Science and Practice for Heated Tobacco Products: Japan as a Test Bed for Novel Tobacco Products 9813345039, 9789813345034

Citation preview

Science and Practice for Heated Tobacco Products Japan as a Test Bed for Novel Tobacco Products

Takahiro Tabuchi

123

Science and Practice for Heated Tobacco Products

Takahiro Tabuchi

Science and Practice for Heated Tobacco Products Japan as a Test Bed for Novel Tobacco Products

Takahiro Tabuchi Cancer Control Center Osaka International Cancer Institute Osaka Japan

ISBN 978-981-33-4503-4    ISBN 978-981-33-4504-1 (eBook) https://doi.org/10.1007/978-981-33-4504-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Acknowledgments

I will begin this book with some words of gratitude. I am deeply indebted to Chihiro Haraguchi and Saki Kasai of Springer Japan. This book would not have been possible without all the activities and thoughts I was able to share with my colleagues in tobacco control, public health, epidemiology, and other related fields. I thank Dr. Julia Mortimer and Mr. Peter L Jaeger for their English language editing. This book was supported by the Japan Society for the Promotion of Science (KAKENHI Grant JP18H03062). Finally, I give my thanks to my wife Makoto and my son Taiki for their spiritual support, which is constant and unflagging.

v

Contents

1 Introduction������������������������������������������������������������������������������������������������   1 1.1 Foreword ��������������������������������������������������������������������������������������������   1 1.2 What Is the Big Problem with New Tobacco Products? ��������������������   3 1.3 What we Must Understand about New Tobacco Products������������������   6 1.4 The Very Image of HTPs Is Dubious��������������������������������������������������   6 References����������������������������������������������������������������������������������������������������   8 2 Tobacco Products in Japan Including a History of Heated Tobacco Products����������������������������������������������������������������������   9 2.1 New Tobacco Products Are Taking Japan by Storm ��������������������������   9 2.2 No Innovation: They Have Been Around a Long Time����������������������  14 References����������������������������������������������������������������������������������������������������  16 3 The JASTIS Project: Product Use Status in Japan��������������������������������  17 3.1 New Tobacco Products Got their Start from “Ame-Talk”: Google Trends Study��������������������������������������������������������������������������  17 3.2 New Tobacco Product Use in Japan: The JASTIS Study��������������������  20 3.3 Why Are New Tobacco Products So Popular?������������������������������������  22 3.4 Japan: The Global Test Site for IQOS������������������������������������������������  26 References����������������������������������������������������������������������������������������������������  27 4 Marketing Strategy for Tobacco Products in Japan ������������������������������  29 4.1 The Japanese Love a New Gadget������������������������������������������������������  29 4.2 The Japanese Public: Manipulated with Imagery and Led to Misunderstanding��������������������������������������������������������������������������������  31 4.3 The Risks of Tobacco the Media Would Not Report, and Why Not ��������������������������������������������������������������������������������������  33 4.4 The Tobacco Companies’ Outrageous Insult to Smokers ������������������  35 References����������������������������������������������������������������������������������������������������  38 5 Substances in Novel Tobacco Products����������������������������������������������������  39 5.1 The Harmful Substances in Tobacco Smoke: Basic Information from Public Health Perspective��������������������������������������  39 5.2 The Harmful Substances in HTP Aerosol������������������������������������������  43 5.3 The Many Unresearched Substances in HTP Aerosol������������������������  50

vii

viii

Contents

5.4 The Harmful Substances in e-Cigarette Aerosol��������������������������������  51 References����������������������������������������������������������������������������������������������������  53 6 Health Effect����������������������������������������������������������������������������������������������  55 6.1 Risk of Cancer������������������������������������������������������������������������������������  55 6.1.1 Reason One ����������������������������������������������������������������������������  55 6.1.2 Reason Two����������������������������������������������������������������������������  56 6.1.3 Reason Three��������������������������������������������������������������������������  56 6.2 Risk of Circulatory Disorders ������������������������������������������������������������  57 6.3 Increasing Nicotine Dependence��������������������������������������������������������  57 6.4 The Pluses and Minuses of Passive Smoke from New Tobacco Products: Children and Family Members Are at Risk������������������������������������������������������������������������������������������  59 6.5 EVALI: e-Cigarette or Vaping Product Use-Associated Lung Injury ����������������������������������������������������������������������������������������  60 References����������������������������������������������������������������������������������������������������  61 7 Social Effect������������������������������������������������������������������������������������������������  63 7.1 Are New Tobacco Products Cigarettes or Not?����������������������������������  63 7.2 New Tobacco Products Are Changing All the Rules��������������������������  65 7.3 With the Introduction of New Tobacco Products, the Difficulty Level of Tobacco Control Has Increased Sharply��������������  67 7.4 New Tobacco Products Have Brought New Problems to Society������  68 7.5 How Our Attitudes Have Been Warped by the Tobacco Industry������  69 7.6 Fanning the Flames of Confrontation to Keep Tobacco Alive������������  71 References����������������������������������������������������������������������������������������������������  74 8 Interpretation of Risks of Novel Tobacco Products, Including Harm Reduction Theory����������������������������������������������������������  75 8.1 How Can We Interpret the Risks of New Tobacco Products��������������  75 8.2 Will we Ever Really Know the Health Risks of New Tobacco Products?��������������������������������������������������������������������������������������������  77 8.3 The Risks of e-Cigarettes: Are They Really a Means of “Harm Reduction”?����������������������������������������������������������������������������������������  79 8.3.1 It Has Not Been Clearly Established that e-Cigarettes Are Less Harmful than Conventional Cigarettes��������������������  80 8.3.2 It Is Not Known if e-Cigarettes Can Help People Quit Smoking Conventional Cigarettes����������������������������������  80 8.3.3 E-Cigarettes Have Their Own Issues��������������������������������������  80 8.4 What Is Optimal for Comparing with New Tobacco Products? ��������  81 References����������������������������������������������������������������������������������������������������  82 9 Suggestions for Practice Regarding Novel Tobacco Product Use Patterns ������������������������������������������������������������������������������������������������������  83 9.1 Cessation in the Era of New Tobacco Products����������������������������������  83 9.1.1 Essential Skills to Ensure that Patients Who Have Quit Remain Tobacco-Free ����������������������������������������������������  84

Contents

ix

9.1.2 For Smokers ��������������������������������������������������������������������������  84 9.1.3 For Medical Doctors��������������������������������������������������������������  85 9.1.4 For People Who Help People Quit����������������������������������������  86 References����������������������������������������������������������������������������������������������������  87 10 Policy Implication Including Interference in Tobacco Control Measures with New Tobacco Products��������������������������������������  89 10.1 For the People Who Make the Rules for our Society (Legislators and Bureaucrats)����������������������������������������������  89 10.2 View of the World Health Organization��������������������������������������������  90 10.3 View from IARC Classifications: “Tobacco Smoke” as a Carcinogen ��������������������������������������������������������������������������������  91 10.4 Can we Trust the Tobacco Companies?: Interference in Tobacco Control Measures with New Tobacco Products��������������  92 References����������������������������������������������������������������������������������������������������  96 11 Conclusions������������������������������������������������������������������������������������������������  97 11.1 Implication for Future Work ������������������������������������������������������������  97 11.2 The World Is Not Logical nor Right ������������������������������������������������  98 11.3 A Matter of Degree ��������������������������������������������������������������������������  99 11.3.1 So, in the End, What Should we Do?������������������������������������ 100 Index�������������������������������������������������������������������������������������������������������������������� 101

List of Figures

Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 1.4 Fig. 1.5 Fig. 2.1 Fig. 2.2 Fig. 2.3 Fig. 2.4 Fig. 2.5 Fig. 2.6 Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 3.4 Fig. 3.5 Fig. 4.1 Fig. 4.2 Fig. 4.3 Fig. 4.4 Fig. 4.5

Fig. 4.6 Fig. 5.1 Fig. 5.2

Tobacco companies altered cigarettes using 9 technical tricks�������������� 5 Japan tobacco TV commercial���������������������������������������������������������������� 7 IQOS store in Central Tokyo������������������������������������������������������������������ 7 Pamphlets on HTPs�������������������������������������������������������������������������������� 8 The questions on everyone’s minds about HTPs������������������������������������ 8 Structural diagram of heated tobacco product�������������������������������������� 10 Structural diagram of e-cigarette���������������������������������������������������������� 11 Structural diagram of paper-rolled cigarette ���������������������������������������� 11 New tobacco products and their regulations (Photos taken by the author’s research group, 2016–2017)������������������ 13 Global timeline for HTPs in the world and Japan�������������������������������� 14 Comparison of accord (1998) and IQOS (2014)���������������������������������� 15 Search results from Google Trends������������������������������������������������������ 18 Searches on Google Trends for new tobacco products in Japan ���������� 19 Trends in new tobacco product usage by Japanese adults�������������������� 20 Countries in which IQOS is sold���������������������������������������������������������� 26 Growth of market share of IQOS sticks in Japan���������������������������������� 26 Heated tobacco pamphlets claiming reduced harmful substances�������� 32 Health warnings on heated tobacco pamphlets������������������������������������ 33 Television programs sponsored by Japan Tobacco ������������������������������ 36 Health risks as described in IQOS pamphlet���������������������������������������� 36 Advertisements by tobacco companies. (a) (Internet ad for PloomTECH by Japan Tobacco); (b) (newspaper ad for IQOS by PMI), 2020. Both advertisements appeal to smokers “if you stay at home, please use HTPs!” �������������������������������������������������������������������������������� 37 Marketing copy displayed in IQOS stores�������������������������������������������� 38 Tobacco smoke: harm caused and routes of causality (Source: US Surgeon General Report 2014) ������������������������������������������������������������ 41 Mechanism of how smoking causes circulatory disorders (Source: Tobacco smoking and health. A report from the review committee on the health effects of tobacco smoking. 2016. http://www.mhlw.go.jp/stf/shingi2/0000135586.html)�������������� 43 xi

xii

List of Figures

Fig. 5.3 Harmful substances in HTPs and their risks ���������������������������������������� 44 Fig. 5.4 Chemical substances emitted by IQOS and cigarettes (μg/stick) �������� 46 Fig. 5.5 Blood nicotine concentration after smoking. Source: Picavet P, Haziza C, Lama N et al. Nicotine and Tobacco Research 2016; 18: 557-563�������������������������������������������������� 49 Fig. 5.6 Particulate matter and harmful substances absorbed by passive smoking, a comparison of HTPs to combustible cigarettes ���� 50 Fig. 5.7 Types and quantities of aldehydes in aerosol of e-cigarettes sold in Japan������������������������������������������������������������������������������������������ 53 Fig. 6.1 Difference in Brain Reactive Function upon Receiving Chocolate (a) non-smoker (n=43), (b) smoker (n=43). Source: J Peters et al., American Journal of Psychiatry 168:540–549, 2011 �������������������������������������������������������� 59 Fig. 7.1 “No-smoking” sign displayed at the 2018 FIFA Soccer World Cup. Photo from the Nagoya Anti-Tobacco Support Group “The Committee to Protect Children from Tobacco, Aichi”���������������� 66 Fig. 7.2 The MPOWER criteria for evaluating world tobacco control performance������������������������������������������������������������������������������ 67 Fig. 7.3 A doctor recommends smoking in an advertisement (USA, 1931). Source: Stanford Research into the Impact of Tobacco Advertising (SRITA), Tobacco Advertisement Database ������ 72 Fig. 7.4 Japanese smoking rates by education level (%, age 25–64, male/female). Source: Ministry of Health, Comprehensive Survey of Living Conditions, 2010, T Tabuchi, N Kondo, Journal of Epidemiology 2017; 27: 186-192 ���� 73 Fig. 8.1 Relationship between cigarettes and ischemic heart disease (paper-rolled cigarettes per day). Source: TF Pechacek, S Babb BMJ 2004: 328(7446):980–3 (Edited) ������������������������������������ 76 Fig. 10.1 Trend in Japan tobacco profits. Source: Mark A Levin, “Five Important Things to Know About Japan Tobacco Inc.,” summary presentation of November 2014 keynote lecture at eighth Annual Meeting of the Japan Society for Tobacco Control, Japanese Journal of Tobacco Control, Vol. 10, No. 1, pp. 13-18, Spring 2015 (in Japanese)�������������������������������������������������������������������� 94 Fig. 10.2 JT’s overseas operations and cigarette sales outside Japan. Source: JT website�������������������������������������������������������������������������������� 94 Fig. 10.3 Countries and regions where JT has #1 market share. Source: M Eriksen, J Mackay, N Schluger et al. The Tobacco Atlas, Fifth Edition: Revised, Expanded, and Updated. Atlanta, Georgia, USA. American Cancer Society, 2015������ 95 Fig. 11.1 Analytical models for examination of health effect from HTPs suggesting three possible comparisons �������������������������������������� 98

