Citation

Miller, Schneller-Najm, Leigh, N.J., Agar, T.K., Quah, A.C.K., Cummings, K.M., Fong, G.T., O’Connor, Goniewicz, M.L. (2024). Biomarkers of exposure to nicotine and selected toxicants in individuals who use alternative tobacco products sold in Japan and Canada in 2018-2019. Cancer Epidemiology Biomarkers & Prevention, [Published online Dec 5, doi: 10.1158/1055-9965.EPI-24-0836].

Abstract

Background: Comparisons of nicotine and toxicant exposure between people who use different alternative tobacco products remains underexplored.

Methods: This cross-sectional, multi-country study analyzed urinary metabolites of nicotine, NNK, and volatile organic compounds (acrolein, acrylamide, acrylonitrile) among established users (n=550) in Japan and Canada. Participants exclusively or concurrently used nicotine vaping products (NVPs; Canada only), heated tobacco products (HTPs; Japan only), and combustible cigarettes (CCs; Japan and Canada), or abstained (Japan and Canada).

Results: All product groups showed substantial nicotine exposure. Both HTPs and NVPs exposed exclusive users to lower toxicant levels than exclusive CC use. Canadian participants who exclusively used NVPs exhibited lower NNK and acrolein exposure but higher acrylamide exposure than Japanese participants who exclusively used HTPs. Concurrent use of CCs alongside alternative products exposed users to higher toxicant levels compared to exclusive use of either alternative product.

Conclusions: Exclusive use of alternative tobacco products results in significant nicotine exposure but substantially lower toxicant exposure compared to exclusive CC use. People who use HTPs in Japan may experience higher exposure to nicotine and certain toxicants (NNK, acrolein) than people who use NVPs in Canada. Concurrent use results suggest that partially substituting CCs with alternative products may reduce toxicant exposure, but to a lesser extent than completely transitioning to alternative products. Impact: Exposure patterns between two popular alternative tobacco products differ. The overall toxicant exposure from these products is lower than CCs, providing critical data for regulatory decisions and public health considerations.

Citation

Togawa, K., Fong, G.T., Quah, A.C.K., Meng, G., Xu, S.S., Ouimet, J., Mochizuki, Y., Yoshimi, I., Odani, S., Tabuchi, T., Katanoda, K. (2024). Impacts of revised smoke-free regulations under the 2020 Japan Health Promotion Act on cigarette smoking and heated tobacco products use in indoor public places and homes: Findings from the 2018-2021 International Tobacco Control (ITC) Japan Surveys. Tobacco Control, [Published online Oct 17, doi: doi: 10.1136/tc-2024-058697].

Abstract

Background: In April 2020, Japan's revised Health Promotion Act (HPA) banned cigarette smoking and heated tobacco products (HTP) use in indoor public places but exempted small establishments and permitted smoking-designated/HTP-designated rooms. This pre-post study evaluated the effectiveness of the HPA.

Methods: Data were from waves 1 to 4 (2018-2021) of the International Tobacco Control Japan Surveys among a national cohort of adults who smoke cigarettes, use HTPs and do not use any tobacco products. The sample sizes in the respective surveys were 4615, 4222, 4387 and 4254. Multivariable logistic regression models employing generalised estimating equations estimated the prevalence of observed and self-reported indoor smoking/HTP use in key public venues (restaurants/cafés, bars/pubs and workplaces), smoke-free places, and homes, and smoke-free/HTP aerosol-free home policies (model 1). The models were additionally adjusted for waves 1-4 to estimate the impacts of the HPA (model 2).

Results: The implementation of the HPA significantly reduced observed indoor smoking in bars/pubs (model 1: 82.2% (pre) to 55.5% (post), model 2: p=0.04) but not in restaurants/cafés (model 1: 53.0%-24.9%, model 2: p=0.15) or workplaces (model 1: 35.3%-30.1%, model 2: p=0.62). Observed indoor HTP use was also common postimplementation (restaurants/cafés: 19.6%, bars/pubs: 53.9%, workplaces: 36.4%). The implementation of the HPA was associated with a significant increase in observed HTP use in smoke-free places (model 1: 26.3%-33.3%, model 2: p=0.001) and a suggestive increase in homes without HTP aerosol-free policies among adults who smoke (model 1: 64.0%-77.0%, model 2: p=0.09).

