.4)	<.001	40 (39.6)	59 (16.0)	<.001
IQOS perception factors, M (SD)§
Fashionable	2.04 (1.2)	2.52 (1.4)	1.93 (1.2)	<.001	3.70 (1.4)	2.20 (1.3)	<.001
E-cigarette/nicotine substitute	2.36 (1.3)	2.68 (1.5)	2.28 (1.3)	<.001	3.67 (1.3)	2.41 (1.4)	<.001
Cigarette substitute	2.99 (1.6)	3.39 (1.6)	2.90 (1.6)	<.001	4.11 (1.2)	3.20 (1.7)	<.001
Innovation	3.17 (1.5)	3.72 (1.4)	3.04 (1.5)	<.001	4.22 (1.2)	3.58 (1.4)	<.001
Youth appeal	2.82 (1.6)	3.18 (1.6)	2.74 (1.6)	<.001	4.09 (1.5)	2.93 (1.6)	<.001
Intentions to use HTPs, M (SD)§	1.27 (0.9)	1.64 (1.4)	1.18 (0.7)	<.001	3.02 (2.0)	1.26 (0.8)	<.001

Other tobacco included little cigars/cigarillos, hookah, and smokeless tobacco.

1 = not at all, 7 = extremely.

Due to participants moving residences since study enrollment.

Boldface indicates p < .05; HTP: heated tobacco product; MSA: metropolitan statistical areas.

Table 2.

Results of Factor Analyses Regarding Perceptions of IQOS.

Item	Factors and factor loadings					M (SD)
	Fashionable	E-cigarette/nicotine substitute	Cigarette substitute	Innovation	Youth appeal
Natural	.90	.08	.03	−.06	−.28	1.82 (1.32)
Attractive	.88	.06	−.18	−.07	.18	2.04 (1.57)
Something I would use	.87	.17	−.06	−.17	−.23	1.71 (1.41)
Fashionable	.83	−.05	−.07	−.02	.21	2.10 (1.55)
Chic	.81	.03	−.12	−.04	.23	2.08 (1.53)
Sophisticated	.74	−.10	.14	.14	−.01	2.22 (1.54)
Clean	.69	.01	.19	.05	-.04	2.30 (1.65)
Less harmful than e-cigarettes	.00	.82	.08	.07	-.03	2.29 (1.52)
Better product than e-cigarettes	.01	.81	−.01	.16	.05	2.37 (1.56)
Cleaner than e-cigarettes	.03	.74	.09	.04	.09	2.37 (1.58)
Better substitute for cigarettes than e-cigarettes	.00	.71	.10	.18	−.00	2.56 (1.66)
More convenient than e-cigarettes	.13	.60	−.01	−.11	.33	2.25 (1.54)
Better option for quitting smoking than nicotine patch	.37	.46	.24	−.10	−.17	2.29 (1.61)
Cleaner than cigarettes	−.10	.11	.89	−.03	.04	3.29 (2.05)
Less harmful than cigarettes	−.10	.26	.81	−.08	−.05	2.87 (1.88)
More convenient than cigarettes	−.07	.03	.75	−.25	.44	2.99 (1.95)
Great substitute for cigarettes	.13	.17	.64	.04	−.05	2.82 (1.77)
Expensive	−.18	.23	−.20	.99	.02	3.49 (1.88)
Technologically advanced	.29	−.12	.28	.44	.14	3.13 (1.83)
Innovative	.30	−.16	.41	.43	−.05	2.89 (1.73)
Appealing to young people	−.14	.09	.09	.05	.84	3.27 (1.90)
Youthful	.47	−.02	−.07	.11	.48	2.38 (1.68)
Average factor score, M (SD)	2.04 (1.24)	2.36 (1.33)	2.99 (1.64)	3.17 (1.53)	2.82 (1.58)	–
Eigenvalue	11.67	1.83	0.96	1.07	0.69	–
% Variance accounted for	61.17%	60.16%	44.56%	48.60%	30.65%	–
Cronbach’s alpha	.92	.92	.88	.80	.70	–
Factor correlations
Fashionable	1.00
E-cigarette/nicotine substitute	.59	1.00
Cigarette substitute	.64	.53	1.00
Innovation	.49	.65	.55	1.00
Youth appeal	.48	.43	.40	.31	1.00

Extraction Method: Principal Component Analysis. Rotation Method: Promax with Kaiser Normalization; rotation converged in 8 iterations.

