18B.4 Awareness, perceptions, and use of heated tobacco products

Last updated: May 2024           

Suggested citation: Greenhalgh, EM. 18B.4 Awareness, perceptions, and use of heated tobacco products. In Greenhalgh EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2024. Available from https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/indepth-18b-non-combustible-cigarettes/18b-4-awareness-perceptions-and-use-of-heated-tobacco-products

 

Research examining awareness and use of heated tobacco products has primarily been conducted in countries with the largest markets (see Section 18B.2). To date, there is very little research on Australians’ perceptions of the products or prevalence of use.

18B.4.1 Awareness of heated tobacco products

Despite not being legally sold in Australia, more than one in four (27.4%) Australian respondents to the 2018 ITC Four Country Smoking and Vaping Survey were aware of heated tobacco products. 1

Research examining awareness of heated tobacco products among US adults between 2016 to 2017 found that it had increased from 9.3% in 2016 to 12.4% in 2017. 2 Research from the US Centre for Disease Control in 2017 indicated that 5.2% of adults were aware of heated tobacco products. Awareness was higher in males (7%) than females (3.7%) and among adults 30 years and under (7.6%) than adults over 30 years of age (4.6%). People who currently smoked had the highest awareness of these products (9.9%) followed by those who had never smoked (4.9%) and formerly smoked (3.7%). 3 In 2020, about 15% of the adult US population reported being aware of heated tobacco products. 4 Among US teenagers, awareness of heated tobacco products increased 51% during 2019-2020, from 12.8% to 19.3%. 5

In Korea, a survey of young adults conducted three months following the introduction of IQOS in 2017 found that 38.1% of respondents were aware of IQOS. Current conventional cigarette users were more likely to be aware of IQOS. 6

An Italian study found that in 2017, one in five (19.5%) respondents were aware of IQOS (the only available heated tobacco product). 7

18B.4.2 Perceptions of heated tobacco products

Although frequently marketed as a less harmful alternative to smoking (see Section 18B.3), perceptions of heated tobacco products vary and many people express uncertainty about health risks. 8 , 9 Users of heated tobacco products generally report more favourable perceptions regarding their harmfulness and addictiveness, and are less supportive of regulations on the products. 10 , 11 Research in Hong Kong and Korea has found generally negative perceptions of heated tobacco products, with most people perceiving them as more harmful than cigarettes, and as ineffective for quitting cigarettes. 12 , 13 In Hong Kong, support for regulations such as bans on use in smokefree areas and on sales to minors was generally high, although lower among those with favourable perceptions of the products. 12 A survey in Hungary of heated tobacco product users found that the large majority (87%) perceived them as less harmful than cigarettes—more than the proportion that perceived nicotine replacement therapy (80%) and e-cigarettes (45%) as less harmful than smoking. 14

In the US, surveys of young adults have found that heated tobacco products were perceived as less harmful and addictive than cigarettes and e-cigarettes, 15 and as more socially acceptable than cigarettes. 15 , 16 Those who perceived IQOS as fashionable and an e-cigarette substitute were more likely to have ever used or have intentions to use heated tobacco products. 17 Research in Japan found that among non-tobacco users, being male, aged under 39 years, and lower education were associated with a perception of heated tobacco products as less harmful. 18 Among people who smoke, another survey in Japan found that about half perceived heated tobacco products as being less harmful than cigarettes. 9

18B.4.3 Prevalence of use of heated tobacco products

18B.4.3.1 Prevalence of use in Australia

Results from the 2018 International Tobacco Control (ITC) survey of people who are current and former smokers and/or users of vaping products showed that 0.9% of Australian respondents had tried heated tobacco products, and 0.2% reported current use. 1 Findings from the 2022–2023 National Drug Strategy Household Survey showed that 0.7% of Australians aged 14+ reported use of heated tobacco products. Among people who smoke, 2.6% reported use, compared with 0.5% of people who do not smoke. 19

18B.4.3.2 International prevalence of use

A systematic review of the global prevalence of heated tobacco product use found that the global pooled prevalence of ever, current and daily use in 2015–2022 was 4.87, 1.53 and 0.79%, respectively. Prevalence of daily use was less than 2% for most countries, except for Czech Republic, Cyprus, Italy, Poland and Slovakia. 20 A study examining heated tobacco product use in Europe in 2020 found that ever use ranged from 2.8% in France to 14.6% in the Czech Republic, with seven countries reporting prevalence above 10%. The countries with the lowest prevalence of current and daily use were Denmark (0.3% and 0.1%, respectively) and Sweden (0.4% and 0.1%), while those with the highest prevalence were Czech Republic (3.1% current and 2.5% daily use) and Cyprus (3.1% and 2.3%, respectively). 21