List of Tables

Table 3.1 Table 3.5 Table 3.6 Table 3.2 Table 3.3 Table 3.4 Table 4.1 Table 4.2 Table 5.1

Sales of heated tobacco products by year������������������������������������������ 19 Reasons for using HTPs �������������������������������������������������������������������� 25 Reasons for using e-cigarettes������������������������������������������������������������ 25 Adjusted prevalence of current heated tobacco (HTP) use (use in previous 30 days) from 2015 to 2019 in Japan���������������� 21 Adjusted prevalence of current heated tobacco (HTP) use in previous 30 days by product types from 2015 to 2019 in Japan������������������������������������������������������������������������ 22 Characteristics by percentage of IQOS users 23 Cancer preventive factors ������������������������������������������������������������������ 34 Cancer risk factors������������������������������������������������������������������������������ 34 Comparison of chemical substances in IQOS aerosol and cigarette smoke, results from tobacco companies, and independent research organizations���������������������������������������������������� 47

xiii

1

Introduction

1.1

Foreword

Advertisements for the tobacco industry’s new heated tobacco products (HTPs) line the windows of Japan’s convenience stores and information racks overflow with pamphlets extolling the virtues of HTPs. Are the Japanese aware that this phenomenon is not global but is confined to Japan. In 2014, the HTP “IQOS” went on sale as a limited release in a few cities in Japan and Italy, and in 2016, Japan became the first country in the world to offer IQOS for sale nationally. As of October 2016, Japanese sales accounted for 96% of IQOS volume globally; almost all the IQOS use in the world was in Japan. In other words, Japan had become the world’s test bed for the so-called novel tobacco products known as HTPs. The only readily available information on HTPs is that disseminated by the tobacco industry. As a result, many Japanese now believe exactly what the tobacco industry wants them to believe. In fact, tobacco companies have been deliberately operating a promotional campaign designed to spread the misconception that HTPs are harmless (no harm or no tar). I myself have been approached by many people who ask, in all seriousness, questions such as “heated tobacco is basically harmless, isn’t it?” or “since heated tobacco is safe, it’s okay to smoke it in front of children, right?” I am shocked by how many people have misunderstood the reality of the situation. Almost all the available information on HTPs thus far has come from the tobacco industry. They have issued statements like “this modern new tobacco is different from traditional tobacco—it’s clean and harmless.” Unfortunately, this sort of claim from tobacco companies is nothing new: for decades, tobacco companies have been making minor tweaks to their products and repeating the same message. The “low-­ tar” cigarettes of the past are just one example. Consumers believed that cigarettes with less tar would be safer, but in fact there is no difference in the health risks.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 T. Tabuchi, Science and Practice for Heated Tobacco Products, https://doi.org/10.1007/978-981-33-4504-1_1

1

2

1 Introduction

At this point, there is no evidence whatsoever that HTPs such as IQOS or PloomTECH pose less risk to health than conventional cigarettes. On the contrary, in fact, numerous academic papers have been released which demonstrate, scientifically, the dangers of HTPs and the hazardous substances they emit. Little by little, research materials, the scientific evidence, and a store of epidemiological data are coming together which will allow the world to judge the safety or otherwise of HTPs. Our society is maturing. Compared to the world when I was entering adulthood, Japanese society today is more mature, is better organized, and has clearer rules and standards. Japanese society has also made much progress with regard to secondhand smoking. When I was a child riding on the unreserved seats of Japan’s famous Bullet Trains “Shinkansen,” I remember the carriages were filled with cigarette smoke which burned my eyes and throat and made me feel ill. Even today there are still some trains which allow smoking, but if we can choose the non-smoking carriages and thus generally avoid suffering the dangers and discomfort of secondhand smoke. Many readers will say there is still not enough being done about secondhand smoke, but with the passing of the Revised Health Promotion Act1 in 2018, Japan has clearly changed direction to a society which aims to prevent secondhand smoking. It is against this backdrop that the problem of new tobacco products has suddenly arisen in Japan. HTPs like Ploom and IQOS were put on sale in Japan without paying the slightest attention to warnings from the physicians and researchers addressing the dangers of tobacco. The tobacco companies introduced these products as if they were simply introducing a new brand of cigarette: they applied to the Japanese Ministry of Finance for permission to sell HTPs and that permission was granted. Yet at the time, HTPs were not for legal sale in any other country in the world. HTPs are a very different product from cigarettes, and it is fair to say that no one had an adequate factual basis to grant permission so easily. Nevertheless, in Japan, permission was granted easily and the sale of HTPs began. I know of no academic or medical discussion surrounding the granting of permission for the sale of HTPs in Japan. Perhaps, it was granted on the basis that HTPs were simply another version of the old HTPs, which were already on sale (e.g., Accord; see the next chapter “Tobacco products in Japan including history of HTPs”). Perhaps, personnel in the Ministry of Finance thought that, like old HTPs, the new HTPs would not sell. However, this new type of tobacco product took off rapidly in Japan, likely surprising the Ministry of Finance. As the Ministry were unable to apply the existing formulas for tobacco tax, there was a risk of lost tax revenue, but they changed the tax laws immediately, creating a new category for HTPs. Not even the tobacco companies could have predicted that HTPs would flourish like this in a mature market such as Japan, and this is clear when we look at how short supply was in the early days of HTPs as demand increased. 1  The Health Promotion Act was revised, and although it is still a provisional measure, in principle smoking is prohibited in bars, restaurants, and public spaces used by large numbers of people.

1.2  What Is the Big Problem with New Tobacco Products?

3

So how should we approach this new issue about which so little is known? This is a situation which no one foresaw. Based on the situation in Japan, some countries have banned HTPs. However, Japan was the first country in the world to have permitted their sale and cannot now easily reverse the decision. New tobacco products are already permeating deeply into Japanese society. As individuals, as a society, and as a nation, we must come to grips with these new tobacco products. There seem to be both advantages and disadvantages to new tobacco products. Like many issues in our world, this is not a binary, black-and-white matter, but a matter of degree. At this time, we have neither the data nor the experience, nor have we had the necessary discussions, to make an informed decision on new tobacco products. Today, most of the world’s information on new tobacco products bears the fingerprints of the tobacco industry. The industry is using television and newspaper advertisements, posters in convenience stores and tobacco shops, and all manner of media and promotion in their marketing activities. The tobacco companies are deliberately spreading the message that these products pose little risk to health. For this reason, many people (the general population) have the mistaken impression that new tobacco products are harmless. The first thing we must do is tell them clearly— this is not so! In this book, I present the latest information, as of June 2020, on new tobacco products. Although it is a book about new tobacco products in general, it has a particular focus on HTPs because of all the new tobacco products in Japan, they are trending especially strongly. I turn my attention first to HTPs, but will also touch on e-cigarettes as necessary, especially in relation to the harm reduction theory.

1.2

What Is the Big Problem with New Tobacco Products?

Why are new tobacco products a problem? The first answer is because they have spread so widely in Japan. As noted in the Foreword, like many societal problems, the introduction of new tobacco products is not a simple black-and-white issue but a matter of degree. One reason why tobacco is a serious societal problem in Japan is that a staggering 20% of the adult population smoke. Tens of millions of Japanese are exposed to the harm of tobacco. Clearly, if almost no one in Japan were exposed in this way, then tobacco would not be seen as a major societal problem.2 But let us consider, if some day in the future, 20% of Japan’s population came to own guns, then the number of shootings would likely escalate, and guns would soon be seen as a much graver societal problem than they are today. I am not saying that guns are not a problem at all in Japan today, I am merely pointing out the degree of the problem. 2  I am not saying that something cannot be a societal problem if only a small number of people are exposed to its harm. For example, there are rare diseases with only a few patients, and of course these diseases nonetheless merit care and support for the patients as well as medical research. I am simply pointing out that to prioritize something as a societal problem requires us to examine not only its causes and criticality, but also the number of people affected.

4

1 Introduction

So, let us think about new tobacco products as a problem on this scale. The number of people smoking new tobacco products in Japan has been increasing rapidly in recent years. We learned from a 2020 survey that more than 10% of the population was now using new tobacco products [1]. How should we, as a society, view new tobacco products and how should we deal with them? Since so many people are already using them, these are questions we must face with considerable urgency. New tobacco products constitute a critical issue for our society. In Japan, of the new tobacco products available, electronic cigarettes (e-cigarettes) have not caught on in the same way as HTPs, and it is probably for this reason that they are not seen as so much of a societal problem. Let us look at some important background information. The problem of new tobacco products has, in fact, been with us for a long time. Tobacco companies are constantly altering their tobacco products and bringing new varieties to the market. In just the past 20 years, all sorts of new variations on cigarettes and tobacco products have been introduced to the Japanese market. Chewing tobacco was introduced in 2003, sniffing tobacco between 2010 and 2013, and in 2013 a sniffing tobacco product from Sweden called SNUS hit the market in Japan. However, none of these products became especially popular, so with a limited number of users they did not pose a significant problem to Japanese society. Meanwhile, in 2007, tobacco companies introduced cigarettes with capsules of menthol built into their filters. These cigarettes could have been seen as a sort of new tobacco product and, what is more, they sold relatively well. However, their only distinguishing feature was that the menthol was packed into a capsule—in fact, mentholated cigarettes had already been on sale in Japan for more than 50 years, so the new encapsulated product was not seen as a new problem in society. The problem of menthol has by no means been ignored by the academic world. Research teams have leveled criticism at the use of menthol-encapsulated cigarettes (which have a fresher, mintier taste) as a tactic to make cigarettes more attractive to women and children. However, since this was similar to past censure of conventional mentholated cigarettes, it was not seen as a new issue.3 It is certainly possible to see menthol capsules as an element of the huge changes that have occurred within the context of the history of conventional cigarettes. Figure 1.1 illustrates nine representative technical tricks which show just how much tobacco companies have done to alter cigarettes over the past 50  years. Astonishing facts such as these have been revealed over many years, by researchers into the tobacco problem, and from the internal documents of tobacco companies4

3  Numerous research teams throughout the world have expressed negative opinions of mentholencapsulated cigarettes, similar to the negative views of conventional menthol cigarettes and socalled low-tar cigarettes. I am not suggesting that these products are not part of the tobacco problem but am explaining why they have not been criticized in the context of new tobacco products. 4  The website of “Truth Tobacco Industry Documents” makes public over 14 million internal documents from tobacco companies [2]. The “British American Tobacco Documents Archive” website makes public six million pages of internal documents from British American Tobacco [3]

1.2  What Is the Big Problem with New Tobacco Products? Bronchodilators

5

Flavorings

Added chemicals expand the lungs’ airways, making it easier for tobacco smoke to pass into the lungs.

Added flavors like liquorice and chocolate mask the harshness of smoke and make products more appealing to new users, especially kids.

Increased Nicotine

Tobacco companies control the delivery and amount of nicotine to ensure addiction

Tobacco-specific Nitrosamines American-style cigarettes are made with blended tobacco that has much higher levels of cancer-causing nitrosamines.

Ammonia Compunds

Adding ammonia compounds increases the speed with which nicotine hits the brain.

Ventilated Filters

Ventilation holes in the filters cause smokers to inhale more vigorously, drawing carcinogens more deeply into the lungs.

Menthol

Menthol cools and numbs the throat to reduce irritation and make smoke feel smoother.

Sugars and Acetaldehyde

Added sugars make tobacco smoke easier to inhale and form acetaldehyde, which enhances nicotine’s addictive effects.

Levulinic Acid

Added organic acid salts reduce harshness of nicotine and make smoke smoother, less irritating.

Fig. 1.1  Tobacco companies altered cigarettes using 9 technical tricks

[2, 3] which were made available to the public thanks to lawsuits against cigarette makers on behalf of the sufferers of tobacco-induced illnesses. These documents show in the starkest light how tobacco companies have, for decades, been intentionally intensifying the addictive qualities of cigarettes. Not only did they boost the nicotine content to foster nicotine dependence, but they added chemicals like ammonia which speed up the delivery of nicotine to the brain. By adding menthol and fragrances, they softened the abrasive harshness of cigarette smoke to suppress the choking reflex. This makes it much easier for women, children, and anyone who has never smoked before to pick up the habit. By placing ventilation holes in the sides of the cigarette filter, they helped smokers inhale greater quantities of smoke more deeply, delivering a more powerful nicotine hit to their brains. The cigarettes of today are far more addictive to first user, and far more palatable to women and children than the cigarettes of 50 years ago. The HTPs which have already caught on in Japan are just some of the tobacco products mainly manufactured by the world’s Big Three tobacco companies (British American Tobacco (BAT), Philip Morris, and Imperial Tobacco Australia. In fact, HTPs are just one page in the long history of variations on conventional paper-rolled cigarettes.