Other Tobacco Product Use

Past-month tobacco use was assessed by asking, “During the past 30 days, on how many days did you smoke/used cigarettes (even a puff)? e-cigarettes? little cigars or cigarillos? hookah? smokeless tobacco?”³⁹ From these items, we created four current use status (≥1 day of use) variables, indicating current use of: (1) cigarettes; (2) e-cigarettes; (3) other tobacco products (ie, little cigars/cigarillos, hookah, smokeless tobacco; and (4) any tobacco product (ie, inclusive of all, excluding HTPs).

Sociodemographic Covariates

Sociodemographic included sex, sexual minority status, race, ethnicity, and education (assessed at baseline) and age and MSA of residence (at Wave 5).

Data Analysis

Stata 15.0 was used for analyses. Descriptive analyses were used to summarize outcomes, correlates of interest, and covariates. Bivariate analyses (Chi-Square tests for categorical variables; two-sample t-tests and analysis of variance [ANOVA] for continuous variables) were used to characterize differences between those who: (1) had heard of HTPs versus had not, and (2) had ever versus never used HTPs (among those who had heard of them).

Exploratory factor analysis using principal components extraction with promax rotation was conducted to determine salient factors that emerged from the 22 IQOS perception items. We initially followed conservative guidelines for factor analysis⁴⁰; specifically, after the matrix was rotated, we examined the three factors whose eigenvalues were greater than 1.0. We also explored 4 and 5 factor solutions to examine interpretability of these solutions. Once the final 5 factor structure was selected, perception items in each factor were summed and averaged to create a score for each factor.

We then examined the 5 IQOS perception factors in relation to our outcomes, using multivariable binary logistic regressions for HTP ever use (as well as past-month cigarette and e-cigarette use, respectively) and multivariable linear regressions for HTP use intentions, controlling for other tobacco use and sociodemographics. We also conducted subgroup analyses to examine IQOS perceptions in relation to HTP ever use and use intentions among past-month cigarette, e-cigarette, and any tobacco users, respectively, using parallel approaches. The proportion of participants with any missing value for any key variable was less than 5%; thus, listwise deletion was used to handle missing values. Significance was set at α = 0.05.

Results

Table 1 presents participant characteristics in total and across HTP awareness and ever use status (N = 2,470). On average, participants were 24.7 years old (SD = 4.7), 55.8% female, 31.3% sexual minority, 71.3% White, and 11.0% Hispanic. Past-month cigarette, e-cigarette, and other tobacco product use prevalence was 19.5%, 25.2%, and 12.4%.

Overall, 19.1% (n = 471) had heard of HTPs (among these participants: 29.3% [n = 138] IQOS only; 22.9% [n = 108] Eclipse only; 47.8% [n = 225] both), and 4.1% (n = 101) ever used HTPs (among these participants: 42.6% [n = 43] IQOS only; 30.7% [n = 31] Eclipse only; 26.7% [n = 27] both, data not shown in tables). Overall, 2.5% (n = 61) reported past 6-month HTP use. Among young adults who had heard of HTPs, 27.0% reported past-month use of cigarettes, 36.1% e-cigarettes, and 21.0% other tobacco products. Among young adults who had used HTPs, 63.4% reported past-month use of cigarettes, 63.4% e-cigarettes, and 39.6% other tobacco products. In bivariate analyses, those who were older, male, Hispanic, heterosexual, and using other tobacco products were more likely to be aware of HTPs, and those who were Hispanic, less educated, and using other tobacco products were more likely to report ever use of HTPs.

