Background IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for ‘reduced exposure’ marketing claims, which has been exploited globally.
Methods In November–December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates.
Results Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message (‘IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers’) was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers.
Conclusions Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.
- advertising and promotion
- harm reduction
- packaging and labelling
- non-cigarette tobacco products
Data availability statement
Data are available on reasonable request.
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Contributors HL, YB-Z, LCA and CJB designed the study, obtained grant funding and oversaw project administration. ZD, AK, JFT, KFR and YW contributed to study design and methodology. HL, ZD and CJB analysed the data and wrote the draft manuscript. All authors reviewed the manuscript and confirm the approval of the submitted manuscript. CJB accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding This work was supported by the US National Cancer Institute (R01CA239178-01A1; Multiple Principal Investigators [MPIs]: CJB, HL). CJB is also supported by other US National Institutes of Health funding, including the National Cancer Institute (R01CA215155-01A1; Principal Investigator [PI]: CJB; R01CA179422-01; PI: CJB), the Fogarty International Center (R01TW010664-01; MPIs: CJB, Kegler), the National Institute of Environmental Health Sciences/Fogarty (D43ES030927-01; MPIs: CJB, Caudle, Sturua) and the National Institute on Drug Abuse (R01DA054751-01A1; MPIs: CJB, Cavazos-Rehg). KFR is supported by the National Institute on Drug Abuse (F32DA055388-01; PI: KFR; R25DA054015; MPIs: Obasi, Reitzel), the Oklahoma Tobacco Settlement Endowment Trust (TSET) contract #R22-03, and the National Cancer Institute grant awarded to the Stephenson Cancer Center (P30CA225520).
Competing interests HL had received fees for lectures from Pfizer Israel Ltd (distributor of a smoking cessation pharmacotherapy in Israel) in 2017. YB-Z has received fees for lectures from Pfizer, Novartis NCH and GSK Consume Health (distributors of pharmacotherapy in Israel) in the past (2012–July 2019). LCA receives royalties for the sale of Text2Quit. No other conflicts of interest are declared.
Patient and public involvement statement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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