6

1.3

1 Introduction

What we Must Understand about New Tobacco Products

I cannot read your mind. However, I am confident that I know what you want to understand, once and for all, about new tobacco products. You want to understand exactly what the introduction of these products means because so many people are already using them. It may be quite an obvious thing to say, but precisely because so many people are now using them, you are very likely to encounter these users in a variety of places, especially in Japan. One in ten people in Japan is now using new tobacco products, especially the heated tobacco product like IQOS. Those of us in the medical profession have patients who are using new tobacco products, and they want to question us and ask our advice on the pros and cons of these products. Without detailed knowledge of the products, we cannot meet their needs. Any doctor who wants to avoid this outcome will surely wish to learn more about the new tobacco products. On the other hand, you yourself may already be a user of new tobacco products. Do you really believe the information in the tobacco company pamphlets about the risks these products pose? Surely you would like to know the facts. It is also possible that someone you love or someone you care about is using new tobacco products or is considering using them. They may have smoked conventional cigarettes before and think that new tobacco products are somehow better for their health—but are they? If they already have that doubt in their mind, you may wish to advise them on the real alternatives available to them. I am an independent specialist on tobacco control; I have no relationship whatsoever with any tobacco company and have never received money from the tobacco industry. I have written this book with the aim of covering all the angles, whether they suit the tobacco companies or not. This is because I want you, the reader, to understand the facts so you can judge for yourself. Although nicotine-containing e-cigarettes have been sold worldwide, the bestselling new tobacco products in Japan are HTPs. The content of this book therefore focuses on HTPs but touches on e-cigarettes as necessary.

1.4

The Very Image of HTPs Is Dubious

I will describe the marketing strategy of the tobacco companies in more detail in Chap. 4, but for now I will touch briefly on the advertisements and sales promotion activities for HTPs undertaken by the tobacco companies. Tobacco companies have run a public relations campaign for HTPs, placing advertisements in newspapers and magazines. They ran television commercials (Fig.  1.2) to push HTPs to the forefront of the public’s mind, set up trendy-looking shops modeled after the Apple Store (Fig.  1.3), and distributed millions of pamphlets at convenience stores (Fig. 1.4). In Japan, almost all the information on HTPs in circulation today comes from the tobacco companies themselves as the first Japanese book on HTPs which was published in March 2019 [4]. For this reason, many people in Japan are asking

1.4  The Very Image of HTPs Is Dubious

7

Fig. 1.2  Japan tobacco TV commercial

Fig. 1.3  IQOS store in Central Tokyo

themselves the sort of questions shown in Fig. 1.5. I have given many lectures and presentations on HTPs and am frequently asked most of these questions. Even if you have read accounts of HTPs from the tobacco companies, it is perfectly normal to wonder whether the information is trustworthy. All the questions in Fig. 1.5 raise real problems. New tobacco products present a veritable smorgasbord of doubts. The aggressive promotion of HTPs by the tobacco companies has spread deeply into our consciousness, but people everywhere have doubts about their safety.

8

1 Introduction

Fig. 1.4  Pamphlets on HTPs

Fig. 1.5  The questions on everyone’s minds about HTPs

References 1. Hori A, Tabuchi T, Kunugita N. Rapid increase in heated tobacco product (HTP) use from 2015 to 2019: from the Japan ‘Society and new Tobacco’ internet survey (JASTIS). Tob Control. 2020; https://doi.org/10.1136/tobaccocontrol-2020-055652. 2. Truth Tobacco Industry Documents., UCSF Library, https://www.industrydocuments.ucsf.edu/ tobacco/. Accessed June 14, 2020. 3. British American Tobacco Documents Archive. University of California. 2012. https://bat. library.ucsf.edu/. Accessed June 14, 2020. 4. Tabuchi T. The real risk of new tobacco and tobacco-like products. Tokyo: Naigai Publishing; 2019. p. 22.

2

Tobacco Products in Japan Including a History of Heated Tobacco Products

2.1

New Tobacco Products Are Taking Japan by Storm

The Japanese word tabako (“tobacco”) is used to mean a conventional cigarette. The term tabako has become so common that most people today are unfamiliar with the original Japanese word for cigarette, which was kami-maki tabako, or “paper-­ rolled tobacco,” whereas almost all Japanese are familiar with the major cigarette brands: Seven Stars, Mevius (previously Mild Seven), and Marlboro. But recently a new type of tobacco product has taken the Japanese tobacco market by storm—specifically heated tobacco and e-cigarettes. In this book, I will refer to both of these as “new tobacco products” but will focus particularly on HTPs. Are you familiar with heated tobacco and e-cigarettes? If you are, you may think you do not need to read this book. However, if your information sources are the tobacco companies and e-cigarette companies themselves, then you do! And why do I say this? Because while it is well known that companies which sell things generally publicize only the information which suits their needs, this is particularly true of tobacco companies, where their spread of “misinformation” has reached the point where it is recognized as a problem all over the world. Today, almost all available information on new tobacco products, and in particular heated tobacco, comes from the tobacco companies themselves. Almost no objective information on these new tobacco products is being communicated to the average person, at least in Japan. HTPs are known by various trade names such as IQOS, PloomTECH, and glo. In 2014, the global tobacco giant, Philip Morris International (PMI), spearheaded the world heated tobacco market with its introduction of IQOS in Japan and Italy [1, 2]. By 2016, Japan Tobacco (JT) and British American Tobacco (BAT) had introduced their own respective heated tobacco brands PloomTECH and glo. It would not be an overstatement to say that these newly introduced HTPs rapidly became one of the most talked-about consumer products in Japan. They were marketed and promoted

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 T. Tabuchi, Science and Practice for Heated Tobacco Products, https://doi.org/10.1007/978-981-33-4504-1_2

9

10

2  Tobacco Products in Japan Including a History of Heated Tobacco Products

aggressively in the media, including television, magazines, and newspapers, and new versions of the products were released one after another. With HTPs, unlike conventional paper-rolled cigarettes, no flame is applied to the tobacco leaves, but instead heat is applied to the leaves to release an aerosol which contains nicotine, among other ingredients. IQOS and glo use their own unique devices into which branded sticks containing tobacco are inserted and heated to 240–350 °C until an aerosol gas containing nicotine is delivered for inhalation by the user (Fig. 2.1). PloomTECH, on the other hand, heats up an aerosol of glycerol and propylene glycol which is then forced through branded capsules containing powdered tobacco leaves, again releasing an aerosol which delivers nicotine and other ingredients to the smoker (Fig. 2.1). With PloomTECH, the tobacco powder is stored in an area which is maintained at a relatively low temperature of around 30 °C, with the result that fewer harmful substances are delivered to the user. PloomTECH and e-cigarettes share a similar design. With e-cigarettes, a branded liquid is supplied to a unique smoking device which heats the liquid into a gas for inhalation by the user (Fig. 2.2). A broad range of products have been developed. The e-cigarette liquids are marketed with a base of glycerine or propylene glycol and additives such as nicotine and a broad range of flavors from strawberry cookies to cappuccino. However, liquids containing nicotine are prohibited in Japan by the Pharmaceutical Affairs Law because nicotine is not considered to be tobacco, but rather a drug, and one which can be toxic. For this reason, the e-cigarette liquids that

Fig. 2.1  Structural diagram of heated tobacco product

2.1  New Tobacco Products Are Taking Japan by Storm

11

Fig. 2.2  Structural diagram of e-cigarette

Fig. 2.3  Structural diagram of paper-rolled cigarette

contain nicotine cannot be offered for sale in Japan, but nicotine-containing liquids imported for personal use are tolerated and some people in Japan use them. In contrast, there are no laws governing e-cigarette liquids which do not contain nicotine, and their use is in fact not even prohibited for minors. The only governing factor is the tobacco industry’s system of self-regulation, and there is insufficient data from which to ascertain whether these products are actually being sold to minors. For reference I have also included a structural illustration of paper-rolled tobacco (a conventional cigarette) (Fig. 2.3). A flame is applied to tobacco leaves rolled into a paper tube, and when the smoker inhales through the filter, the leaves burn at a temperature of about 900 °C. The smoker inhales the generated gases, which contain nicotine and many other chemical substances. Unlike conventional cigarettes, the new tobacco product user does not inhale actual smoke, but rather an aerosol, often referred to as a vapor. But the aerosols generated by new tobacco products do not only contain steam. In Chap. 5, I will discuss the chemicals and harmful substances contained in these aerosols. So, what are the major differences between heated tobacco and e-cigarettes? If we examine these differences more closely, the discussion becomes somewhat trickier. Looking simply at the list of ingredients in the products, JT’s heated tobacco PloomTECH is very similar to an e-cigarette. With PloomTECH, the smoker inhales a heated aerosol which has been forced through a capsule containing powdered tobacco leaves, whereas with e-cigarettes the smoker inhales an aerosol formed by heating a liquid which may or may not contain nicotine.

12

2  Tobacco Products in Japan Including a History of Heated Tobacco Products

From the Japanese legal perspective, what matters is simply whether or not the product contains tobacco leaf, which heated tobacco does, but e-cigarettes do not. When HTPs which contain nicotine were governed by the Tobacco Business Act of 1984, there was no legal category which perfectly matched heated tobacco; the tobacco companies therefore made their applications to the government for a form of “pipe tobacco” and the applications were approved. In the Japanese legal interpretation, the nicotine used in e-cigarette liquid is extracted from tobacco leaves, but it does not contain actual tobacco leaves, so it is considered a drug, and it is prohibited by pharmaceutical law. In other words, in Japan, heated tobacco is considered a tobacco product, while e-cigarettes are not considered tobacco at all. While e-cigarettes are known in English-speaking countries as e-cigarettes or vapes, there is no direct translation for e-cigarette in Japanese, so they are called “electronic cigarettes (denshi tabako in Japanese)” and many Japanese seem to believe that they are simply another kind of tobacco (tabako). Like many Japanese, I also think that e-cigarettes should be treated as another form of tobacco, but it is not that simple. The English term e-cigarette which is used globally does not include the word “tobacco,” and around the world, for example in the UK, there are those who energetically promote e-cigarettes, saying that conventional cigarettes are bad, but e-cigarettes are not [3]. There are even authorities in the tobacco research field who insist that e-cigarettes are not a tobacco product (more on this in Chaps. 5 and 7). For this reason, when research papers are published referring to e-cigarettes, these authorities put forward the somewhat baffling statement that “e-cigarettes are not tobacco,” although some academic papers suggested that e-cigarettes should be included in tobacco products. I introduce an experience that when I submitted a paper about HTPs and e-cigarettes in Japan to a journal, the editor strongly suggested that e-cigarette should not be included in tobacco products. In this book, I refer to both heated tobacco and e-cigarettes as new tobacco products, but there are many research papers in the world which do not follow this definition (more on this in Sect. 7.1). Figure 2.4 shows the appearance, typical brand names, and laws governing various new tobacco products. As you can see, there are broad differences between products in both shape and style. There are e-cigarettes designed to look like conventional cigarettes; pen-like models; models with higher capacity tanks that hold larger volumes of liquid; and models which allow the current to be adjusted to deliver larger or smaller doses [4]. Figure 2.4 shows just 11 types, but there are over 500 different types of e-cigarettes in the world today. I have discussed the different structures and appearances of new tobacco products, as well as the legal treatment of each. However, I have not yet touched upon the problems surrounding new tobacco products, nor on what you most need to know about them. To understand these problems, first we must understand how new tobacco products are being used in Japan today.