Initially, exploratory factor analyses indicated three factors with eigenvalues greater than 1.0. After exploring alternative solutions, we chose the 5-factor solution based on interpretability (see Table 2): (1) fashionable, indicating that IQOS was perceived as attractive, chic, clean, fashionable, natural, and sophisticated (8 items, eigenvalue = 11.67, accounted for 61.2% of variance; Cronbach’s alpha = 0.92; M = 2.04, SD = 1.24); (2) e-cigarette/nicotine substitutes, indicating that IQOS was perceived as less harmful than e-cigarettes and a better substitute for cigarettes than e-cigarettes (six items, eigenvalue = 1.82, accounted for 60.2% of variance; Cronbach’s alpha = 0.92; M = 2.36, SD = 1.33); (3) cigarette substitute, indicating that IQOS was perceived as a less harmful substitute for cigarettes (four items, eigenvalue = 0.96, accounted for 44.6% of variance; Cronbach’s alpha = 0.88; M = 2.99, SD = 1.64); (4) innovation, indicating that IQOS was perceived as expensive, innovative and technologically advanced (three items, eigenvalue = 1.07, accounted for 48.6% of variance; Cronbach’s alpha = 0.80; M = 3.17, SD = 1.53); and (5) youth appeal (two items, eigenvalue = 0.69, accounted for 30.7% of variance; Cronbach’s alpha = 0.70; M = 2.82, SD = 1.58). See Table 2 for complete data regarding the 22 IQOS perception items, factor loadings, average item scores, average factor scores, eigenvalues, Cronbach’s alpha, and correlations across factors. The correlations ranged from 0.31 between innovation and youth appeal to 0.65 between innovation and e-cigarette/nicotine substitutes.

Table 3 presents the multivariable regression results. Ever HTP use was correlated with perceiving IQOS as more fashionable (aOR = 1.60, 95%CI = 1.17, 2.17) and as an e-cigarette/nicotine substitute (aOR = 1.48, 95%CI = 1.11, 1.97) but less as a cigarette substitute (aOR = 0.74, 95%CI = 0.56, 0.97). In addition, ever HTP use was associated with past-month use of cigarettes (aOR = 2.03, 95%CI = 1.17, 3.52), e-cigarettes (aOR = 2.28, 95%CI = 1.31, 3.97), and other tobacco products (aOR = 2.24, 95%CI = 1.33, 3.80), respectively.

Table 3.

Multivariable Regression Analyses Examining Perceptions of HTPs as Correlates of HTP Ever Use, HTP Use Intention, and Past-Month Cigarette and E-Cigarette Use, N = 2,470.

