Heated Tobacco Products at the Point of Sale
What are heated tobacco products?
According to the CDC, “heated tobacco products heat processed tobacco leaf, allowing users to inhale nicotine into their lungs.” They are sometimes also called “heat-not-burn” products and vary in design.
Although various heated tobacco products were introduced starting in the 1990s (e.g. RJ Reynolds’ Eclipse,” and “Revo”; Philip Morris’ “Accord”), use has remained low so far with 2.4% of adults reporting ever use of the products in 2018. However, with the introduction of newer heated tobacco products with sleek designs and the market shift to other electronic products like e-cigarettes, use may grow in coming years.
The most well-known heated tobacco product in the United States is Philip Morris International’s IQOS, authorized for sale through Altria in the U.S. by the FDA in April 2019. It consists of a rechargeable heating device that holds Marlboro-branded “HeatSticks.” When these tobacco-containing HeatSticks are inserted, a glass-covered ceramic blade from the device pierces the tobacco in order to heat it. Unlike conventional, combustible cigarettes which ignite and burn, the IQOS device heats tobacco to a much lower temperature and generates an inhalable aerosol. In design, the product aims to simulate a conventional smoking experience; tactilely, IQOS provides a similar look and feel to cigarettes, and the HeatSticks, similar to cigarettes, are sold in packs of 20 and in both menthol and non-menthol flavors. In December 2020, the next generation of these products, IQOS 3, was also authorized by the FDA for sale in the U.S.
Where are they sold in the United States?
IQOS debuted in test markets in Atlanta, Georgia, and Richmond, Virginia in late 2019 and expanded to Charlotte, NC in 2020. The devices are currently sold at flagship stores in malls, mobile units (sometimes in parking lots of convenience stores) and kiosks, as well as pop-up stores inside convenience stores. HeatSticks can also be found in additional various tobacco retailers (e.g. convenience stores, gas stations, grocery stores, and even pharmacies) across these cities.
Most of the flagship stores require individuals to be 21 years old to enter and with their high-tech and minimalist design, have been reported to have a similar feel to an Apple store. Some stores also screen customers based on their smoking status.
According to a Truth Initiative report on “IQOS in the U.S.”, “During their visits [visitors] were told that IQOS was designed for people to switch from traditional cigarettes, that traditional smokers rather than e-cigarette users would be more likely to enjoy iQOS without the unknown risks of vaping, and that iQOS was a safer alternative to smoking – a marketing claim that iQOS was not allowed to legally make.” They also note that “Visitors to the Atlanta stores received follow-up emails promoting iQOS and announcing a rewards program for customers to exchange points for product coupons.”
How are they regulated?
The FDA has classified heated tobacco products as cigarettes, so they are federally regulated as such. You can see how they are (or will be) regulated at the state level in this 50 state review from the Public Health Law Center. Also see their fact sheet, Heated Cigarettes: How States Can Avoid Getting Burned for more on the regulatory landscape.
However, in some places, thanks to lobbying from IQOS maker Altria, heated tobacco products are being taxed at a lower rate than cigarettes. In Virginia, where Altria is headquartered, a recent law change means that heated tobacco products are not included in the state definition of a cigarette.
How are they marketed at the point of sale?
Internationally, IQOS marketing at the point of sale has involved heavy promotional activity and prominent displays. Marketing materials and promotions for the product contain themes that position it as a tool for quitting (despite the fact that they have not been scientifically shown to help smokers quit), as a healthy, and as a stylish lifestyle product. Much of Philip Morris International’s advertising campaigns for the product have also been youth oriented, as documented in a report from Stanford University.
Flavors. Monitoring of these products in the retail environment will be an ongoing need. In particular, tobacco control advocates should closely watch how these products are targeted and maintain a critical eye on whether the marketing of the mentholated versions of HeatSticks is being targeted at African-American individuals and communities. The industry is notorious for their targeted marketing towards these communities, and it is yet to be seen whether they will follow down the same path for IQOS and the mentholated HeatSticks. Similarly, given the youth appeal of many of their international marketing campaigns, marketing in the US should be monitored for any youth targeting as well. IQOS products are available in menthol flavors, and research has shown that youth are most likely to initiate tobacco use with flavored products.
