Objective To examine consumer perceptions, attitudes and behaviours regarding the heated tobacco product, IQOS, as well as to document the product’s marketing strategies to determine its potential for appealing to youth and young adults. Method Truth Initiative, in collaboration with Flamingo, collected qualitative data via: (1) expert interviews, (2) semiotic analysis of IQOS packing and marketing materials, and (3) 12 focus groups with adults in Switzerland (ages 19–44 years; June 6–9, 2016) and Japan (ages 20–39 years; June 22–24, 2016) (n=68 for both groups). Results Expert interviews and IQOS packing and marketing analyses revealed the product is being marketed as a clean, chic and pure product, which resonated very well in Japan given the strong cultural values of order, cleanliness, quality and respect for others. Focus groups results indicated Japanese IQOS users used the product for socialising with non-smokers. Focus group participants in both Japan and Switzerland reported lower levels of satisfaction with the product relative to combustible cigarettes, although many found the product packaging to be appealing. While participants identified several benefits and barriers related to IQOS, few reported any potential health benefits of use compared with combustible tobacco products. Conclusion IQOS was marketed as a sophisticated, high tech and aspirational product. Because youth and young adults are more interested in such product positioning, this approach raises some concern about youth appeal. This research shows cultural factors appeared to affect the appeal of this messaging, indicating that prevalence and uptake data will likely not be similar from country to country.

Among youth, the frequency and prevalence of using more than one tobacco (small cigar, cigarette, and hookah) or nicotine-containing product (e-cigarettes-ENDS) are changing. These shifts pose challenges for regulation, intervention, and prevention campaigns because of scant longitudinal data on the stability of use patterns in this changing product landscape. A nationally representative longitudinal survey of 15- to 21-year olds (n = 15,275) was used to describe transitions between never use, noncurrent use, and past 30-day use of combustible tobacco, e-cigarettes (ENDS), and dual use of both kinds of products. A multistate model was fit to observations collected every 6 months across 2.5 years to estimate the probability of transitions between states (TPs), the average time in state (sojourn time), and the effect of age on transitions. Current state strongly predicted future state over time intervals of 1 year or less, but only weakly predicted future state at longer intervals: TP to noncurrent use was higher for ENDS-only than combustible-only users over a 6-month interval but was similar for both groups over a 2-year interval. Sojourn time was significantly longer for combustible-only (0.52 years) and dual use (0.55 years) than ENDS-only use (0.27 years); older youth were more likely than younger youth to stay combustible tobacco users or noncurrent users. The dynamics of transitions between combustible tobacco products and ENDS in a population of youth and young adults suggest that policy and prevention efforts must consider the frequent changes and instability over a 1-year or less time period in use patterns among young people. The study addresses an urgent need in public health for timely information on how youth and young adults use tobacco and nicotine products. We found that youth, particularly adolescents, moved frequently between using ENDS and combustible tobacco products either alone or together. Importantly, the utility of current-use states for predicting future use states declined for time horizons longer than 1 year. Our results demonstrate a need for caution in interpreting product transitions. Longitudinal data with frequent observations and coverage of a wide range of possible product types is required to fully characterize usage patterns in youth.

Objective: Antismoking mass media campaigns have contributed to significant declines in combustible tobacco use among young people. This study evaluates a national anti-e-cigarette campaign to determine its association with knowledge, attitudes and beliefs in the context of increasing e-cigarette use in the USA.Methods: A national sample of respondents aged 15–24 years (n=8421) was drawn from a repeated cross-sectional online panel survey (220 participants/week) (October 2018 to December 2019). Self-reported exposure to the truth anti-e-cigarette campaign was measured according to level of ad awareness. Outcomes were subjective knowledge of campaign-targeted facts about e-cigarettes and attitudinal constructs about perceived e-cigarette harm, social unacceptability and anti-industry sentiments. Covariates included respondent demographics, current e-cigarette use and cigarette use, parental smoking, sensation seeking, mental health and growth in e-cigarette sales.Results: Ad awareness was associated with knowledge that e-cigarette users are more likely to start smoking (low OR: 1.28, 95% CI 1.14 to 1.44; high OR: 1.88, 95% CI 1.66 to 2.13) and of the nicotine content of JUUL compared with cigarettes (low OR: 1.63, 95% CI 1.45 to 1.82; high OR: 2.50, 95% CI 2.21 to 2.84). High ad awareness was associated with knowledge that the long-term health effects of JUUL use are unknown (OR: 1.88, 95% CI 1.57 to 2.28). High ad awareness was associated with significantly higher perceived product harm (OR: 1.35, 95% CI 1.18 to 1.54), social unacceptability (OR: 1.32, 95% CI 1.15 to 1.53) and anti-industry attitudes (OR: 1.40, 95% CI 1.21 to 1.62), compared with respondents with no awareness.Conclusions: Young people with awareness of anti-e-cigarette ads demonstrate higher levels of campaign-targeted knowledge, attitudes and beliefs. Future campaign evaluation priorities include measuring the campaign effects on e-cigarette use behaviours.

Policy interventions such as public health mass media campaigns disseminate messages in order to improve health-related knowledge, attitudes, beliefs and behaviors at the population level. Only more recently have campaigns that promote health-related behaviors adopted branding, a well-established marketing strategy, to influence how consumers think and feel about a message. This study examines whether positive brand equity for the national truth^® campaign is associated with lower likelihood of cigarette use over time using the nationally representative Truth Longitudinal Cohort of youth and young adults, aged 15–21. Logistic regression models were used to examine the relationship between brand equity and the likelihood of reporting past 30-day smoking over a 12-month period. Respondents who reported positive brand equity were significantly less likely to report past 30-day smoking 12 months later (OR = 0.66, p < 0.05), controlling for covariates known to influence tobacco use behavior. Findings also translate the effect size difference to a population estimate of more than 300,000 youth and young adults having been prevented from current smoking over the course of a year. Building brand equity is a strategic process for health promotion campaigns, not only to improve message recall and salience but also to influence behavioral outcomes.