Variable	Ever used HTPs		Past-month cigarette use		Past-month e-cigarette use		Intention to use HTPs
	N = 2,368		N = 2,368		N = 2,368		N = 2,360
	aOR	CI	aOR	CI	aOR	CI	β	CI
MSA (ref: Atlanta)
Boston	0.41	0.14–1.17	1.78	1.11–2.87	0.77	0.49–1.20	-0.03	-0.15–0.09
Minneapolis	0.54	0.21–1.40	1.46	0.90–2.35	1.39	0.91–2.13	0.00	-0.12–0.12
Oklahoma City	0.36	0.09–1.41	1.09	0.60–1.99	1.19	0.69–2.04	0.03	-0.12–0.18
San Diego	0.89	0.39–2.02	0.84	0.51–1.37	1.19	0.78–1.81	0.03	-0.09–0.14
Seattle	0.84	0.35–2.03	1.20	0.73–1.97	1.16	0.75–1.79	0.16	0.04–0.28
Other	0.83	0.39–1.77	1.65	1.08–2.52	0.83	0.56–1.22	0.03	-0.08–0.13
Sociodemographics
Age	1.06	1.00–1.11	1.07	1.04–1.10	0.96	0.93–0.98	0.01	0.01–0.02
Female (ref: male)	0.67	0.40–1.10	0.80	0.62–1.04	1.05	0.83–1.33	-0.07	-0.14–0.01
Other gender (ref: male)	0.70	0.08–5.82	1.04	0.49–2.20	0.87	0.43–1.78	0.00	-0.20–0.20
Sexual minority (ref: heterosexual)	0.67	0.37–1.22	1.19	0.90–1.57	1.09	0.84–1.40	-0.13	-0.20–0.06
Race (ref: White)
Black	1.42	0.58–3.47	0.77	0.44–1.36	0.73	0.43–1.26	-0.07	-0.22–0.07
Asian	0.48	0.18–1.26	0.90	0.60–1.36	0.77	0.53–1.10	-0.05	-0.15–0.05
Other	1.92	1.01–3.64	0.86	0.57–1.29	1.19	0.82–1.72	0.05	-0.05–0.16
Hispanic (ref: non-Hispanic)	1.63	0.90–2.95	1.72	1.18–2.50	0.70	0.47–1.03	0.23	0.13–0.34
Education (ref: not college)	0.52	0.32–0.87	0.53	0.41–0.70	0.58	0.45–0.75	0.03	-0.04–0.11
Tobacco use, past-month (ref: no)
Cigarette use	2.03	1.17–3.52	–	–	5.33	4.06–6.98	0.44	0.35–0.53
E-cigarette use	2.28	1.31–3.97	5.32	4.05–6.99	–	–	0.14	0.06–0.23
Other tobacco use	2.24	1.33–3.80	3.43	2.52–4.68	2.40	1.74–3.31	0.05	-0.05–0.15
IQOS perception factors
Factor 1: Fashionable	1.60	1.17–2.17	1.74	1.46–2.06	2.79	2.34–3.32	0.26	0.21–0.30
Factor 2: E-cigarette/nicotine substitute	1.48	1.11–1.97	1.34	1.14–1.57	0.53	0.45–0.62	0.14	0.09–0.18
Factor 3: Cigarette substitute	0.74	0.56–0.97	0.72	0.63–0.82	1.63	1.45–1.82	-0.06	-0.10–0.03
Factor 4: Innovation	0.92	0.72–1.18	0.90	0.80–1.02	0.84	0.75–0.94	-0.03	-0.06–0.01
Factor 5: Youth appeal	1.16	0.95–1.43	0.96	0.86–1.08	0.64	0.57–0.71	-0.03	-0.06–0.00

Boldface indicates p < .05; HTP: heated tobacco product; MSA: metropolitan statistical areas.

Past-month cigarette use was associated with perceiving IQOS as more fashionable (aOR = 1.74, 95%CI = 1.46, 2.06) and as an e-cigarette/nicotine substitute (aOR = 1.34, 95%CI = 1.14, 1.57) but less as a cigarette substitute (aOR = 0.72, 95%CI = 0.63, 0.82). Past-month e-cigarette use was correlated with perceiving IQOS as more fashionable (aOR = 2.79, 95%CI = 2.34, 3.32) and as a cigarette substitute (aOR = 1.63, 95%CI = 1.45, 1.82), but less as an e-cigarette/nicotine substitute (aOR = 0.53, 95%CI = 0.45, 0.62), innovative (aOR = 0.84, 95%CI = 0.75, 0.94), and appealing to youth (aOR = 0.64, 95%CI = 0.57, 0.71).

Greater intention to use HTPs was correlated with perceiving IQOS as more fashionable (β = 0.26, 95%CI = 0.21, 0.30) and as an e-cigarette/nicotine substitute (β = 0.14, 95%CI = 0.09, 0.18) but less as a cigarette substitute (β = −0.06, 95%CI = −0.10, −0.03) and youth appeal (β = −0.03, 95%CI = −0.06, −0.00). Greater HTP use intention was also correlated with living in Seattle (β = 0.16, 95%CI = 0.04, 0.28) and being older (β = 0.01, 95%CI = 0.01, 0.02), male (β = 0.07, 95%CI = 0.01, 0.14), heterosexual (β = 0.13, 95%CI = 0.06, 0.20), Hispanic (β = 0.23, 95%CI = 0.13, 0.34), a cigarette user (β = 0.44, 95%CI = 0.35, 0.53), and an e-cigarette user (β = 0.14, 95%CI = 0.06, 0.23).