2.1  New Tobacco Products Are Taking Japan by Storm Product type and Sample Products

Sample Brand Names (from left) IQOS, glo, PloomTECH

13 Applicable Japanese Regulations Regulated as pipe tobacco under the Tobacco Business Act of 1984 Newly defined as HTPs under the tobacco tax law in 2018

HTPs Disposable e-cigarettes

Tsukai-kiri NEO (photo), NJOY, Flavorvapes

Rechargeable e-cigarettes

Premium Smoker (upper photo), Joyetech 510 (lower photo), Blu, GreenSmoke

Rechargeable pen-type e-cigarettes

Aspire (upper photo), Ego-T (lower photo), Vapor King Storm

Rechargeable tank-type e-cigarettes

iTaste VTR (photo), Volcano Lavatube

E-cigarettes containing nicotine are regulated under Pharmaceutical Affairs Law, so electronic tobacco products which contain nicotine cannot be sold to the public. However, there are no clear regulations governing e-cigarettes which do not contain nicotine, so their sale is not prohibited, even to minors. The only regulation in force is the autonomous self-regulation practiced by the e-cigarette industry.

Fig. 2.4  New tobacco products and their regulations (Photos taken by the author’s research group, 2016–2017)

14

2  Tobacco Products in Japan Including a History of Heated Tobacco Products

2.2

No Innovation: They Have Been Around a Long Time

In fact, tobacco companies have been engaging in research on reducing the harm of tobacco for a long time. However, no one has ever seen this research succeed. Long before HTPs like IQOS, PloomTECH, and glo were invented, the tobacco companies tried time and again to introduce tobacco heating devices to the market (Fig. 2.5). Over thirty years ago in 1988, RJ Reynolds launched a HTP called “Premier” in the USA. The Premier was a heatable carbon rod lodged inside a paper cigarette, wrapped in tobacco leaves with granules of flavoring around it. RJ Reynolds’ idea was to target ex-smokers who had quit and try to get them to start again using Premier. They used catchy advertising copy to imply that although it looked like a cigarette, you could enjoy the flavor without burning tobacco leaves and that it contained almost no tar or nicotine—very similar to the promotional language being used today for IQOS and PloomTECH. The product did not do well with smokers, and it was withdrawn from the market within a year. Undaunted, RJ Reynolds tried again in 1996 with the launch of their next HTP, “Eclipse,” but production of Eclipse was halted in 2014; the name was changed to “Revo,” and that also failed within a year. PMI launched their HTP “Accord” in 1998. It was test-marketed simultaneously in Tokyo by JT as “Oasis.” Accord was smoked by inserting a branded conventional cigarette into a dedicated heating device. However, like the other HTPs, Accord was not popular with smokers, and manufacture was discontinued in 2006. So why did IQOS succeed where Accord failed? There is an academic paper, written in 2018, which explains this in detail [5]. Is IQOS different from Accord? Has there been some innovation? The academic paper concludes that there was in fact no innovation whatsoever. The basic structure is the same, the advertising concept is the same, and even the method of smoking is the same (Fig. 2.6). What is more, the quantity of harmful substances released is about the same as well. So, what was the secret of IQOS’s success? Jesse Elias of the Center for Tobacco Control Research and Education, University of California, San Francisco, observes that a tweak in marketing strategy was responsible. While Accord was sold as a Phillip Morris launches IQOS in Japan

Philip Morris launches Accord (in Japan, JT markets it as “Oasis”)

Manufacture of Eclipse terminated

JT launches PloomTECH in Japan JT launches Ploom in Japan

British American Tobacco launches glo in Japan

89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19

Manufacture of Accord terminated

Manufacture of Heatbar terminated

19

19

88

RJ Reynolds launches Premier

RJ Reynolds launches Eclipse (in Japan, JT markets it as “AIRS” from 1997-2004)

Manufacture of Premier terminated

Philip Morris launches Heatbar

Fig. 2.5  Global timeline for HTPs in the world and Japan

Manufacture of Revo terminated Philip Morris launches iFUSE

JT launches PloomTECH+ and Ploom S in Japan

2.2  No Innovation: They Have Been Around a Long Time

Tobacco Stick

15

Mouthpiece filter

MPF (7 mm)

Tipping paper

Hollow acetate tube (8 mm)

Free flow filter Cigarette paper overw rap

Tipping adhesive

Tobacco filler

Cavity Mat

PLA (18 mm)

Diameter max 7.42 mm

Laser perforations Inner wrap

Tipping paper

Outer paper

DAPTC perforations

Tobacco plug (12 mm)

Heater

Mouth Piece Circuit boards w/microchip

Tobacco

Heater LCD

Heater

Blades

Circuit board Battery

Battery

Product advertisement

Product in use

Fig. 2.6  Comparison of accord (1998) and IQOS (2014)

“clean” tobacco product, the advertising campaign for IQOS suggested it posed “less risk to health.” People today are more health conscious than they were ten or twenty years ago when Accord was launched; people thus are tempted by the IQOS promise of reduced risks to their physical well-being. It was the right idea for the right time, but there is no evidence that it has been developed to be less harmful to health. If we look at the year 2019 in the timeline in Fig. 2.5, we can see that on January 17, 2019, JT announced that on January 29 it would launch a new HTP, the Ploom S, which heated tobacco to a temperature of about 200 °C. The news articles which

16

2  Tobacco Products in Japan Including a History of Heated Tobacco Products

covered this story simply copied the JT press release verbatim, and sadly, the serious issues surrounding this event have not been discussed in public. JT’s earlier product, PloomTECH, had been marketed on the premise that its smell and the harmful substances it delivered to the smoker’s body were about 1% that of conventional cigarettes. However, when JT released Ploom S, it clearly had far more harmful substances than its predecessor. Ploom S was marketed as having about 5% the smell of conventional cigarettes and about 10% of the harmful substances. Simple arithmetic tells us this means the smell was five times that of PloomTECH and harmful substances were ten times that of PloomTECH! I will let the reader be the judge of the potential dangers of this new product.

References 1. Liu X, Lugo A, Spizzichino L, Tabuchi T, Pacifici R, Gallus S. Heat-not-burn tobacco products: concerns from the Italian experience. Tob Control. 2019;28(1):113–4. 2. Tabuchi T, Gallus S, Shinozaki T, Nakaya T, Kunugita N, Colwell B. Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol. Tob Control. 2018;27(e1):e25–33. 3. McNeill A, Hajek P. E-cigarettes: an evidence update A report commissioned by Public Health England, 2015. 4. Grana R, Benowitz N, Glantz SA.  E-cigarettes: a scientific review. Circulation. 2014;129(19):1972–86. 5. Elias J, Dutra LM, St Helen G, et al. Revolution or redux? Assessing IQOS through a precursor product. Tob Control. 2018;27(Suppl 1):s102–10.

3

The JASTIS Project: Product Use Status in Japan

3.1

 ew Tobacco Products Got their Start from “Ame-Talk”: N Google Trends Study

How interested are you in new tobacco products? One gauge of the general interest of people in a subject is its Google search volume; today, 90% of Japanese have access to the Internet and, of those, 60% use Google searches. By checking Google Trends, a research service provided free of charge by Google, it is possible to check data known as the search volume, which indicates how frequently and from what date Google users throughout the world have searched a certain term. Google search volume takes the most-searched period from the specified conditions (key word, time period, country, etc.) and references that period as 100. For example, searching the key word “soccer” with the time period “the past five years” and “Japan” as the country, it can be seen, as shown in Fig. 3.1, that the maximum number of searches performed for the word soccer in Japan during that period took place in the week from June 24 to June 30, 2018. The search volume for that week is referenced as 100. Searches for “soccer” spiked twice in Japan, in June 2014 and June 2018, coinciding with the FIFA World Cup. Clearly, many more people search “soccer” when the World Cup is on. This sort of search volume data can be a useful indicator of the interest the people of Japan (or anywhere in the world) have in a given subject. I conducted a study of the searches for “IQOS”, “Ploom/PloomTECH,” and “glo” that had been carried out in Japan. The resulting trend in search volume between 2013 and 2017 for both the English and Japanese spellings of these product names is shown in Fig. 3.2. It is clear from the chart that the search volume for “IQOS” spiked spectacularly in April of 2016. What could have caused this? Well, on April 28, 2016, the popular TV show “Ame-Talk” ran an episode dramatically entitled “Latest Comedian Tobacco News.” “Ame-Talk” airs after 11.00 pm and is an extremely popular show

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 T. Tabuchi, Science and Practice for Heated Tobacco Products, https://doi.org/10.1007/978-981-33-4504-1_3

17

18

3  The JASTIS Project: Product Use Status in Japan 100

100 90

83

80 70 60 50 40 30 20 10 0 June 2014 FIFA World Cup, Brazil

June 2018 FIFA World Cup, Russia

Fig. 3.1  Search results from Google Trends

with very large audience. In the past, when a new product was featured on “Ame-­ Talk,” such as an electrical appliance, it sold out almost instantly. So, how did the popular comedians who appeared on “Ame-Talk” discover IQOS? And how did they use IQOS? “Ame-Talk” showed funny and interesting scenes about smoking and using IQOS. I like “Ame-Talk” and always record it, so, with my personal interest in all things related to smoking, this episode caught my attention immediately. Afterward, I published a research paper on how sharply the Japanese people’s interest in IQOS had risen following the broadcast. The event kindled anew my astonishment at the level of influence television has on public interest and opinion. From April 2016, searches for “IQOS” increased dramatically, and even long after April, they led searches for all other new tobacco products. In fact, IQOS was the only new tobacco product discussed on “Ame-Talk” that night. The timing coincided exactly with April 18, 2016, when IQOS was expanded from a limited sales program in 12 large cities and prefectures to full-scale national sales rollout in all 47 large cities and prefectures (the program had been recorded before that date). At that time, glo was not yet on sale and PloomTECH was also not available on a national basis. Perhaps, IQOS was featured because it was the most well known at the time (Table 3.1). Or, could there have been something else behind the introduction of IQOS on that particular airing of “Ame-Talk”? I do not know the answer to that question, and in response to telephone queries, the producers of the program said they had received no funding from tobacco companies.

3.1 New Tobacco Products Got their Start from “Ame-Talk”: Google Trends Study

19

IQOS was introduced in a popular TV programme, Ame-talk, broadcasted on 28 Aprill 2016.

Relative search volume 100

E-cigarette 75

Ploom

50

IQOS

glo 25

3

2

0 2013/04/01

1

2014/04/01

1

2015/04/01

2 2016/04/01

3

1

2 2017/04/01

Fig. 3.2  Searches on Google Trends for new tobacco products in Japan

Table 3.1  Sales of heated tobacco products by year 1 12/1/2013 PloomTECH

2 3/1/2016 3 6/1/2016 1 11/1/2014

IQOS

glo

2 9/1/2015

3 4/18/2016 1 11/9/2016 2 12/12/2016

Limited online sales of PloomTECH prototype “Ploom” Sales launch in some tobacco shops in Fukuoka and nationally online (orders outstrip production capacity and sales are paused) Sales recommenced Limited launch in shops in Nagoya Sales area expanded to 12 large cities & prefectures: Hokkaido, Miyagi Pref, Chiba Pref, Saitama Pref, Kanagawa Pref, Tokyo, Aichi Pref, Kyoto, Osaka, Hyogo Pref, Hiroshima Pref, Fukuoka Pref. Nationwide sales commenced Announcement of Dec 12, 2016 launch date Sales launch

20

3.2

3  The JASTIS Project: Product Use Status in Japan

New Tobacco Product Use in Japan: The JASTIS Study

How much do the Japanese use new tobacco products? An Internet survey known as the “Japan Society and New Tobacco Internet Survey” (JASTIS) was carried out since 2015 to the present. This was a longitudinal internet cohort study of the use of HTPs, electronic cigarettes, and conventional tobacco products among the people of Japan. A research firm known at the time as Rakuten Research (now Rakuten Insight Co. Ltd.) randomly chose recipients from its client base of 2.5 million users and survey forms were sent directly to the clients. The first survey was conducted in January and February 2015 and was closed when 9000 men and women from all over Japan aged 15–69 (as of January 2015) had responded. Forms with apparent contradictions or inaccuracies were excluded, with the result that 8240 valid responses were surveyed. The same respondents were surveyed again annually from 2016 onward. Further details of the JASTIS study were described in a study profile paper [1]. To gauge the degree of usage of new tobacco products, the survey respondents were asked the following questions about each product: “In the past 30 days, have you smoked or used any of these tobacco products?” There were two choices of response: “I did not smoke or use them” and “I did smoke or use them.” Typically, when tobacco use is surveyed, an active smoker is often defined as a person who has smoked in the past 30 days, and a person who has not smoked for 30 days is often defined as having quit smoking. In terms of the percentage of people who had used in the past 30 days or currently use HTPs, in 2015 only 0.3% of all respondents had used IQOS but by 2017 that percentage had jumped to 3.6% (Fig. 3.3). This is a tenfold increase in just 2 (%) 4.0 E-cigarette

