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Low compliance and proliferation of IQOS purchase cues at points-of-sale: a comparative study before and after Israel’s display ban
  1. Yael Bar-Zeev1,
  2. Carla J Berg2,3,
  3. Amal Khayat1,
  4. Lorien C Abroms2,3,
  5. Yan Wang2,3,
  6. Zongshuan Duan4,
  7. Cassidy R LoParco2,
  8. Yuxian Cui2,
  9. Daniel Elbaz1,
  10. Hagai Levine1
  1. 1Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem - Hadassah Medical Centre, Jerusalem, Israel
  2. 2Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
  3. 3GW Cancer Center, George Washington University, Washington, DC, USA
  4. 4Population Health Sciences, Georgia State University, Atlanta, Georgia, USA
  1. Correspondence to Prof. Yael Bar-Zeev, Braun School of Public Health and Community Medicine, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel;{at}


Introduction It is unclear how tobacco companies respond to increasing restrictions on points-of-sale (POS) (eg, advertisement ban, display ban), especially regarding newer products, such as IQOS, a heated tobacco product. This study compared POS marketing strategies for IQOS (and HEETS tobacco sticks) before and after Israel implemented a display ban and plain packaging.

Methods Audits of stores selling IQOS (n=87) in four Israeli cities were conducted, 16–20 months post display ban and plain packaging introduction, including previously audited stores (n=60) (prior to the implementation of these measures). Descriptive analyses and matched pre–post comparisons were conducted to assess regulatory compliance and marketing strategies over time.

Results Almost all stores (90.8%) were non-compliant with the display ban; but most were compliant with plain packaging (81.6%) and advertisement ban (83.5%) regulations. Following the display ban, there was a significant increase in the number of IQOS/HEETS internal advertisements (21.7% vs 41.7%, p=0.023). These were mostly compliant with the advertisement ban (ie, did not mention the brand name explicitly), and appeared in the form of generic signs or flags and/or special displays. The percentage of stores featuring the IQOS device increased (1.7% to 20.0%, p=0.003), as did the percentage carrying at least four HEETS flavours (36.7% to 63.3%, p=0.006).

Conclusion This sample of Israeli stores selling IQOS showed low compliance with the display ban. The increase in signs/special displays, mostly compliant with the advertisement ban, could serve as purchase cues circumventing the intent of the legislation. Regulatory efforts should consider more specific legislative language and comprehensive enforcement plans.

  • Advertising and Promotion
  • Electronic nicotine delivery devices
  • Public policy
  • Surveillance and monitoring
  • Tobacco industry

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  • X @yaelbarzeev, @AmalKhayat5, @lorien_a, @HagaiLevine

  • Contributors YB-Z, HL and CJB designed the study. CJB, HL and YB-Z obtained grant funding. AK and YB-Z oversaw all the data collection. YB-Z analysed the data and wrote the draft manuscript. CJB, AK, LA, YW, ZD, CRL, YC, DE and HL reviewed the manuscript and confirmed the submitted version. YB-Z serves as the guarantor of the study and as such accepts full responsibility for the work and/or conduct of the study, had access to the data and controlled the decision to publish.

  • Funding This research was supported by the National Cancer Institute (R01CA239178-01A1; MPIs: CJB, HL) and by the Israel Lung and Tuberculosis Association (MPIs: YB-Z, HL).

  • Competing interests YB-Z has received fees for lectures from Pfizer, Novartis NCH and GSK Consumer Health (distributors of smoking cessation pharmacotherapy in Israel) in the past (2012–July 2019). HL had received fees for lectures from Pfizer Israel (distributor of a smoking cessation pharmacotherapy in Israel) in 2017. LA receives royalties for the sale of Text2Quit.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.