Conclusions: The implementation of the HPA was limited in its effectiveness. Comprehensive regulations with no exemptions are needed in Japan.

Citation

Craig, L., Yoshimi, I., Fong, G.T., Meng, G., Yan, M., Mochizuki, Y., Tabuchi, T., Thrasher, J.F., Xu, S.S., Quah, A.C.K., Ouimet, J., Sansone, G., Chung-Hall, J. (2020). Awareness of marketing of heated tobacco products and cigarettes and support for tobacco marketing restrictions in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(22), 8418.

Abstract

Japan is one of the world's largest cigarette markets and the top heated tobacco product (HTP) market. No forms of tobacco advertising, promotion, and sponsorship (TAPS) are banned under national law, although the industry has some voluntary TAPS restrictions. This study examines Japanese tobacco users' self-reported exposure to cigarette and HTP marketing through eight channels, as well as their support for TAPS bans. Data are from the 2018 ITC Japan Survey, a cohort survey of adult exclusive cigarette smokers (n = 3288), exclusive HTP users (n = 164), HTP-cigarette dual users (n = 549), and non-users (n = 614). Measures of overall average exposure to the eight channels of cigarette and HTP advertising were constructed to examine differences in exposure across user groups and products. Dual users reported the highest exposure to cigarette and HTP advertising. Tobacco users (those who used cigarettes, HTPs, or both) reported higher average exposure to HTP compared to cigarette advertising, however non-users reported higher average exposure to cigarette compared to HTP advertising. Retail stores where tobacco or HTPs are sold were the most prevalent channel for HTP and cigarette advertising, reported by 30-43% of non-users to 66-71% of dual users. Non-users reported similar exposure to cigarette advertising via television and newspapers/magazines as cigarette smokers and dual users; however, advertising via websites/social media was lower among non-users and HTP users than among cigarette smokers and dual users (p < 0.05). Most respondents supported a ban on cigarette (54%) and HTP (60%) product displays in stores, and cigarette advertising in stores (58%).

Citation

Xu, S.S., Meng, G., Yan, M., Gravely, S., Quah, A.C.K., Ouimet, J., O’Connor, R.J., Sutanto, E., Yoshimi, I., Mochizuki, Y., Tabuchi, T., Fong, G.T. (2020). Reasons for regularly using heated tobacco products among adults current and former smokers in Japan: Findings from 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(21), 8030.

Abstract

The market growth of heated tobacco products (HTPs), such as IQOS, Ploom TECH, and glo, has increased dramatically in Japan since 2016. Little is known about the reasons why current and former smokers are using HTPs. The data for this cross-sectional study were from the 2018 (Wave 1) International Tobacco Control (ITC) Japan Survey, a national web-based survey of 4500 people, including 658 current HTP users, of whom 549 were concurrently smoking cigarettes and 109 were former smokers. The most common reasons for regularly using HTPs were: beliefs that HTP are less harmful than cigarettes to themselves (90.6%) or to others (86.7%), enjoyment (76.5%), and social acceptability (74.4%). About half of current smokers (55.1%) reported using HTPs because these products might help them quit smoking. However, a near-equal percentage (52.0%) of current smokers reported using HTPs to replace some of the cigarettes they smoked so that they did not have to give up smoking altogether. If smokers are using HTPs to complement rather than quit their smoking, then the harm reduction potential of HTPs suggested by the toxicity studies will be diminished.

Citation

Cummings, K.M., Nahhas, G., Sweanor, D. (2020). What is accounting for the rapid decline in cigarette sales in Japan? International Journal of Environmental Research and Public Health, 17(10), 3570.

Abstract

This study describes how trends in the sale of cigarettes in Japan between 2011 and 2019 correspond to the sales of heated tobacco products (HTPs) that were introduced into the Japanese market in late 2015. Data used for this study come from the Tobacco Institute of Japan and Philip Morris International. The findings show that the accelerated decline in cigarette only sales in Japan since 2016 corresponds to the introduction and growth in the sales of HTPs.

