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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
  1. Connor R Miller1,
  2. Edward Sutanto1,
  3. Danielle M Smith1,
  4. Sara C Hitchman2,
  5. Shannon Gravely3,
  6. Hua H Yong4,
  7. Ron Borland5,
  8. Richard J O'Connor1,
  9. K Michael Cummings6,
  10. Geoffrey T Fong3,7,
  11. Andrew Hyland1,
  12. Anne C K Quah3,
  13. Maciej L Goniewicz1
  1. 1 Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
  2. 2 Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
  3. 3 Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
  4. 4 School of Psychology, Deakin University, Geelong, Victoria, Australia
  5. 5 School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
  6. 6 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  7. 7 Ontario Institute for Cancer Research, Toronto, Ontario, Canada
  1. Correspondence to Dr Maciej L Goniewicz, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; maciej.goniewicz{at}


Objective To evaluate heated tobacco product (HTP) awareness, trial and current use among adult cigarette smokers and vaping product users in four countries with varying regulations governing HTP sales.

Design Data came from Wave 2 of the ITC Four Country Smoking and Vaping Survey, collected from February to July 2018. Respondents were current and former smokers and/or users of vaping products (18 years or older) from Canada (CA; n=3778), England (EN; n=4848), the USA (US; n=2846) and Australia (AU; n=1515). At the time of the survey, only Canada and England permitted the sale of contemporary HTPs (eg, IQOS).

Results Overall, 30.2% of respondents reported being aware of HTPs (CA=30.4%; EN=31.0%; US=30.2%; AU=27.4%; p=0.346), 2.4% had ever tried HTPs (CA=3.3%; EN=2.4%; US=2.0%; AU=0.9%; p=0.001) and 0.9% currently used HTPs at least monthly (CA=0.8%; EN=1.2%; US=0.7%; AU=0.2%; p<0.001). Trial and current use were higher among those who concurrently smoked and vaped (at least monthly) versus other nicotine use categories (trial: 10.9% v. 1.2%–2.0%, p<0.001; current use: 8.4% v. 0.1%–1.0%, p<0.001). In multivariable analyses, HTP awareness did not differ across countries, whereas odds of trial and current use were lower where HTPs were unavailable. Odds of HTP trial did not differ by regulatory environment when restricting analysis to HTP-aware concurrent smokers–vapers.

Conclusion Approximately one third of respondents were aware of HTPs, even in the USA and Australia, where contemporary HTPs were not yet on the market. Trial and use were uncommon, except among concurrent smokers–vapers. Restrictions on availability may have limited HTP use generally, but less so for concurrent smokers–vapers.

  • non-cigarette tobacco products
  • surveillance and monitoring
  • public policy
  • harm reduction
  • electronic nicotine delivery devices

Data availability statement

Data are available upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors All authors have made substantial contributions to this paper. MLG, CRM and DMS conceptualised the study. CRM carried out the analysis and along with ES, DMS and MLG interpreted the results. CRM drafted the paper with critical review and significant comments from all other authors.

  • Funding This study was supported by grants from the US National Cancer Institute (P01 CA200512), the Canadian Institutes of Health Research (FDN-148477), and by the National Health and Medical Research Council of Australia (APP 1106451). GTF was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. CRM, DS, RO, AH and MLG were supported by a Tobacco Centers of Regulatory Science US National Cancer Institute grant (U54CA238110).

  • Competing interests KMC has received payment as a consultant to Pfizer for service on an external advisory panel to assess ways to improve smoking cessation delivery in health care settings. KMC also has served as paid expert witness in litigation filed against the tobacco industry. GTF has served as expert witnesses on behalf of governments in litigation involving the tobacco industry. MLG received research grant from Pfizer and served as a member of scientific advisory board to Johnson&Johnson.

  • Provenance and peer review Not commissioned; externally peer reviewed.