Table 4 presents multivariable regression among tobacco user subgroups. Among past-month cigarette users, ever use of HTPs was correlated with perceiving IQOS as more fashionable (aOR = 2.04, 95%CI = 1.23, 3.37), as an e-cigarette/nicotine substitute (aOR = 2.80, 95%CI = 1.73, 4.54), and as having more youth appeal (aOR = 1.46, 95%CI = 1.03, 2.07)—but perceiving IQOS less as a cigarette substitute (aOR = 0.47, 95%CI = 0.28, 0.80). Greater intention to use HTPs was correlated with perceiving IQOS as more fashionable (β = 0.33, 95%CI = 0.16, 0.49) and an e-cigarette/nicotine substitute (β = 0.32, 95%CI = 0.17, 0.46)—but perceiving IQOS less as a cigarette substitute (β = −0.16, 95%CI = −0.29, −0.04).

Table 4.

Multivariable Regression Analyses Examining Perceptions of HTPs as Correlates of Tobacco and HTP Use Outcomes.

	Past-month cigarette users				Past-month e-cigarette users				Past-month any tobacco users
	Ever used HTPs		Intention to use HTP		Ever used HTPs		Intention to use HTP		Ever used HTPs		Intention to use HTP
	N = 451		N = 462		N = 588		N = 604		N = 844		N = 863
Variable	aOR	CI	β	CI	aOR	CI	β	CI	aOR	CI	β	CI
MSA (ref: Atlanta)
Boston	0.22	0.04–1.24	0.17	-0.31–0.65	0.27	0.06–1.26	-0.07	-0.46–0.32	0.28	0.07–1.08	0.03	-0.28–0.33
Minneapolis	0.20	0.04–0.96	0.25	-0.22–0.73	0.31	0.08–1.19	-0.02	-0.37–0.32	0.32	0.10–1.10	-0.02	-0.31–0.28
Oklahoma City	0.59	0.10–3.44	0.30	-0.29–0.89	0.32	0.05–2.08	0.00	-0.43–0.44	0.48	0.11–2.19	0.16	-0.21–0.53
San Diego	0.57	0.14–2.27	0.12	-0.38–0.63	0.28	0.08–1.04	0.00	-0.36–0.36	0.80	0.29–2.20	-0.01	-0.31–0.28
Seattle	0.89	0.21–3.87	0.67	0.18–1.16	0.70	0.20–2.50	0.30	-0.05–0.66	0.74	0.25–2.19	0.31	0.01–0.61
Other	0.40	0.11–1.45	0.23	-0.20–0.66	0.46	0.14–1.50	-0.04	-0.37–0.29	0.68	0.26–1.74	0.08	-0.18–0.35
Sociodemographics
Age	0.95	0.87–1.03	0.03	0.01–0.06	1.06	0.98–1.14	0.03	0.01–0.05	1.01	0.94–1.07	0.03	0.01–0.04
Female (ref: male)	0.56	0.25–1.26	-0.22	-0.46–0.03	0.49	0.23–1.05	-0.10	-0.30–0.09	0.57	0.30–1.06	-0.18	-0.34–-0.02
Other gender (ref: male)	–	–	-0.27	-1.02–0.48	–	–	-0.14	-0.73–0.44	–	–	-0.23	-0.74–0.27
Sexual minority (ref: heterosexual)	0.28	0.10–0.82	-0.38	-0.65–-0.11	0.49	0.19–1.25	-0.24	-0.45–-0.03	0.41	0.18–0.92	-0.26	-0.43–-0.09
Race (ref: White)
Black	2.75	0.65–11.58	0.07	-0.45–0.59	1.86	0.49–6.97	-0.19	-0.64–0.26	2.07	0.71–6.03	-0.08	-0.43–0.27
Asian	0.24	0.06–1.02	-0.26	-0.66–0.15	0.33	0.09–1.27	-0.12	-0.42–0.19	0.27	0.08–0.96	-0.17	-0.44–0.09
Other	3.76	1.37–10.29	-0.07	-0.44–0.30	2.54	0.98–6.62	0.32	0.03–0.60	2.23	1.02–4.88	0.12	-0.12–0.35
Hispanic (ref: non-Hispanic)	0.60	0.22–1.59	0.75	0.41–1.09	2.37	0.96–5.87	0.14	-0.16–0.44	1.16	0.55–2.42	0.47	0.24–0.71
Education (ref: not college)	0.38	0.17–0.83	0.12	-0.14–0.37	0.45	0.22–0.94	-0.08	-0.27–0.11	0.59	0.32–1.09	0.06	-0.11–0.22
Tobacco use, past-month (ref: no)
Cigarette use	–	–	–	–	4.21	1.71–10.36	0.43	0.23–0.63	2.43	1.21–4.87	0.42	0.25–0.58
E-cigarette use	3.81	1.47–9.85	0.38	0.11–0.64	–	–	–	–	2.92	1.41–6.06	0.29	0.11–0.48
Other tobacco use	1.70	0.78–3.72	0.02	-0.24–0.28	1.71	0.79–3.71	0.19	-0.03–0.40	2.30	1.26–4.19	0.06	-0.11–0.22
IQOS perceptions factors
Factor 1: Fashionable	2.04	1.23–3.37	0.33	0.16–0.49	1.49	0.91–2.45	0.25	0.12–0.38	1.60	1.10–2.34	0.31	0.21–0.41
Factor 2: E-cigarette/nicotine substitute	2.80	1.73–4.54	0.32	0.17–0.46	2.20	1.43–3.40	0.29	0.18–0.41	1.90	1.34–2.70	0.24	0.15–0.33
Factor 3: Cigarette substitute	0.47	0.28–0.80	-0.16	-0.29–-0.04	0.57	0.36–0.89	-0.07	-0.16–0.01	0.60	0.42–0.87	-0.09	-0.16–-0.01
Factor 4: Innovation	0.71	0.48–1.04	-0.01	-0.13–0.10	0.95	0.65–1.39	-0.01	-0.10–0.08	0.85	0.62–1.15	0.00	-0.08–0.07
Factor 5: Youth appeal	1.46	1.03–2.07	0.01	-0.09–0.12	1.39	0.99–1.93	-0.01	-0.10–0.07	1.36	1.05–1.77	-0.04	-0.11–0.03