Citation

Thompson, M.E., Boudreau, C., Quah, A.C.K., Ouimet, J., Li, G., Yan, M., Mochizuki, Y., Yoshimi, I., Fong, G.T. (2020). Survey Methods of the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(7), 2598

Abstract

This paper describes the methods of the Wave 1 (2018) International Tobacco Control (ITC) Japan Survey. The respondents were adults aged 20 years and older in one of four user groups: (1) cigarette-only smokers who smoked at least monthly and used heated tobacco products (HTPs) not at all or less than weekly, (2) HTP-only users who used HTPs at least weekly and smoked cigarettes not at all or less than monthly, (3) cigarette-HTP dual users who smoked at least monthly and used HTPs at least weekly, and (4) non-users who had never smoked or who smoked less than monthly and used HTPs less than weekly. Eligible respondents were recruited by a commercial survey firm from its online panel. Respondents were allocated proportionally to sample strata based on demographic, geographic, and user type specifications benchmarked to a national reference. Survey weights, accounting for smoking/HTP use status, sex, age, education, and geography, were calibrated to benchmarks from a nationally representative survey in Japan. Response rate was 45.1% and cooperation rate was 96.3%. The total sample size was 4615 (3288 cigarette smokers, 164 exclusive HTP users, 549 cigarette-HTP dual users, and 614 non-users). The 2018 ITC Japan Survey sampling design and survey data collection methods will allow analyses to examine prospectively the use of cigarettes and HTPs in Japan and factors associated with the use of both products and of transitions between them.

Citation

Gravely, S., Fong, G.T., Sutanto, E., Loewen, R., Ouimet, J., Xu, S.S., Quah, A.C.K., Thompson, M.E., Bordereau, C., Li, G., Goniewicz, M., Yoshimi, I., Mochizuki, Y., Elton-Marshall, T., Thrasher, J.F., Tabuchi, T. (2020). Perceptions of harmfulness of heated tobacco products compared to combustible cigarettes among adult smokers in Japan: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(7), 2394.

Abstract

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers’ harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Citation

Sutanto, E., Miller, C., Smith, D.M., Borland, R., Hyland, A., Cummings, K.M., Quah, A.C.K., Xu, S.S., Fong, G.T., Ouimet, J., Yoshimi, I., Mochizuki, Y., Tabuchi, T., O’Connor, R.J., Goniewicz, M. (2020). Concurrent daily and non-daily use of heated tobacco products with combustible cigarettes: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(6), 2098

Abstract

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Citation

Sansone, G., Fong, G.T., Meng, G., Craig, L., Xu, S.S., Quah, A.C.K., Ouimet, J., Mochizuki, Y., Yoshimi, I., Tabuchi, T. (2020). Secondhand smoke exposure in public places and support for smoke-freelaws in Japan: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 17(3), 979. Doi: https://doi.org/10.3390/ijerph17030979.

Abstract

Comprehensive smoke-free policies such as those called for by the WHO FCTC are the only way to protect the public effectively from the harms of secondhand smoke (SHS), yet Japan has been slow to implement this important health measure. This study examines baseline levels of smoking and SHS exposure in public places and support for smoking bans in Japan prior to the implementation of the 2018 national smoke-free law. Data are from the International Tobacco Control (ITC) Japan Wave 1 Survey (Feb–Mar 2018), a web survey of adult cigarette smokers, heated tobacco product users, dual users, and non-users (total N = 4684). Measures included prevalence of smoking (whether respondents noticed people smoking inside restaurants and bars at their last visit, and workplaces in the last month), and support for complete smoking bans in these venues. Smoking prevalence in each venue was high overall in 2018 (49% of workplaces, 55% of restaurants, and 83% of bars), even higher than in China, the country with the greatest toll of SHS. Support for complete smoking bans was very high overall (81% for workplaces, 78% for restaurants, and 65% for bars). Non-users were less likely to be exposed to SHS and had higher support for smoking bans than tobacco users. These findings point to the ineffectiveness of partial smoke-free laws in Japan and reinforce the call for comprehensive smoke-free laws, which even smokers would support at higher levels than in many other ITC countries.