Japan is the largest market for heated tobacco products—see Section 18B.2—and use has increased rapidly since the products were introduced in the mid-2010s. 22 The most recent national prevalence estimates are from 2017 and 2018, which researchers note may now be outdated with the large growth in this market in recent years. 20 In 2018, 14.1% of adult men and 3.7% of adult women reported ever use of heated tobacco products, while 8.3% of men and 1.9% of women reported current use. 23 A large internet-based survey in 2022 reported current use of heated tobacco products at 11.8%. 24 Among adolescents, in 2017, 0.5% of junior high school students, and 0.9% of high school students reported current use of heated tobacco. 25

South Korea has the second-largest heated tobacco product market after Japan. In 2019, the prevalence of heated tobacco product use in men and women aged 19 years or older in South Korea was 8.8% and 1.5%, respectively. The proportions of single, dual, and triple users of the products were 23.6%, 58.0%, and 18.4%, respectively. 26  Among adolescents, 4.7% reported current use. 20

In the US, 2.2% of adults reported having ever used heated tobacco products in 2020. 4 In 2021, 0.8% of high school students and 0.4% of middle school students reported current use of heated tobacco products. 27 In the UK, 6.6% of adults in 2020 reported ever use of heated tobacco, and 0.9% reported current use. 21 Among adolescents, 1.3% reported ever use and 0.5% reported current use of heated tobacco products in 2020. 28

Relevant news and research

For recent news items and research on this topic, click here. (Last updated May 2024)

References

1. Miller CR, Sutanto E, Smith DM, Hitchman SC, Gravely S, et al. Awareness, trial and use of heated tobacco products among adult cigarette smokers and e-cigarette users: findings from the 2018 ITC Four Country Smoking and Vaping Survey. Tobacco Control, 2022; 31(1):11-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32994299

2. Nyman AL, Weaver SR, Popova L, Pechacek TF, Huang J, et al. Awareness and use of heated tobacco products among US adults, 2016-2017. Tobacco Control, 2018; 27(Suppl 1):s55-s61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30158204

3. Marynak KL, Wang TW, King BA, Agaku IT, Reimels EA, et al. Awareness and Ever Use of "Heat-Not-Burn" Tobacco Products Among U.S. Adults, 2017. American Journal of Preventive Medicine, 2018; 55(4):551-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30033025

4. Karim MA, Talluri R, Chido-Amajuoyi OG, and Shete S. Awareness of heated tobacco products among US Adults - Health information national trends survey, 2020. Substance Abuse, 2022; 43(1):1023-34. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35435808

5. Puvanesarajah S, Wang T, Alexander DS, Gomez Y, Head SK, et al. Awareness and Use of Heated Tobacco Products Among Middle School and High School Students, United States, 2019-2020. Nicotine & Tobacco Research, 2022; 24(8):1273-80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35380704

6. Kim J, Yu H, Lee S, and Paek YJ. Awareness, experience and prevalence of heated tobacco product, IQOS, among young Korean adults. Tobacco Control, 2018; 27(Suppl 1):s74-s7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30158210

7. Liu X, Lugo A, Spizzichino L, Tabuchi T, Pacifici R, et al. Heat-not-burn tobacco products: concerns from the Italian experience. Tobacco Control, 2019; 28(1):113-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29374094

8. East KA, Tompkins CNE, McNeill A, and Hitchman SC. 'I perceive it to be less harmful, I have no idea if it is or not:' a qualitative exploration of the harm perceptions of IQOS among adult users. Harm Reduct J, 2021; 18(1):42. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33849549

9. Gravely S, Fong GT, Sutanto E, Loewen R, Ouimet J, et al. Perceptions of Harmfulness of Heated Tobacco Products Compared to Combustible Cigarettes among Adult Smokers in Japan: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 2020; 17(7). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32244619

10. Majek P, Jankowski M, Nowak B, Macherski M, Nowak M, et al. The Frequency of Use and Harm Perception of Heated Tobacco Products (HTPs): The 2019 Cross-Sectional Survey among Medical Students from Poland. International Journal of Environmental Research and Public Health, 2021; 18(7). Available from: https://www.ncbi.nlm.nih.gov/pubmed/33805180