3.5

Ploom

3.0 IQOS

2.5 glo

2.0 1.5 1.0 0.5 0.0

2015

2016

Fig. 3.3  Trends in new tobacco product usage by Japanese adults

2017

3.2 New Tobacco Product Use in Japan: The JASTIS Study

21

years! The number of PloomTECH users also increased gradually, but compared to all other new tobacco products, IQOS was way ahead. In 2017, when the age of the survey respondents ranged from 17 to 71, 3.6% of the Japanese population were using IQOS. There are 86 million people in that age group, meaning that about three million people were using IQOS in 2017. Obviously, from this survey alone, we cannot know with certainty the entire picture of IQOS usage in Japan, but the data are almost perfectly in line with surveys from other research firms and with tobacco industry sales results. HTP use in Japan increased from 0.3% in 2015 to 8.0% in 2018 and 11.3% in 2019 (Table 3.2) [2]. In 2019, HTP use prevalence was over 30% among current smokers with or without intention to quit (30.8% and 43.2%, respectively). HTP use prevalence was more than 10% higher among men and participants in their 20s and 30s than other categories. Of those who currently smoked with or without intention to quit in 2015, more than 30% were smoking a new tobacco product in 2019: 30.8% and 43.2%, respectively. 3.7% of those who had quit conventional cigarettes in 2015 were using new tobacco products in 2019. A previous study examining HTP use in 2015–2017 [3] showed that more than half of the people who used new tobacco products also smoked conventional paper-­rolled cigarettes. In other words, they had not been able to quit smoking cigarettes. Table 3.2  Adjusted prevalence of current heated tobacco (HTP) use (use in previous 30 days) from 2015 to 2019 in Japan Characteristics at 2015 baseline Total Gender Men Women Age (years) 15–19 20–29 30–39 40–49 50–59 60–69 Cigarette smoking status Never smoker Former smoker Smoker with intention to quit Smoker without intention to quit

Adjusted percentage (95% confidence interval) of HTP usea 2018 2019 8.0 (6.5–9.8) 11.3 (9.3–13.6) 12.3 (9.7–15.5) 3.9 (2.7–5.7)

17.2 (14.0–21.1) 5.6 (3.8–8.2)

7.4 (2.7–18.7) 14.1 (9.1–20.8) 9.0 (5.9–12.5) 8.5 (5.7–12.5) 6.8 (4.5–10.2) 2.0 (0.9–4.6)

4.8 (1.7–12.4) 17.0 (11.3–24.7) 15.2 (10.4–21.6) 12.5 (8.8–17.5) 9.1 (6.0–13.7) 3.3 (1.8–6.0)

2.7 (1.8–4.2) 4.0 (2.2–7.2) 22.0 (11.4–38.3) 27.5 (21.4–34.6)

2.7 (1.7–4.2) 3.7 (1.8–7.3) 30.8 (16.0–51.0) 43.2 (35.7–51.0)

Adjusted for “being a respondent in an Internet survey” using a nationally representative sample in Japan. NC not counted

a

22

3  The JASTIS Project: Product Use Status in Japan

Table 3.3  Adjusted prevalence of current heated tobacco (HTP) use in previous 30 days by product types from 2015 to 2019 in Japan

Total IQOS Ploom/PloomTech Glo

Adjusted percentage (95% confidence interval) of HTP usea 2018 2019 8.0 (6.5–9.8) 11.3 (9.3–13.6) 6.3 (4.9–8.1) 5.8 (4.4–7.6) 2.5 (1.7–3.7) 6.1 (4.7–7.8) 2.9 (2.1–4.0) 3.6 (2.6–5.0)

Ploom S, PloomTech + are counted as Ploom in 2019 Adjusted for “being a respondent in an Internet survey” using a nationally representative sample in Japan

a

According to product type, the most recent 2019 HTP use prevalence (95% confidence interval) in Japan was estimated as follows: 5.8 (4.4–7.6) % for IQOS, 6.1 (4.7–7.8) % for PloomTECH, and 3.6 (2.6–5.0) % for glo (Table 3.3).

3.3

Why Are New Tobacco Products So Popular?

In the JASTIS 2017 Internet survey, respondents were asked if they had seen the “Latest Comedian Tobacco News” episode of “Ame-Talk,” and if they had then begun to use IQOS. 10% of those who had begun to use IQOS had seen the show, compared to only 3% of those who had not. While it is true that more people who had seen “Ame-Talk” later became IQOS users than those who had not, we cannot be sure the program is actually what influenced them to use IQOS. I therefore conducted a multivariable logistic regression analysis taking related factors into account to explore what sort of person became an IQOS user. The results of that analysis are shown in Table. 3.4. For women, the odds were 0.28, which means that women were 0.28 times as likely to use IQOS as men. Odds of greater than 1 mean an individual is more likely to use; odds of less than 1 mean an individual is less likely to use. Women were less than 1/3 as likely to use IQOS as men. Because the 95% confidence interval odds ratio does not exceed 1, this is a statistically significant difference. The group which used IQOS most were those who wanted to quit smoking. At 18.5, this was far and away the highest odds ratio in the survey. Smokers who did not want to quit had an odds ratio of 11.4, but among all smokers, even more of those who wanted to quit started IQOS. Furthermore, the odds ratio of people who had seen the particular episode of “Ame-Talk” was 3.66 (1.65–8.08). People who had seen the program were three times more likely to use IQOS than those who had not seen it. The powerful impact of “Ame-Talk” was proven by this Internet survey. Next, we surveyed the reasons why people began to use HTPs, and the percentage of respondents for each reason. HTP users were asked to choose the reason why

3.3 Why Are New Tobacco Products So Popular?

23

Table 3.4  Characteristics by percentage of IQOS users Characteristic (data as of 2015 survey) Multivariate adjusted odds (95% confidence)a Gender  Male 1 (standard)  Female 0.28 (0.10–0.77) Age bracket  15–19 1 (standard)  20–29 2.76 (0.76–10.06)  30–39 1.58 (0.32–7.91)  40–49 1.20 (0.29–4.99)  50–59 1.36 (0.24–7.66)  60–69 0.00 (0.00–0.05) Smoking experience   Never smoked 1 (standard)   Smoked but quit 1.02 (0.34–3.03)   Want to quit smoking 18.5 (3.37–102.0)   Don’t want to quit smoking 11.4 (3.98–32.8) Smoking at workplace   Not prohibited (smoking room or smoking 1 (standard) area provided)   Smoke-free building 1.76 (0.63–4.91)   Don’t work/don’t know 1.54 (0.46–5.19) Use of heated tobacco products or e-cigarettes   Have not used and do not plan to use 1 (standard)   Have not used but would like to try 3.58 (1.26–10.2) Equivalent household income   1st quartile (lowest) 1 (standard)   2nd quartile 0.48 (0.12–1.85)   3rd quartile 1.69 (0.64–4.41)   4th quartile (highest) 1.72 (0.63–4.70)   Don’t know/won’t say 1.36 (0.38–4.89) Own a home?  No 1 (standard)  Yes 0.60 (0.27–1.33) Education   Middle/high school 1 (standard)   University/vocational school or other 1.13 (0.43–2.95) Marriage  Married 1 (standard)  Unmarried 0.88 (0.38–2.07)  Divorced/widowed 0.58 (0.08–3.99) Alcohol use   Don’t drink 1 (standard)   Drank formerly 0.50 (0.11–2.35)  Drink 0.34 (0.13–0.88) (continued)

24

3  The JASTIS Project: Product Use Status in Japan

Table 3.4 continued Characteristic (data as of 2015 survey) Multivariate adjusted odds (95% confidence)a Health self-evaluation  Good 1 (standard)   Not good 1.95 (0.65–5.88) Poverty level of domicile   1st quartile (wealthiest) 1 (standard)   2nd quartile 3.76 (1.31–10.8)   3rd quartile 1.32 (0.39–4.42)   4th quartile (least wealthy) 3.41 (1.17–9.94) Seen “Ame-Talk”?b  No 1 (standard)  Yes 3.66 (1.65–8.08) Frequency of seeing tobacco advertisements   Never seen, rarely see, occasionally see 1 (standard)   See often, see very often 3.03 (1.00–9.17) a Table displays the result of all items after multivariate adjustment b Refers to the episode aired in 2016 “Latest Celebrity Tobacco News” Source: T Tabuchi, S Gallus, T Shinozaki et al, Tob Control 2018; 27: e25–e33

they decided to use HTPs from (1) to (9) on the grid in Table 3.5. For each reason the possible responses were (a) “applies,” (b) “applies somewhat,” (c) “does not apply much,” or (d) “does not apply.” (a) or (b) responses indicated reasons for taking up HTP use, while c) and d) responses were not regarded as reasons for taking up HTP use. Of 680 respondents to the JASTIS 2018 survey who used HTPs, most (60.6% or 412 people) cited (4), “Because I believe they’re less harmful than other tobacco products” as their primary reason for starting. The next most common reason was “To avoid bothering others with my cigarette smoke,” followed by “Because my friends or acquaintances use (used) them.” In the 2018 survey, we asked 267 e-cigarette users their reasons for using e-­cigarettes in the same way. The results are shown in Table 3.6. Similar to the case of HTPs, the most common reason was “Because I believe they’re less harmful than other tobacco products” followed by “To avoid bothering others with my cigarette smoke.” It became clear that many people choose HTPs or e-cigarettes out of concern for the harmful effects of tobacco on themselves and others. At the same time, about 30% of users of both HTPs and e-cigarettes cited “Because I can use them in places where I can’t smoke cigarettes.” The reasons people give for using new tobacco products constitute extremely important information and are closely related to the discussion of how each of us can deal with new tobacco products as individuals.

3.3 Why Are New Tobacco Products So Popular?

25

Table 3.5  Reasons for using HTPs Respondents

%

(1) Because my family or relatives use (used) them

168

24.7

(2) Because my friends or acquaintances use (used) them

375

55.2

(3) As a means of communication with other users

117

17.2

(4) Because I believe they’re less harmful than other tobacco products

412

60.6

(5) I like the design and functionality of HTPs

198

29.1

(6) To help me quit smoking

154

22.7

(7) To avoid bothering others with my cigarette smoke

400

58.8

(8) Because I can use them in places where I can’t smoke paper-rolled cigarettes

207

30.4

(9) To reduce the number of cigarettes I smoke

253

37.2

From 2018 survey of 680 people who use HTPs Source: JASTIS study 2018

Table 3.6  Reasons for using e-cigarettes Respondents

%

(1) Because my family or relatives use (used) them

73

27.3

(2) Because my friends or acquaintances use (used) them

107

40.1 26.6

(3) As a means of communication with other users

71

(4) Because I believe they’re less harmful than other tobacco products

144

53.9

(5) I was interested in the fruit flavor and other flavorings

97

36.3

(6) To increase my vitamin intake

58

21.7

(7) I like the design or functionality of e-cigarettes

89

33.3

(8) To help me quit smoking

103

38.6

(9) To avoid bothering others with my cigarette smoke

128

47.9

(10) Because I can use them in places where I can’t smoke paper-rolled cigarettes

98

36.7

(11) To reduce the number of cigarettes I smoke

117

43.8

From 2018 survey of 267 people who use e-cigarettes Source: JASTIS study 2018

3.4

Japan: The Global Test Site for IQOS

The HTP IQOS was first offered for sale in Japan and Italy in 2014, and by 2020 was being sold in about 40 countries around the world (Fig. 3.4). With the exception of Japan, IQOS was sold only in a limited number of cities. In April 2016, Japan

26

3  The JASTIS Project: Product Use Status in Japan

became the first country in the world in which IQOS was offered for sale on a nationwide basis. Between April and October of 2016, the market share of IQOS branded sticks grew from 1.6% to 4.9% in Japan. (Fig. 3.5) According to the British market research firm Euromonitor International, the size of the global market for HTPs and e-cigarettes in 2016 was $12 billion. According to the same data, Japan’s share of the world market for IQOS was 96%. It is in fact no exaggeration to say that almost all the IQOS on earth was being consumed by the Japanese. Without even the slightest understanding of what harmful effects IQOS could have, Japan had become the testing site for the entire world.

Russia Sweden

Canada

EU Region* Ukraine Moldova

United States Mexico

Dominican Republic

Curacao

South Korea

Cyprus Serbia

Armenia

Palestine Israel

Guatemala South Africa

Colombia

Kazakhstan

United Arab Emirates

Japan Malaysia

La Reunion New Zealand

Markets where IQOS is availabel

* EU Region: Albania, Andorra, Austria, Belarus,Bosnia, Bulgaria, Canary Islands, Croatia, Cyprus, Czech Republic, Denmark, France, Germany, Greece, Hungry, Italy, Latvia, Lithuania, Monaco, Netherlands, Poland, Romania, Slovak Republic, Slovakia, Slovenia, Spain, Switzerland, United Kingdom.