Cost. IQOS has a high start-up cost, with a device and pack of 200 HeatSticks selling for $80 or more, but packs of HeatSticks are sold for as low as $5.75 per pack, similar to the price of a pack of cigarettes. In addition, IQOS offers discounts for referrals and rewards programs.
Sampling. In flagship stores, adult customers who say that they currently smoke can test out a trial version of the product for $1.00.
Modified exposure claims: In July 2020, the FDA authorized Philip Morris to market its IQOS Tobacco Heating System as a ‘modified risk tobacco product’, making the IQOS device and its accompanying HeatSticks only the second set of products to be authorized as modified risk tobacco products and the first tobacco products to receive “exposure modification” orders. With this authorization, Philip Morris can now market claims that the IQOS system “heats tobacco but does not burn it” and that completely switching to the product from cigarettes “significantly reduces the production of harmful and potentially harmful chemicals”; they can also advertise that “scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful products.” Whether these products are truly safer than cigarettes remains questionable, with more research needed on both the short- and long-term effects on morbidity and mortality. In 2018 FDA Tobacco Product Scientific Advisory Committee found that the IQOS did not substantially reduce risks of tobacco-related death and disease, and in 2019, FDA did not approve the products for a “risk modification” label.
Even with authorization of the modified risk claim, the FDA maintains that the products are neither safe nor FDA-approved. The nicotine in the product is highly addictive, and independent, peer-reviewed research assessing the short- and long-term effects of these products is severely lacking. As well, a significant portion of the current research has been led, funded by, or in some way associated with the tobacco industry. As a result, the authorization requires both the FDA and Philip Morris to continue to monitor the appropriateness of the modified risk order and its impact on youth use. In response to the FDA authorization, multiple organizations, including the Campaign for Tobacco-Free Kids, American Cancer Society Cancer Action Network, American Heart Association, American Lung Association and Truth Initiative, issued a joint counterstatement, arguing the authorization puts youth and the public’s health at risk. Their concerns center on Philip Morris International’s marketing of IQOS as a safe, sleek, and stylish product, in a similar way that e-cigarettes were marketed, and concerns that this will lead to non-smokers and youth, in particular, being enticed by the advertising and initiating tobacco use.
It is imperative that the FDA and other independent researchers not only continue to assess the risk of harm of these products but also routinely assess how these products are being marketed and sold; as this new modified risk claim will likely impact perceptions of harm, there is a critical need to keep a finger on the pulse of how the marketing of this product affects use, especially among youth who research indicates may misunderstand reduced exposure claims.
It is also important that new tobacco control policy language is inclusive of heated tobacco products and that already established ordinances and polices are amended to include them if existing definitions are not comprehensive enough to do so already. This includes licensing ordinances so that jurisdictions can keep track of where heated tobacco products are being sold, ensure they are not being sold to underage youth, and implement other restrictions on the sale and marketing of the products as appropriate.
(Photo from TruthInitiative.org)
Transcript for the episode can be found here.
- CDC’s page on Heated Tobacco Products
- Public Health Law Center’s S. Heated Cigarette Regulations – 50 State Review and factsheet “Heated Cigarettes: How States Can Avoid Getting Burned”
- Global Marketing of IQOS: The Philip Morris Campaign to Popularize “Heat Not Burn” Tobacco, Stanford Research into the Impact of Tobacco Advertising
- WHO’s Heated tobacco products: a brief (2020) and Heated Tobacco Products Information Sheet (2ndedition)
- Campaign for Tobacco Free Kids’ Heated Tobacco Products
- UCSF Smoking Cessation Leadership Center’s recorded webinar: Unboxing iQOS: History, risk perceptions, and clinical implications