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There has been increasing commercial promotion of heated tobacco products (HTPs). The WHO has indicated that there is no conclusive scientific evidence that HTPs are less harmful than conventional cigarettes.1 2 However, cigarette smokers in Japan continue to take up and regularly use HTPs primarily due to the perception that they are less harmful.3 4 Moreover, the lack of a comprehensive and effectively enforced domestic ban on the advertisement, promotion and sponsorship of cigarettes and HTPs has led to pervasive public exposure to tobacco advertising in Japan.5 Currently, at least one multinational tobacco company has extended HTP promotions to the cosmetic dentistry field.
On 28 September 2021, the Japan Dental News (Nihon Shika Shinbun), which is a weekly medical newspaper focused on dental care, published a two-page advertisement by Philip Morris International (PMI) on IQOS, its HTP (figure 1). The Japan Dental News is read by dental professionals and has the largest circulation in the industry, with 21 000 copies in circulation (direct contact to the editorial office in January 2022). The advertisement presented four studies on heated tobacco in the oral hygiene field. The research was led by a PMI scientist and was partially funded by the company. It reported that although smoking causes discolouration of the enamel, dentin and composite resin, as well as colour mismatch between the hard tissue of teeth and composite resin, heated tobacco vapour causes less discolouration than smoke from combustible cigarettes.6 The advertisement included a reconstructed figure from the research paper (figure 2).7 Moreover, the advertisement included a reprint of a study conducted by Zanetti et al on the effect of exposure to aerosols or smoke on the cytotoxicity and tissue morphology of organotypical gingival cultures8 (data not shown). Additionally, the advertisement included excerpted quotes from dentists (unsourced and without any indication whether they received compensation) conveying positive impressions regarding the research results, which suggested that the dentists approved of the findings and might recommend the products. Further, this implied that the products had been evaluated and validated in the oral health field, with independent scientific evidence showing that these products caused less harm than cigarettes.
Philip Morris International promotes heated tobacco products (HTPs) to dentists.7 This provides an intuitive impression that dentists have positive comments regarding HTPs as alternatives to cigarettes.
Advertisement by Philip Morris International, showing tooth discolouration after 3 weeks of exposure to IQOS heated tobacco products (HTPs) and cigarettes.7 The image on the left is the control image, the image in the centre shows a tooth that was exposed to IQOS HTPs and the image on the right shows a tooth that was exposed to conventional cigarettes. These images show that cigarette smoking causes discolouration of the tooth enamel, dentin, composite resin, and colour mismatch between the hard tissue of teeth and composite resin.
The aforementioned advertisement was not the first time PMI had used health professionals to advertise tobacco products. In 2018, Nikkei Medical, which is a monthly informational medical magazine for clinicians across all specialties with 105 000 copies in circulation, published an advertisement containing a picture of extensive comments from a highly respected oral surgeon.9 10 Notably, at this time, the PMI-sponsored research was still ongoing. The highly technical interview-style advertisement claimed that HTPs may help reduce the risk of exacerbation of chronic periodontal disease, which offered a favourable view of the products.9 The advertisement likened the switch from cigarettes to HTPs to that from horse-drawn carriages to automobiles, that is, an advancement that should be embraced even though it still involves some risks, which foreshadowed the future announcements of the favourable study results.9 It is important to note that this interview implied, but did not explicitly state, that HTPs reduce periodontal disease.
According to the Japanese Ministry of Finance (MOF), a comprehensive advertising ban is not consistent with the country’s constitutional principles, which justifies inaction toward enforcing Section 2 of Article 13 of the WHO Framework Convention on Tobacco Control. Accordingly, tobacco advertisement, promotion and sponsorship (TAPS) in Japan are self-regulated by the Tobacco Institute of Japan. Additionally, although there are regulations for medical care-related TAPS, regulations for uninsured medical treatment are relatively lax. Despite the tightening of the self-regulation in 2020, there remain loopholes, including the contents of newspapers and magazines such as publications for medical and dental professionals. Additionally, the Fair Trade Commission is not considered a watchdog in Japan given its close ties to the MOF despite the tobacco industry potentially having deceptive or exaggerated advertisements that mislead vulnerable consumers.11 The tobacco industry is exploiting loopholes within regulations to promote HTPs using their own health claims. The aforementioned advertisements confirm that PMI is taking advantage of people’s trust in aesthetic dentistry professionals to promote the switch from cigarettes to IQOS.7
In September 2021, the FDI (Fédération Dentaire Internationale) World Dental Federation’s General Assembly held in Sydney, Australia, adopted the 2021 FDI Policy Statement, which indicated the appropriateness of promoting tobacco-free practices for oral health.12 Furthermore, the statement asserted that oral health practitioners should not recommend the use of e-cigarettes or HTPs as an alternative to conventional cigarettes or as a tobacco cessation tool since these products have not been proven to be safe and the recommendations may prompt young users to take up combustible cigarette smoking.12 Dental professionals, as well as medical and dental journal editors, should be aware of the sophistication of PMI’s TAPS and spread awareness about their tactical promotion of HTPs in the oral health field.
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Acknowledgments
The authors wish to thank Professor Mark A Levin for valuable comments on the draft manuscript, English language editing and critical review of legal aspects. Moreover, we would like to thank Ms Sonoko Hirose for her collaboration in the early stages of this work.
Footnotes
Contributors THanioka collected information regarding the marketing activities of PMI and THirano analysed this information. THirano prepared the first draft of the manuscript. THanioka reviewed all drafts and helped in the preparation of the final manuscript.
Funding This study was funded by the Ministry of Health, Labour, and Welfare under the Fund for Tobacco Research and Analysis Project. This work was a component project commissioned by the National Cancer Center (R4).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.