Fig. 3.4  Countries in which IQOS is sold

iQOS: Strong HeatSticks Share Growth in Japan 4.9

2016 Weekly Market Share (%) 4.8

1.6 Mid-April

! : Percentage of total Tobacco Market held by IQOS brand sticks (Heat Stick) June

September

October

Note: Reduced-Risk Product (”RRPs”) is the company uses to refer to products with the reduce individual risk population and harm in comparision to smoking cigarettes. Market share represnts total sales volume for HeatSticksas a percentage of the total estimated sales volume for cigarettes and HeatSticks. Pack designs are for illustrative purposes only Source: PMI Financials or estimates, and Tobacco Institude of Japan

Fig. 3.5  Growth of market share of IQOS sticks in Japan

References

27

References 1. Tabuchi T, Shinozaki T, Kunugita N, et al. Study profile: the Japan society and new tobacco internet survey (JASTIS): a longitudinal internet cohort study of heat-not-burn tobacco products, electronic cigarettes, and conventional tobacco products in Japan. J Epidemiol. 2019;29(11):444–50. 2. Hori A, Tabuchi T, Kunugita N. Rapid increase in heated tobacco product (HTP) use from 2015 to 2019: from the Japan 'Society and new Tobacco' internet survey (JASTIS). Tob Control. 2020; https://doi.org/10.1136/tobaccocontrol-2020-055652. 3. Tabuchi T, Gallus S, Shinozaki T, et al. Heat-not-burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol. Tob Control. 2018;27(e1):e25–33.

4

Marketing Strategy for Tobacco Products in Japan

4.1

The Japanese Love a New Gadget

In October 2016, 96% of the world’s IQOS were being consumed in Japan which had become their global test site. Why did this happen in Japan? The head of the marketing department at JT made the comment below to explain why HTPs had taken off so dramatically in Japan. “In addition to the fact that legal restrictions have hindered the spread of e-cigarettes, the Japanese people aspire to be considerate to those around them, and they have a love of gadgets” (article in the Bloomberg July 3, 2017). There were six conditions which had to be fulfilled for HTPs to catch on. ① There must be a lot of cigarette smokers; ② they must acquire a favorable impression of HTPs; ③ they must want to try HTPs; ④ they must be able to pay for the HTP devices; ⑤ there must be a distribution channel; and ⑥ there must be a lack of strong competing products. Japan filled all six conditions perfectly. ① There are over 20 million cigarette smokers in Japan; ② the Japanese love gadgets, and they do not have an unfavorable impression of tobacco companies1; ③ the Japanese have a tendency to anticipate what those around are feeling, and in the years leading up to the launch of HTPs, the trend for smokers to be more considerate of those around them was emerging, as exemplified by the passing of ordinances to prevent secondhand smoking in Kanagawa and Hyogo prefectures. HTPs entered the scene as a means of being more considerate to others; ④ not only was Japan fully established as one of the world’s highest income countries, but also, unlike other countries, smokers are not heavily concentrated among the poor, and were seen as more than capable of paying for HTP devices; ⑤ in Japan, every convenience store throughout the country is 1  In 2017 our research group conducted an internet survey (the JASTIS study) and found that many people have a favorable impression of the activities of Japan Tobacco (a report in Japanese).

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 T. Tabuchi, Science and Practice for Heated Tobacco Products, https://doi.org/10.1007/978-981-33-4504-1_4

29

30

4  Marketing Strategy for Tobacco Products in Japan

allowed to sell HTPs; and ⑥ while e-cigarette products fueled with nicotine were rapidly gaining market share in countries such as the USA and the UK and were seen as strong competitors for heated tobacco products, in Japan e-cigarettes containing nicotine are illegal. With all these conditions fulfilled, the tobacco companies were able to induce Japanese smokers to try HTPs, and they succeeded in large measure. To enable the spread of HTP use, there were two further conditions which had to be fulfilled. ⑦ The tobacco companies had to acquire approval from the authorities to market HTPs, and ⑧ the tobacco companies had to conduct advertising, marketing, and promotion campaigns. In the USA, not all of these conditions had been fulfilled, and HTPs were not put on sale until April 20192 [1]. The tobacco companies decided that Japan was the place where all eight conditions could be met. In Japan, tobacco is governed by the Tobacco Business Law of 1984, the objective of which is “to promote the sound development of the Japanese tobacco industry, thereby securing the stability of fiscal revenue.”3 Japan as a country is extremely lenient toward tobacco use and one often-cited reason for this is JT, now privatized but formerly known as the Japan Tobacco and Salt Public Corporation. The major shareholder of JT is the government of Japan, under the name of the Finance Minister for reasons pertaining to securities law, with a shareholding of 33.5%, or more than one-third. JT has long been a provider of retirement posts for officials of the Finance Ministry, and the connection between the Finance Ministry and JT is known to be both strong and deep [2]. In Japan, tobacco products are regulated by the Ministry of Finance under the Tobacco Business Law. It was under this same legal body that HTPs were so easily approved for sale in Japan (as discussed above in condition ⑦ “the tobacco companies had to acquire approval from the authorities”). Whereas in many countries, print and television advertising of tobacco products is prohibited, in Japan it is not prohibited, merely governed by the industry’s self-­ regulatory guidelines. While the tobacco companies have autonomously banned themselves from advertising tobacco products, there are many exceptions to the rule. For example, advertisements for JT itself as a company, advertisements to promote “smoking manners,” and advertisements to discourage youth smoking are all permitted. The self-regulatory guidelines which cover the use of advertising to target young people are porous and loose. Even publications widely read by minors contain advertisements which should only be seen by adults. With the advent of new tobacco products, interpretation of these industry self-­ regulatory guidelines came to be more advantageous to the tobacco companies than ever. JT ran television commercials to direct people’s thoughts to new tobacco products (Fig. 1.2). BAT ran commercials that included keywords which directed the reader to the promotional website for glo when typed into an Internet search engine.  HTPs approved for sale by the US Food and Drug Administration since April 2019.  Clause 1 of the Tobacco Business Law reads, “Following the abolition in Japan of the government monopoly system for tobacco, and in consideration of the ranking among fiscal revenue sources of tax revenue on manufactured tobacco and other factors, the objective of this law is to promote the sound development of Japan’s tobacco industry, by implementing appropriate measures to support businesses involved in the domestic production of tobacco leaves as an ingredient of manufactured tobacco products, as well as the purchase, manufacture, and sale of tobacco products, thus securing a stable source of fiscal revenue and contributing to the healthy development of the national economy.”

2 3

4.2 The Japanese Public: Manipulated with Imagery and Led to Misunderstanding

31

Such commercials are essentially product advertisements, which many believe should be made illegal in Japan. The tobacco companies ran advertisements for HTPs even in magazines read by young readers, fulfilling condition ⑧: that the tobacco companies had to conduct advertising, marketing, and promotion campaigns. So long as they could advertise, the launch was child’s play for the tobacco companies—after all, in half a century of hard selling their product to an unsuspecting public, they had accumulated a tremendous store of strategic marketing know-how. As a result of the tobacco companies’ concentrated campaign to promote HTPs as something new and fashionable, the use of the products spread—literally like wildfire. In 2020, the product name for IQOS was written with four capital Roman letters. However, at the time of the launch, the spelling was “iQOS,” similar to the spelling of iPhone or iPad, and even today the tobacco capsules known as “heat sticks” are still labeled discreetly as “iQOS.” Research by the American anti-tobacco non-profit organization Truth Initiative suggests that the use of the small “i” was a deliberate marketing ploy to cash in on the image of the iPhone and the Apple Store, and that many in the target audience were indeed influenced by this ploy.

4.2

 he Japanese Public: Manipulated with Imagery T and Led to Misunderstanding

It is widely believed that the tobacco companies’ marketing strategy had an immense influence on the success of HTPs in Japan. All the companies in the tobacco industry use a similar strategy to claim the merits of their product. Figure 4.1 shows the packages of three HTPs making very similar claims. IQOS claims to have “reduced the nine highest priority harmful substances identified by international health organizations by about 90%”; PloomTECH claims “99% less substances of concern to health,” and glo claims “90% less harmful substances.”4 People were manipulated by this concerted marketing effort. You can almost hear tobacco companies making the excuse: “we never claimed you won’t get sick from them, all we said is that they have reduced harmful substances!” This is certainly true—the pamphlets simply say that harmful substances are reduced compared to conventional cigarettes—they do not claim the products pose less harm to health. However, many people in the world will read these claims and come away with the mistaken conclusion that “these are healthier” or that these products will hardly ever make anyone sick. It may have occurred even to the marketing staff of the tobacco companies that many people would misunderstand these claims. This is probably why they added health warnings such as those seen in Fig. 4.2, with statements such as “the claim ‘quantity of harmful substances reduced by about 90%’ does not mean that this product poses fewer risks to health than other tobacco products.”5 All the HTPs carry a similar warning. But unless the smoker reads the pamphlets extremely carefully, he or she will never even notice these 4  glo has been criticized for using language in its pamphlet to mislead consumers into thinking that the product has been endorsed by the WHO. Author’s underlines: “greatly reduced compared to paper-rolled cigarettes the nine harmful substances which the World Health Organization (WHO) has recommended reducing”. 5  “Other tobacco products” here refers to conventional cigarettes.

32

4  Marketing Strategy for Tobacco Products in Japan

Fig. 4.1  Heated tobacco pamphlets claiming reduced harmful substances

messages. The warning for glo in particular is quite problematic. This excerpt “‘much less harmful’ … does not mean that this product poses fewer risks to health than other tobacco products” is in itself a contradiction in terms. Do they think that if you add a warning, you can just write whatever you want?

Column: There Is No “Light” Tobacco

The manipulation of consumers with imagery to lead them to a mistaken understanding is not a new technique for the tobacco companies. For decades tobacco companies have been promoting cigarettes as “light” or “mild” with the intention of misleading consumers into thinking they are somehow less harmful to health. In Japan, cigarettes with 0.3 mg of nicotine are still being sold as “light” or “extra light,” but the amount of other harmful substances hardly differs from cigarettes containing 1.2 mg of nicotine. They are both still cigarettes, and since both of them have air holes in their filters, the only difference between them is that one of them tests in a laboratory as having less nicotine. The smoker covers the air holes with his fingers or lips when he inhales, with the result that almost any cigarette delivers about the same quantity of harmful substances. The cigarettes which tobacco companies sell as “light” and the standard cigarettes are both equally harmful. The tobacco companies have succeeded in creating the image and the misunderstanding that “light” cigarettes are somehow better for health.

4.3 The Risks of Tobacco the Media Would Not Report, and Why Not Fig. 4.2 Health warnings on heated tobacco pamphlets

IQOS

33

The chart and the claim “quantity of harmful substances reduced by about 90%” do not mean that this product poses fewer risks to health than other tobacco products.

PloomTECH

The statements describing PloomTECH as “low, clean, clear, smooth, sweet, light, gentle, contains almost no substances which pose health concerns, 99% less concerning substances, concerning substances cut by 99%” does not mean that this product poses fewer risks to health than other tobacco products.

glo

The statements describing glo as “no ashes”, “much less harmful”, ”satisfying flavor”, ”no cigarette smoke”, ” 90% less harmful substances”, “much less of nine harmful substances than cigaretts”, do not mean that this product poses fewer risks to health than other tobocco products.

4.3

 he Risks of Tobacco the Media Would Not Report, T and Why Not

To an astonishing degree, the Japanese media do not report on the risks of tobacco. Sadly, the societal problem of tobacco is hardly covered by television, radio, or the major print media. The problem with medical coverage is the need for scientific evidence. The Japanese reader may have seen television shows on how to prevent cancer, they may have seen shows which said eating vegetables could help reduce the risk of colon cancer, or that the lycopene in tomato has anti-carcinogenic properties. Unfortunately, these messages are not based on scientific priorities. There is indeed research which shows that people who eat plenty of fruits and vegetables will, on the whole, have fewer occurrences of stomach and colon cancer than those who do not, but the correlations are still within the realm of “possible correlation.”6

6  I am not denigrating the value of eating vegetables as a cancer preventive factor. I am merely stating that from a priority standpoint, it is far more important to quit smoking for cancer prevention.

