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Evaluating trends in cigarette and HTP use in Japan and measurement issues in the National Health and Nutrition Survey
  1. David T Levy1,
  2. Mona Issabakhsh1,
  3. Kenneth E Warner2,
  4. Alex Liber1,3,
  5. Rafael Meza4,
  6. Michael Cummings5
  1. 1Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
  2. 2School of Public Health, University of Michigan-Ann Arbor, Ann Arbor, Michigan, USA
  3. 3Research Triangle Institute, Research Triangle Park, North Carolina, USA
  4. 4Department of Integrative Oncology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
  5. 5Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  1. Correspondence to Dr David T Levy, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA; dl777{at}


Introdution Studies have reported that the rapid rise in heated tobacco product (HTP) sales in Japan accompanied an accelerated decline in cigarette sales. However, these studies do not distinguish whether those who previously smoked cigarettes became dual users with HTPs (smoking fewer cigarettes) or instead switched completely to HTPs. If HTPs present lower health risks than cigarettes, replacing cigarettes with HTPs is more likely to improve public health than cigarette users continuing as dual users.

Methods To evaluate the role of HTP introduction relative to smoking prevalence, we examine trends in cigarette prevalence as related to trends in HTP use using Japan’s National Health and Nutrition Survey (NHNS) from 2011 to 2019. We develop measures of relative changes in smoking prevalence use by age and gender in the pre-HTP and post-HTP periods. We then analyse prevalence data by year using joinpoint regression to statistically distinguish changes in trend.

Results Compared with the pre-HTP 2011–2014 period, cigarette prevalence decreased more rapidly during the post-HTP 2014–2017 period, particularly among younger age groups. However, the changing format of NHNS questions limits our ability to determine the impact on smoking prevalence, particularly after 2017.

Conclusions While suggesting that HTPs helped some people who smoke to quit smoking, this study also shows the difficulties in eliciting accurate survey responses about product use and distinguishing the impact of a potentially harm-reducing product in an environment subject to rapidly evolving patterns of use.

  • Harm Reduction
  • Public policy
  • Surveillance and monitoring
  • Non-cigarette tobacco products
  • Tobacco industry

Data availability statement

Data are available on reasonable request.

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  • Contributors DTL analysed the data, wrote the original draft and revisions, MI helped write the original draft, survey the recent literature, analysed the data and wrote the original draft and revisions, KEW helped write the original draft and provided critical comments, AL edited the draft, provided critical comments and helped write revisions, RM edited the draft, provided critical comments, provided the joinpoint analysis and helped write revisions, MC helped gain funding, helped write the original and revisions. DTL is responsible for the overall content of the article.

  • Funding DTL, MI, AL and MC received funding through the National Cancer Institute (NCI) International Tobacco Control Policy Evaluation Project grant P01CA200512.

  • Competing interests KC has served as a paid expert witness in litigation against cigarette companies. DTL gave a short talk virtually to an industry-sponsored conference (GTNF, 2023). He did not otherwise attend the conference and received no financial support.

  • 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.