Boldface indicates p < .05; HTP: heated tobacco product; MSA: metropolitan statistical areas.

Among past-month e-cigarette users, ever use of HTPs was associated with perceiving IQOS more as an e-cigarette/nicotine substitute (aOR = 2.20, 95%CI = 1.43, 3.40), but perceiving IQOS less as a cigarette substitute (aOR = 0.57, 95%CI = 0.36, 0.89). Greater intention to use HTPs was associated with perceiving IQOS as more fashionable (β = 0.25, 95%CI = 0.12, 0.38) and as an e-cigarette substitute (β = 0.29, 95%CI = 0.18, 0.41).

Among past-month any tobacco users, ever using HTPs was associated with perceiving IQOS as more fashionable (aOR = 1.60, 95%CI = 1.10, 2.34), an e-cigarette substitute (aOR = 1.90, 95%CI = 1.34, 2.70), and appealing to youth (aOR = 1.36, 95%CI = 1.05, 1.77)—but perceiving IQOS less as a cigarette substitute (aOR = 0.60, 95%CI = 0.42, 0.87). Greater HTP use intention was correlated with perceiving IQOS as more fashionable (β = 0.31, 95%CI = 0.21, 0.41) and an e-cigarette substitute (β = 0.24, 95%CI = 0.15, 0.33)—but perceiving IQOS less as a cigarette substitute (β = −0.09, 95%CI = −0.16, −0.01).

Discussion

The current study is among the first to examine specific dimensions of HTP perceptions and their associations with HTP use and use intentions among US young adults. Findings from these 2020 data (after IQOS’ FDA MRTP authorization) indicated that HTP awareness (19.1%) and ever use (4.1%) among US young adults are increasing, compared to prior estimates, for example, from our fall 2019 data (9.7% awareness, 3.5% ever use),¹⁹ a 2017 study (7.6% awareness, 1.6% ever use),¹⁷ and the 2016/2017 Tobacco Products and Risk Perceptions Survey (13.9% awareness, 3.0% ever use).¹⁸ However, note that the higher rates of awareness and use in the current study sample may be due to its larger proportion of tobacco users (due to study design and recruitment targets) and their prior exposure to HTP assessments, which may have impacted awareness and use.¹⁹