34

4  Marketing Strategy for Tobacco Products in Japan

Table 4.1  Cancer preventive factors Stomach Definite correlation Near definite correlation Possible correlation Insufficient data

Colon

Liver

Lung

Breast

Fruit

Soybeans, isoflavones

Vegetables

Vegetables, fruit

Coffee Vegetables, fruit, green tea (in females) Green tea (in males)

Calcium, fiber, unsaturated fatty acids from fish Vegetables, fruit

Vegetables, fruit

Table 4.2  Cancer risk factors Stomach Smoking, Heliocobacter pylori

Colon Heavy drinking

Near definite correlation

Salt intake

Possible correlation

Grains

Smoking, obesity, sedentary lifestyle Preserved meats

Insufficient data

Drinking, obesity

Definite correlation

Liver Smoking, heavy drinking, hepatitis virus infection Obesity, diabetes

Lung Smoking

Breast Post-­ menopausal obesity

Passive smoking, asbestos

Lack of exercise, obesity, drinking

Smoking, lack of exercise, no breastfeeding, pre-­ menopausal obesity Heavy drinking

The National Cancer Center of Japan has categorized preventive factors for cancer based on scientific proofs (Table 4.1, a full explanation will follow). Table 4.2 shows cancer risk factors: in other words, factors which elevate the risks of developing cancer. Taking stomach cancer as an example, there is scientific evidence that both smoking and the infection of Helicobacter pylori have a definite association with stomach cancer. “Definite” means that the scientific evidence is adequate. Taking too much salt in the diet has a near definite association, while taking too much grain in the diet is possibly associated with stomach cancer. Finally, there is insufficient data to determine the association between either drinking or obesity and stomach cancer. This table covers the most prevalent five types of cancer in Japan. Cancers of the stomach, colon, liver, lung, and breast comprise almost 80% of the cancer cases in Japan. Looking at the table across all these types of cancer, it is very clear that there is one risk factor which they all have in common. In particular, look at the “definite” and “near definite” row, smoking figures as a risk factor in four of the sites.

4.4 The Tobacco Companies’ Outrageous Insult to Smokers

35

It should be clear from these data that the most important way to avoid cancer is to not smoke. That is the conclusion from the total current scientific evidence. On the other hand, Table 4.1 lists things that we can do to prevent cancer. Let us examine the two tables: as they are read in the same way, they should be very easy to compare. There are no “definite” and almost no “near definite” foods known to prevent cancer. We know that those who drink coffee will almost definitely be less susceptible to liver cancer than those who do not. This is the only preventive factor with any degree of definite correlation. However, I would not attempt to force people who do not like coffee to drink it based merely on this data. Even if we could be certain that coffee would prevent cancer, this applies only to liver cancer. What is more, coffee contains caffeine and other ingredients which pose their own health risks. Instead, if I were to suggest ways to prevent cancer, I would refer to Table 4.2 and encourage patients to eliminate definitely correlated risk factors, such as heavy drinking or hepatitis virus infection. This would be advice with a definite association. We are not even sure if consuming a lot of specific foods such as fruits or vegetables can actually help prevent cancer—there is insufficient data to say. It is unfortunate that instead of focusing on scientific evidence, the media prefer to present stories in ways that will appeal to their audiences, and so end up broadcasting catchy soundbites such as “you can prevent cancer by eating vegetables.” Worse than the soundbite coverage, however, is the back story of why the Japanese media find it difficult to devote coverage to the tobacco problem. JT continuously plies the media with advertising revenue. Looking at the TV programs that it sponsors (Fig. 4.3), it becomes clear that JT is a major advertiser on TBS, TV Asahi, TV Tokyo, Fuji TV, and Nippon TV. It has been suggested that the commercials with which JT built the image of new tobacco products (Fig. 1.2) were illegal. This is because a commercial which aims to make tobacco or new tobacco products look cool is tantamount to a commercial for the product itself—which is a violation of the FCTC rules. Tobacco and cigarettes already have an “uncool” image. In a survey of university students in Japan, 89% of respondents of both sexes said “smoking cigarettes gives a negative impression to the opposite sex.” 69% of male respondents and 61% of female respondents said they “could not marry a smoker.” The tobacco companies, however, will do their damnedest to use new tobacco products as a way to overturn the negative “uncool” image which tobacco has acquired in Japan.

4.4

The Tobacco Companies’ Outrageous Insult to Smokers

With their advertisements for HTPs, the tobacco industry sent a message to smokers on New Year January 1, 2017. PMI took out a huge two-page spread in the Japanese national newspapers. One section of the advertisement used similar wording to the warning in the nationally distributed pamphlets advertising IQOS (Fig. 4.4): “We are not saying that IQOS is harmless.” “The best way to reduce the risks of smoking is to stop smoking both paper-rolled cigarettes and IQOS.” The tobacco companies had essentially laughed at their own customers, the people who smoke their products. “How stupid are you? We’ve even told you tobacco has risks and you’ll still smoke our product!”—it is really rude to the smokers.

36

4  Marketing Strategy for Tobacco Products in Japan Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday TV TOKYO serie Reality Show 18:30~19:54

18:00

TV Asahi series Reality Show 18:30~19:58

19:00

20:00

21:00

TV Asahi series News STATION 21:54~23:15

22:00

TBS series News STATION 22:00~22:57

Fuji-TV series Special oneoff program 21:00~23:10

TV TOKYO series Doumentary flim 22:00~22:54

Nippon-TV series Reality Show 21:00~21:54

Nippon-TV series news zero 23:00 23:59

23:00

TBS series NEWS23 23:00~23:56 Fuji-TV series Live News a 23:40~24:25

24:00

TBS series NEWS23 23:30~24:15 

Fuji-TV series Live News a 23:40~24:25 



(Provided every other)

Fig. 4.3  Television programs sponsored by Japan Tobacco

(1) This is not to say that IQOS is without risk (2) The best way to reduce health risks related to tobacco is to stop using both paper-rolled cigarettes and IQOS

Fig. 4.4  Health risks as described in IQOS pamphlet

4.4 The Tobacco Companies’ Outrageous Insult to Smokers

37

Why did PMI deliberately put this message out at New Year? This may seem like a somewhat pernickety question, but in Japan, New Year’s is a long and quiet holiday spent at home with family. It is also a time when people make resolutions, for example, to quit smoking. It would be interesting to know how many people abandoned their New Year’s resolutions to quit smoking in 2017, and switched to HTPs instead because of this advertising campaign. In the same way, tobacco companies launched an advertising campaign in 2020 when people were forced to stay at home due to the new coronavirus infection (Fig. 4.5). The poster shown in Fig. 4.6 is displayed in IQOS Stores. I was astonished to read the six “Fundamental Policies for the Switch to IQOS” that it lists. It is easy enough to understand the logic of “policies” one through three, which make the case for switching from conventional cigarettes to IQOS.  However, there are serious logic problems starting with “policy” number four. a

b

Fig. 4.5  Advertisements by tobacco companies. (a) (Internet ad for PloomTECH by Japan Tobacco); (b) (newspaper ad for IQOS by PMI), 2020. Both advertisements appeal to smokers “if you stay at home, please use HTPs!”

38

4  Marketing Strategy for Tobacco Products in Japan IQOS This changes everything IQOS is a scientifically proven smokeless product, which can be said to be a far better choice than paper-rolled cigarettes for every adult smoker. We aim for the day when every smoker has switched from paper-rolled cigarettes to smokeless products such as IQOS. Our Fundamental Policies for the Switch to IQOS 1. 2. 3. 4. 5. 6.

IQOS is a product for adult smokers who want to keep enjoying tobacco into the future We will not push IQOS to non-smokers or ex-smokers We aim to help all smokers who wish to continue smoking into the future switch to smokeless products like IQOS IQOS is not a method for quitting smoking. The best way to reduce the health risks related to tobacco is to stop smoking both paper-rolled cigarettes and IQOS. For adult smokers to experience the full benefit of IQOS, it is necessary for them completely stop smoking paper-rolled cigarettes and switch completely to IQOS IQOS is not without risk, and it is not a safe alternative to paper-rolled cigarettes. However, it can be said that IQOS is a far better choice than paper-rolled cigarettes. Source: seen by the author in an IQOS Store, November 2018

Fig. 4.6  Marketing copy displayed in IQOS stores

While “policy” four states clearly that the best way to reduce the risks of tobacco is to completely stop smoking both cigarettes and IQOS, “policy” five suggests that smokers must switch completely to IQOS to experience the full benefits! “Policy” six is also rife with contradiction. While saying that IQOS is not without risks, it claims that it is far better than cigarettes. In fact, the entire poster is all wrong from the start. While it claims that IQOS is a “scientifically proven smokeless product,” it has never been scientifically or academically proven that IQOS emits no smoke. However, the issue is not really whether IQOS emits smoke or not. As we saw in Chap. 3, research done by independent research institutes as well as that done by tobacco companies proves that HTPs do indeed release harmful chemical substances into the atmosphere. By arguing that IQOS is smokeless (i.e., what it does not emit), Philip Morris are able to avoid discussing what it does emit. The fact is that these products emit harmful chemical substances into the air, and if there is another person nearby, that person’s body will absorb those substances.

References 1. US Food and Drug Administration: FDA permits sale of IQOS Tobacco Heating System through premarket tobacco product application pathway. 2019. https://www.fda.gov/newsevents/press-announcements/fda-permits-sale-iqos-tobacco-heating-system-through-premarket-tobacco-product-application-pathway. Accessed June 14, 2020. 2. Matsuzawa S. JT, The Ministry of Finance, and tobacco interests: the mystery of Japan’s last huge vested interest: Wani Press; 2013.

5

Substances in Novel Tobacco Products

5.1

 he Harmful Substances in Tobacco Smoke: Basic T Information from Public Health Perspective

What sort of harmful substances are contained in cigarette smoke? Before moving to new tobacco products, let us discuss conventional cigarettes first. This is important background knowledge to understand, so we do not find ourselves deceived by the available information on new tobacco products. If we use specialized equipment to analyze tobacco smoke, we will find that it contains over 5000 chemical compounds. Of those, 70 are known to have carcinogenic properties. Many others are known to damage the respiratory and cardiovascular systems of humans, and some are known to retard both the growth of children and the development of the brain. The most representative harmful substances in conventional cigarette smoke are nicotine, carbon monoxide, benzene, and formaldehyde. Nicotine is the dependence-inducing substance which makes it hard to quit smoking. Nicotine in the bloodstream reaches peak density within about 5 min of smoking, and its density drops quickly after inhalation stops (nicotine has a half-life in the body of 1–2 h). Smokers become dependent on nicotine, and they must smoke intermittently to maintain the level of nicotine in the bloodstream. Nicotine is also known to retard the development of the brain. Carbon monoxide (CO) bonds with the hemoglobin in the smoker’s red blood cells, to form carboxyhemoglobin. Oxygen also bonds with hemoglobin and is transported throughout the body, but because CO bonds with hemoglobin far more readily than with oxygen, if CO is present the bonding of oxygen is obstructed, causing anoxia (oxygen does not reach body tissue). The shortness of breath experienced by many smokers is related to this reaction. CO can also be a causative factor in the development of ischemic heart disease.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2021 T. Tabuchi, Science and Practice for Heated Tobacco Products, https://doi.org/10.1007/978-981-33-4504-1_5

39

40

5  Substances in Novel Tobacco Products

Benzene has been cited by the International Agency for Research on Cancer (IARC) as a substance which has been adequately proven to be carcinogenic and is therefore on the agency’s watch list for carcinogens.1 Formaldehyde is also a carcinogen. A research paper was recently published, detailing cytological experiments which showed that of all the carcinogens in tobacco smoke, the aldehydes such as formaldehyde are among the most strongly indicated for carcinogenic impact [1]. Many other substances found in tobacco smoke cause harm to the body. I have outlined some of the damage caused and the routes of causality of each in Fig. 5.1. Some readers may say this is not news. It has been known for a long time that smoking is bad for health, and indeed, cigarette smoke contains carcinogens including formaldehyde and many others. Animal testing has proven that the major representative harmful substances in smoke are carcinogenic. But, in terms of all the different substances found in smoke, the fact is that there are many types of harmful substances about which we still know very little. While we have researched the cancer-causing properties of formaldehyde, there are many other potential carcinogens we have still not researched. There are many for which we have simply not yet conducted any research or experiments. What is more, even for substances like formaldehyde which have already been proven harmful, there is still much we do not know. The compound effect of these substances is an area which has still not been fully researched. In other words, while we know about the harm formaldehyde can cause in isolation, we still know very little about the harm it may cause in combination with other substances—and this includes combinations with not just one, but with two, three, or four other substances. There are so many potential permutations and variations that researching, experimenting, and clinically proving any causality is prohibitively complex. It should come as no surprise that we still have so much to learn about the harm these substances may cause in combination with one another. While some of the mechanisms are not fully understood, we know that smoking tobacco is linked to numerous health risks, including lung cancer, chronic obstructive pulmonary disease (COPD), heart attacks, diabetes, and many other diseases. This is what we know today. Conventional cigarettes contain many harmful substances, and the damage caused by tobacco is significant. What is important to note here is not what we do not understand about the mechanisms, but that there is plenty of adequate evidence which proves that smoking tobacco leads to these diseases and conditions. From the facts based on the premise smoking will make you sick, we must now make a logical shift toward policies and countermeasures of how to deal with tobacco. And this shift is equally important in dealing with new tobacco products. I have written the following supplementary column to reinforce the reader’s understanding of this logic. 1  When the IARC has determined that a substance has been adequately proven, it is classified in the IARC Monographs as “Group 1, Carcinogenic to Humans”.