Citation

Chung-Hall, J., Fong, G.T., Meng, G., Yan, M., Tabuchi, T., Yoshimi, I., Mochizuki, Y., Craig, L., Ouimet, J., Quah, A.C.K. (2020). Effectiveness of Text-only Cigarette Health Warnings in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey. International Journal of Environmental Research and Public Health, 17(13), 952. Doi: https://doi.org/10.3390/ijerph17030952.

Abstract

Health warnings are an effective strategy for communicating the health harms of smoking, encouraging quitting, and preventing smoking initiation. This study examines the effectiveness of existing text-only health warnings, identifies key predictors of warning effectiveness, and assesses support for pictorial warnings in Japan. Data are from the 2018 International Tobacco Control (ITC) Japan Survey, a cohort survey of adult cigarette smokers (n = 3306), dual users of cigarettes and heated tobacco products (n = 555), and non-cigarette smokers (n = 823). Weighted multivariable logistic regression models were used to assess predictors of warning effectiveness and support for pictorial warnings. Overall, 15.6% of respondents noticed warnings, and 7.9% read or looked closely at warnings. Overall, 10.3% of smokers and dual users said the warnings stopped them from having a cigarette, and 7.2% avoided warnings. Overall, 27.5% of respondents said the warnings made them think about health risks of smoking, but only 2.7% of smokers and dual users said the warnings made them more likely to quit. Overall, 57.6% of respondents supported pictorial warnings. The weak effectiveness of Japan’s text-only warnings is consistent with that in other countries with similar warnings. There is majority support for pictorial warnings in Japan, although the level of support is lower than in other countries.

Citation

Sutanto, E., Smith, D.M., Miller, C., O’Connor, R.J., Hyland, A., Tabuchi, T., Quah, A.C.K., Cummings, K.M., Xu, S., Fong, G.T., Ouimet, J., Yoshimi, I., Mochizuki, Y., Goniewicz, M.L. (2019). Use of Heated Tobacco Products within Indoor Spaces: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 16(23), 4862.

Abstract

Although heated tobacco products (HTPs) have become increasingly popular in Japan, little is known about whether these emerging tobacco products are being used within indoor public spaces. Nationally representative data were obtained prior to implementation of a comprehensive smoke-free law in Japan as part of Wave 1 of the International Tobacco Control Japan Survey (February–March 2018). We estimated the weighted prevalence of HTP use within indoor public spaces among tobacco users and compared these to estimates for combustible cigarettes (CCs). Overall, 15.6% of current tobacco users in Japan declared that they used HTPs within indoor public spaces. Any HTP use within indoor public spaces was significantly lower than any CC use (80.1% vs. 96.7%). Dual HTP + CC users reported using CCs more frequently than using HTPs within indoor public spaces (97.7% vs. 76.0%). In conclusion, HTP use is less common than CC use within indoor public spaces. Findings of this study can inform the development of targeted smoke-free policies to benefit public health.

Citation

Sutanto, E., Miller, C., Smith, D., O’Connor, R.J., Quah, A.C.K., Cummings, K.M., Xu, S., Fong, G.T., Hyland, A., Ouimet, J., Yoshimi, I., Mochizuki, Y., Tabuchi, T. Goniewicz, M. (2019). Prevalence, use behaviors, and preferences among users of heated tobacco products: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 16(23), 4630.

Abstract

Heated tobacco products (HTPs), such as IQOS, glo, and Ploom TECH, with a variety of flavored tobacco-containing inserts, have reportedly achieved a significant market share in Japan. We analyzed data from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted in February to March 2018 among 4684 adult participants to estimate the prevalence of HTP use, describe characteristics of HTP users, and explore user preferences for HTP device and flavor. The overall prevalence of monthly HTP use was 2.7% (1.7% daily use). Virtually all HTP users were current cigarette smokers (67.8%) or former smokers (25.0%); only 1.0% of HTP users were never smokers. Among HTP users, IQOS was the most frequently reported brand used (64.5%), and menthol was the most common flavor reported (41.5%). IQOS was used more by younger respondents and those who reported daily use, while Ploom TECH was more popular among older respondents and non-daily HTP users. This is one of the first non-industry funded studies to explore the use of HTPs in Japan.