Regardless, the larger proportion of young adults who were aware of or who used HTPs in the current study may be (at least partially) due to the targeted marketing of HTPs to young adults, which may have been particularly salient since IQOS’ FDA’s MRTP authorization.^21,26,27 Prior literature indicates that, in various global markets, PMI has used launch events staffed by young adults, sponsorships of concerts and art festivals, distribution channels with a young adult target market (eg, specific magazines/websites),^24,41 and unique types of point-of-sale (eg, pop-ups)^24,42 located in young adult oriented settings, regardless of their assertions that the target market for IQOS is current cigarette smokers and specifically not young people.⁴³ Marketing content and distribution channels promoting IQOS in the United States also indicate targeting of those interested in technology and innovation, which may skew toward younger populations.

As hypothesized, certain favorable perceptions of IQOS were correlated with HTP use and use intentions. For example, young adults perceiving IQOS as more fashionable and an e-cigarette/nicotine substitute were more likely to report ever HTP use and use intentions in the full study sample and among the tobacco user subgroups. These findings suggest that the device design may be perceived as fashionable (particularly among cigarette and e-cigarette users in this study) and thus might entice young adults to use IQOS. These findings align with previous studies on e-cigarettes, in which their design was among primary reasons for use among youth and young adults.^44,45 Moreover, perceiving IQOS as an e-cigarette/nicotine substitute may be partially attributable to IQOS marketing that both draws parallels between IQOS and e-cigarette design features and benefits (ie, emphasizes IQOS’ “reduced risk”,^13–15 technology,¹¹ less smell/ash¹¹) but also distinguishes IQOS from e-cigarettes.¹¹ It is important to note that, contrary to our hypotheses, the innovation factor was not significantly correlated with HTP ever use or use intentions in any multivariable analyses. However, one reason for this may be that the item that loaded most highly on this factor was “expensive”—which may be a particular deterrent to use among young adults.⁴⁶

Somewhat consistent with our hypotheses, young adult cigarette, e-cigarette, and any tobacco product users who perceived IQOS more as an e-cigarette/nicotine substitute were more likely to have used or intend to use HTPs. However, this did not hold true in the overall sample including tobacco nonusers, and perceiving IQOS as a cigarette substitute correlated with less likelihood of using HTPs and lower HTP use intentions in the overall sample analyses and among the tobacco user subgroups.

Notably, multivariable analyses indicated that cigarette users (vs. nonusers) rated IQOS more as an e-cigarette/nicotine substitute and less as a cigarette substitute, while e-cigarette users (vs. nonusers) perceived them less as an e-cigarette/nicotine substitute but more as a cigarette substitute. In addition, multivariable findings indicated that e-cigarette users (vs. nonusers) perceived IQOS to be less innovative and to have less appeal to youth, which may reflect young adult e-cigarette users’ level of savviness about the broad range of e-cigarette products available, their technology and customization, and their flavors and other attributes that appeal to youth.^45,47 In short, these findings may suggest that, while young adult e-cigarette users are likely to try HTPs, they are unlikely to switch to IQOS—and that young adult cigarette users are particularly unlikely to switch to IQOS. Given the dearth of literature documenting similar findings, future cohort studies are needed to examine perceptions of HTPs as cigarette substitutes in relation to HTP use patterns and intentions, to clarify the correlations observed in this study.

Regarding correlates of HTP use previously explored in the literature, past-month use of cigarettes or e-cigarettes was positively associated with ever use of HTPs and use intentions (consistent with prior studies^16,18,19), perhaps due to common liabilities or underlying propensity to use tobacco products.⁴⁸ Additionally, greater likelihood of prior HTP use and future use intentions was correlated with being older and male, as documented elsewhere.^19,49