5.1 The Harmful Substances in Tobacco Smoke: Basic Information from Public…

41

Inhalation of Tobacco Smoke

There are numerous harmful substances in tobacco smoke

• Over 5,000 harmful substances • 70 are carcinogenic • In addition, there are many substances which are harmful to the respiratory and circulatory system

The harmful substances damage the body through numerous mechanisms

• The effects of many of the harmful substances are understood to a degree • The compound effects of the interaction of the different are still almost completely

Cancer, chronic disorders, and many other forms of damage to health result (see illustration below) • There is sufficient evidence that tobacco smoke can cause cancer, ischemic heart disease, stroke, diabetes, chronic obstructive pulmonary disease, rheumatoid arthritis, erectile dysfunction, blindness and cataracts, Buerger's disease, and many other diseases and conditions • Of the many more diseases and conditions still to be sufficiently researched, it is believed that many will be eventually be proven to be triggered by tobacco smoke

Cancers

Chronic Diseases Stroke Blindness, cataracts, age-related macular degeneration* Congenital defects–maternal smoking: orofacial elefts*

Oropharynx

Periodontitis

Larynx

Aortic aneurysm, early abdominal aortic atheroscleros]s in young adults

Esophagus

Coronary heart disease Peumonia

Trachea, bronchus, and lung Acute myeloid leukemia Stomach Liver* Pancreas Kidney and ureter Cervix Bladder

Atherosclerotic peripheral vascuLar disease Chronic obstructive pulmonary disease, tuberculosis,* asthma, and other respiratory effects Diabetes* Reproductive effects in women (including reduced fertility) Hip fractures Ectopic pregnancy* Male sexual function-erectile dysfunction*

Colorectal*

Rheumatoid arthritis* Immune fuuction* Overall diminished health

Fig. 5.1  Tobacco smoke: harm caused and routes of causality (Source: US Surgeon General Report 2014)

42

5  Substances in Novel Tobacco Products

Column: The Trap of the “Mechanism”

There are numerous mechanisms by which harmful substances cause damage to the body. One of these complex mechanisms, how smoking tobacco can trigger various cardiovascular conditions, is diagrammed in Fig. 5.2. Each of the arrows in the diagram is based on the results of prior experimental study. What I wish to highlight here is not the complexity of the mechanisms, but an extremely important concept in preventive medicine, which is that it is not necessary to understand a complex mechanism to prevent disease. As an illustration of this concept, let us consider the story of Dr. John Snow and the pump handle. At the end of August 1854, there was an outbreak of cholera in the Soho area of London. In the first 3 days of the outbreak, 127 people died in the vicinity of one particular street, Broad Street. By September tenth over 500 people had died. Suspecting that contaminated water might be a cause of the problem, Dr. Snow set out to trace the water supply of the victims. He was helped by the parish priest, Reverend Henry Whitehead, who was familiar with the living conditions of the residents and together they realized that everyone who had contracted cholera had drunk water from a street pump in Broad Street. In other words, they proved that water from that pump was the “cause” of cholera. Even without fully understanding the mechanisms by which smoking harms health, we have a way to stop the harm of tobacco. It is no more complex than keeping tobacco away from people.

The handle was removed from the pump so that it could no longer be used, and as Dr. Snow had predicted, the number of cases and deaths dropped rapidly. They had no idea that the bacteria vibrio cholerae causes cholera, nor did they understand the actual mechanism of disease development, but even without this knowledge, they were able to prevent the spread of the disease. Now let us apply this logic to tobacco. We still do not know the precise mechanism by which smoking tobacco causes lung cancer, and indeed there are still people who deny that tobacco is harmful to health. However, it has been more than sufficiently proven that smoking tobacco causes lung cancer—one need merely track the probability of contracting lung cancer between groups of smokers and non-smokers and the relationship is clear. Had Dr. John Snow spent too much time trying to study the mechanism by which the people around Broad Street contracted cholera, he would have been unable to halt the spread of the disease. Even though vibrio cholera had not been discovered, and the mechanism of infection was not clearly understood, by removing the handle of the street pump he was able to prevent further infection. With this thorough introduction, I will now turn to a discussion of the chemical substances emitted by new tobacco products in the following section.

5.2 The Harmful Substances in HTP Aerosol

43

Bold lines indicate the likely mechanisms by which tobacco smoke causes atherothrombotic diseases, based on complex pathophysiology

Main Smoke Source

Secondary Smoke Source

Active Smoking

Passive Smoking

Particular State

Gaseous State

Tobacco smoke components deposited in lungs

Free Radicals from Tobacco Smoke

Is endogenous production free radicals activated?

Neutrophils, monocytes, platelets and T-cells are activated

Oxidative stress

Reduced NO production

Congealing

Reduced Vascular Fibrinogen Function

olysis

Increased cytokine

Activation of inflammation-related Genes

White cells & Platelets activated

Lipid Peraxidation

Adhesive & Inflammatory Molecules

Growth of Smooth Muscle

Other cardiovascular risk factors including genetic factors and insulin resistance

Induction and development of atherothrombotic disease

Fig. 5.2  Mechanism of how smoking causes circulatory disorders (Source: Tobacco smoking and health. A report from the review committee on the health effects of tobacco smoking. 2016. http:// www.mhlw.go.jp/stf/shingi2/0000135586.html)

5.2

The Harmful Substances in HTP Aerosol

What are the harmful substances emitted by HTPs, and how much is emitted? As a member of the WHO Tobacco Laboratory Network (TobLabNet), the National Institute of Public Health (NIPH) in Wako, Saitama Prefecture, Japan, carried out research to analyze the harmful substances emitted by various tobacco products.

1,3-Butadiene

1

acetaldehyde

2B

acrolein

3

benzene

1

Benzo[a]pyrene

1

dependence

Reproduction or development

cardiovascular system

respiratory organs

carcinogenic

FDA-list

WHO-9

5  Substances in Novel Tobacco Products

IRACgroup

44

carbon monoxide

formaldehyde

1

N-Nitrosonornicotine

1

4-(methylnitrosoamino) -1-(3-pyridyl)-1-butanone

1

nicotine * International Agency for Research on Cancer Risk Group (Source) Japanese Ministry of Health Labour & Welfare so-called Tobacco White Paper Simonavicius E, McNeill A, Shahab L, et al. Heat-not-burn tobacco products: a systematic literature review. Tob Control 2019;28(5):582-94.

Fig. 5.3  Harmful substances in HTPs and their risks

As part of this research, they developed a methodology to analyze the chemical substances emitted by new tobacco products. What sort of chemical substances should we analyze when we deal with tobacco? Clearly, it is the substances which can cause harm to the human body. For this reason, much of the research on substances in tobacco smoke focuses on only a very limited selection of substances which have already been established as harmful. For example, tobacco is known to contain at least 70 carcinogens alone. Figure 5.3 displays various representative harmful chemical substances which have been recommended for further investigation in relation to tobacco, by groups such as

5.2 The Harmful Substances in HTP Aerosol

45

the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO). The IARC has categorized chemical substances into IARC Groups according to their carcinogenic properties, based on scientific research collected from around the world. Group 1 is defined as “the agent is carcinogenic to humans,” based on research which demonstrates the carcinogenic properties conclusively. Group 2B is defined as “the agent is possibly carcinogenic to humans,” and Group 3 is defined as “the agent is not classifiable as to its carcinogenicity to humans.”2 The WHO-9 refers to nine harmful substances in tobacco smoke which the WHO nominated for reduction in 2008 [2]. This WHO-9 category does not contain “nicotine.” In 2012, the US Food and Drug Administration (FDA) announced a list of 93 harmful and potentially harmful constituents (HPHCs; the “HPHC list”) of tobacco smoke, and required that tobacco companies measure and report their quantities [3]. Almost all of the items on the HPHC list are known carcinogens. The HPHC list also includes substances which cause damage to the respiratory and circulatory systems, as well as substances which retard the development of fetuses in pregnant women and the development of the brain. All of these substances are contained in the smoke of conventional cigarettes. How does the HTP aerosol compare? One important information source is the findings of the research group at the NIPH in Wako, Japan. Figure 5.4 shows the results of their tests on the quantities of harmful substances in the aerosol of one IQOS stick, compared to those in the smoke of a standard 3R4F reference cigarette. The study showed that there are 2100 μg of nicotine in the smoke of a conventional cigarette (3R4F), 33 mg of carbon monoxide, 110 μg of benzene, 41 μg of formaldehyde, 838 ng of tobacco-specific N′-nitrosamines, 1800  μg of glycerol, and 34  mg of particulates. The aerosol of one IQOS stick, on the other hand, contains 1200 μg of nicotine, 0.44 mg of carbon monoxide, 0.66 μg of benzene, 4.8 μg of formaldehyde, 70 ng of tobacco-specific N′-nitrosamines, 4000 μg of glycerol, and 39 mg of particulates. The key fact here is that IQOS aerosol does indeed contain as many harmful substances as combustible cigarettes. Next let us compare conventional cigarettes with HTPs. Is it what the tobacco companies claim in their advertisements really true—that HTPs contain fewer harmful substances than conventional cigarettes? A very helpful paper published in 2018 collates the results of a number of different analyses [4]. Table 5.1 is a comparison of the quantities of chemical substances detected in HTP aerosol and conventional cigarette smoke, as reported in eight different reference works. I shall explain how to read the table by starting with the leftmost reference work. The research by Schaller in 2016 was conducted by researchers in the tobacco company, PMI. The researchers employed the HCI method3 [5] to measure the chemical substances in the aerosol of the Regular IQOS Stick (R.IQOS in the table; not menthol) using the smoke of a standard cigarette 3R4F as reference. The quantity of 2  In addition, Group 2A is defined as “The agent is probably carcinogen to humans” and Group 4 is defined as “The agent is probably not carcinogenic to humans”. 3  There are two methods for measuring the harmful substances in the aerosol of HTPs and conventional cigarette smoke: the HCI method and the ISO method. The HCI method is preferred. I will leave further discussion of measurement methodologies for other works.

46

5  Substances in Novel Tobacco Products

iQOS, µg/stick Element 1,3-Butadiene Isoprene Acrylonitrile Diacetyl Benzene 2,5-DMF Acetol Propylene glycol Toluene Glycerol Nicotine Formaldehyde Acetaldehyde Acetone Acrolein Crotonaldehyde 2-butanone Cutanal Benzaldehyde I-valeraldehyde Glyoxal Methylglyoxal Heptanal 2-nonenal Total gaseous and particulate matter(mg/cig) Tar (mg/cig) Carbon monoxide(mg/cig) Tobacco specific nitrosamines(ng/cig) N-nitrosonornicotine N-nitrosoanatabine N-nitrosoanabasine Nicotine-derived nitrosamine ketone Total of tobacco specific nitrosamines Average quantities ± standard deviation

reference

regular 0.21 ± 0.03 1.7 ± 0.45 0.14 ± 0.02 43 ± 5.4 0.66 ± 0.09 1.2 ± 0.25 150 ± 32 320 ± 82 1.7 ± 0.26 4000 ± 970 1200 ± 130 4.8 ± 1.0 190 ± 16 36 ± 4.1 7.3 ± 1.1 7.5 ± 0.72 9.9 ± 0.93 19 ± 1.1 2.0 ± 0.37 9.5 ± 0.74 4.5 ± 0.34 7.5 ± 1.8 6.1 0.40