11. Ho LLK, Li WHC, Cheung AT, Xia W, and Lam TH. Awareness and Use of Heated Tobacco Products among Youth Smokers in Hong Kong: A Cross-Sectional Study. International Journal of Environmental Research and Public Health, 2020; 17(22). Available from: https://www.ncbi.nlm.nih.gov/pubmed/33227929

12. Wu YS, Cheung YTD, Ho SY, Tong HSC, Lai VWY, et al. Perception of heated tobacco products and support for regulations: a cross-sectional study in Hong Kong. Tobacco Control, 2024; 33(e1):e132-e5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36344255

13. Kim SH, Kang SY, and Cho HJ. Beliefs about the Harmfulness of Heated Tobacco Products Compared with Combustible Cigarettes and Their Effectiveness for Smoking Cessation among Korean Adults. International Journal of Environmental Research and Public Health, 2020; 17(15). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32756449

14. Penzes M, Joo T, and Urban R. Perceived harm of heated tobacco products, e-cigarettes, and nicotine replacement therapy compared with conventional cigarettes among ever and current heated tobacco users. Addictive Behaviors Reports, 2022; 15:100432. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35600227

15. Duan Z, Le D, Ciceron AC, Dickey-Chasins R, Wysota CN, et al. 'It's like if a vape pen and a cigarette had a baby': a mixed methods study of perceptions and use of IQOS among US young adults. Health Education Research, 2022; 37(5):364-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36036655

16. Berg CJ, Romm KF, Patterson B, and Wysota CN. Heated Tobacco Product Awareness, Use, and Perceptions in a Sample of Young Adults in the United States. Nicotine & Tobacco Research, 2021; 23(11):1967-71. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33822111

17. Duan Z, Wysota CN, Romm KF, Levine H, Bar-Zeev Y, et al. Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020. Nicotine & Tobacco Research, 2022; 24(12):1968-77. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35901840

18. Momosaka T, Saito J, Otsuki A, Yaguchi-Saito A, Fujimori M, et al. Associations of individual characteristics and socioeconomic status with heated tobacco product harmfulness perceptions in Japan: A nationwide cross-sectional study (INFORM Study 2020). J Epidemiol, 2024. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38191179

19. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2022–2023. Canberra: AIHW, 2024. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey

20. Sun T, Anandan A, Lim CCW, East K, Xu SS, et al. Global prevalence of heated tobacco product use, 2015-22: A systematic review and meta-analysis. Addiction, 2023; 118(8):1430-44. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37005862

21. Laverty AA, Vardavas CI, and Filippidis FT. Prevalence and reasons for use of Heated Tobacco Products (HTP) in Europe: an analysis of Eurobarometer data in 28 countries. Lancet Reg Health Eur, 2021; 8:100159. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34557853

22. Hori A, Tabuchi T, and Kunugita N. The spread of heated tobacco product (HTP) use across various subgroups during 2015-16 and 2017-18 in Japan. Environ Health Prev Med, 2023; 28:5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36653145

23. Kinjo A, Kuwabara Y, Fujii M, Imamoto A, Osaki Y, et al. Heated Tobacco Product Smokers in Japan Identified by a Population-Based Survey. J Epidemiol, 2020; 30(12):547-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31787705

24. Odani S and Tabuchi T. Prevalence and denial of current tobacco product use: Combustible and heated tobacco products, Japan, 2022. Preventive Medicine Reports, 2022; 30:102031. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36531095

25. Kuwabara Y, Kinjo A, Fujii M, Imamoto A, Osaki Y, et al. Heat-not-burn tobacco, electronic cigarettes, and combustible cigarette use among Japanese adolescents: a nationwide population survey 2017. BMC Public Health, 2020; 20(1):741. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32434517

26. Yu H and Lee CM. Comparison of Tobacco Use and Cessation Behavior between Conventional Cigarette and Heated Tobacco Product Users: Based on the Analyses of the Eighth Korea National Health and Nutrition Examination Survey 2019. Korean J Fam Med, 2022; 43(5):296-304. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36168901

27. Gentzke AS, Wang TW, Cornelius M, Park-Lee E, Ren C, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021. MMWR Surveill Summ, 2022; 71(5):1-29. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35271557

28. McNeill A, Simonavičius E, Brose L, Taylor E, East K, et al. Nicotine vaping in England: 2022 evidence update. A report commissioned by the Office for Health Improvement and Disparities. London: Office for Health Improvement and Disparities,  2022. Available from: https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update