Current findings have implications for research and practice. First, although the overall prevalence of awareness and ever use of HTPs was low, 73% of young adults who had heard of HTPs were not current cigarette users, and 26.6% of those who had ever used HTPs were cigarette nonusers, suggesting that HTP manufactures may not exclusively target current cigarette users. As HTPs become increasingly available, it is critical to monitor the marketing among tobacco-naïve young adults to inform preventive and regulatory efforts and to reduce potential HTP-related public health harms. Second, how HTPs are promoted is of concern, especially given our findings that suggest that e-cigarette users are likely to dabble in HTP use but do not find them to be a satisfactory substitute for e-cigarettes and that cigarette users are particularly unlikely to see IQOS as a substitute for cigarettes. These findings have regulatory implications, as PMI claims that IQOS is intended as a cigarette substitute for adult smokers—which these results do not support.⁴³ Third, the extent to which perceived expense plays a role in the appeal of IQOS among young adults warrants further examination in terms of reducing uptake of HTPs and other tobacco products in this population. Finally, findings regarding perceiving IQOS as a substitute for e-cigarettes/nicotine (eg, “less harmful than e-cigarettes”) might also suggest that reduced exposure and reduced risk claims may be very effective in influencing young adult perceptions,^13,15 which may impact HTP use behaviors. These findings underscore the need for FDA to cautiously consider MRTP claims for IQOS and other tobacco products and how they are perceived by consumers, particularly young adults.

Our study has limitations. First, findings may not be generalizable to the included MSAs or other places in the United States, as the current study sample was recruited via social media, included large proportions of specific subgroups (eg, sexual minorities, those with high education levels), and was designed to oversample cigarette and e-cigarette users. As such, rates of HTP and other tobacco produce use should not be interpreted as prevalence. Second, our outcome of ever use of HTPs did not distinguish experimental use, occasional use, and more frequent use, and our assessments of HTP perceptions were specific to IQOS and may not have been comprehensive of all important factors. Third, this study used cross-sectional online survey data using self-report assessments, which may introduce self-selection bias, recall bias, and social desirability bias, and does not allow us to infer causal associations between IQOS perceptions and HTP use outcomes.

Current findings indicate that HTP awareness and use were low, but higher than in previous studies. Lifetime HTP use and use intentions were positively correlated with perceiving IQOS as more fashionable and an e-cigarette/nicotine substitute, and were negatively correlated with perceiving IQOS as a cigarette substitute. Despite uncertainty regarding the future of HTPs in the US²⁰—for example, due to COVID-19 hampering IQOS retail expansion²⁵ and the patent-infringement lawsuit against PMI²⁹—IQOS marketing will likely expand once the current events and restrictions become less relevant. This expansion will require further surveillance of consumer HTP awareness, perceptions, and use patterns, and how MRTP language authorized by FDA and HTP marketing in general influence these constructs.

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 work was supported by the US National Cancer Institute (R01CA215155-01A1; PI: Berg). Dr. Berg is also supported by other US National Cancer Institute funding (R01CA179422-01; PI: Berg; R01CA239178-01A1; MPIs: Berg, Levine), the National Institute on Drug Abuse (R01DA054751-01A1; MPIs: Berg, Cavazos-Rehg), the US National Institutes of Health/Fogarty International Center (1R01TW010664-01; MPIs: Berg, Kegler), and the US National Institute of Environmental Health Sciences/Fogarty International Center (D43ES030927-01; MPIs: Berg, Marsit, Sturua). Dr. Romm is supported by the National Institute on Drug Abuse (F32DA055388-01; PI: Romm; R25DA054015; MPIs: Obasi, Reitzel). Dr. Choi is supported by the Division of Intramural Research, National Institute on Minority Health and Health Disparities. Comments and opinions expressed belongs to the authors and do not necessarily reflect those of the US government, Department of Health and Human Services, National Institutes of Health.

Declaration of Interests

Yael Bar-Zeev has received fees for lectures from Pfizer Ltd, Novartis NCH, and GSK Consumer Health (distributors of smoking cessation pharmacotherapy in Israel) in the past (2012- July 2019). Hagai Levine had received fees for lectures from Pfizer Israel Ltd (distributor of a smoking cessation pharmacotherapy in Israel) in 2017.

Acknowledgments

This study was approved by the Emory University Institutional Review Board (IRB00097895).

Data Availability

Data not publicly available (available upon request).