Adolescent Use of and Susceptibility to Heated Products Shuwen Li, MPP,a Katherine Braden, MPH,a Yue-Lin Zhuang, PhD,a Shu-Hong Zhu, PhD,a,b

BACKGROUND AND OBJECTIVES: A leading brand of heated tobacco products (HTPs), IQOS, was abstract authorized to be sold in the United States in 2019. Researchers have examined the awareness and use of HTPs among US adults. In this study, we examined high school students’ awareness, use, and susceptibility pertaining to HTPs. METHODS: A large, cross-sectional population survey of randomly sampled 10th- and 12th- graders in California (N 5 150 516) was conducted online during school hours from September 2019 to March 2020. RESULTS: Overall, 8.9% (95% confidence interval [CI], 8.7%–9.1%) of California high school students had heard of HTPs. Approximately 0.67% (95% CI, 0.61%–0.73%) had ever tried HTPs, and 0.20% (95% CI, 0.17%–0.23%) were current users (ie, 30% of ever users continued to use HTPs at the time of survey). Among those who never tried HTPs, 18.3% (95% CI, 17.9%–18.8%) were susceptible to future use. The susceptibility to HTP use was greater among users of or e-cigarettes than among nonusers. CONCLUSIONS: The awareness of HTPs among adolescents was remarkable given the low availability of products at the time of survey. Only a small percentage of adolescents experimented with HTPs. However, almost a third of those who had experimented with HTPs continued to use them. This high ratio and the fact that almost 1 out of 5 never users were susceptible to future HTP use should put the public health community on high alert as more HTP products are coming into the market, with promotion of these products likely to increase.

aMoores Cancer Center and bHerbert Wertheim School of Public Healh, University of California San Diego, La Jolla, WHAT’S KNOWN ON THIS SUBJECT: The awareness and California use of heated tobacco products (HTPs) among US adults Dr Zhu conceptualized and designed the study and finalized the draft of the manuscript; Ms Li have been studied both before and after a leading brand, conducted the analysis, wrote the first draft, and critically reviewed and revised the IQOS, received premarket tobacco product application manuscript; Ms Braden coordinated and supervised the data collection and critically reviewed authorization in 2019. Little is known about its impact on and revised the manuscript; Dr Zhuang conducted the analysis and critically reviewed and adolescents. revised the manuscript; and all authors approved the final manuscript as submitted and agree WHAT THIS STUDY ADDS: Approximately 9% of California to be accountable for all aspects of the work. high school students had heard of HTPs. Among those who Deidentified individual participant data will not be made available. had tried HTPs, 30% continued to use HTPs at the time of DOI: https://doi.org/10.1542/peds.2020-049597 survey. Among those who had not tried HTPs, 18% were susceptible to future use. Accepted for publication May 10, 2021 Address correspondence to Shu-Hong Zhu, PhD, University of California, San Diego and Moores Cancer Center, MC-0905, 9500 Gilman Dr, La Jolla, CA 92093-0905. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. To cite: Li S, Braden K, Zhuang Y-L, et al. Adolescent Use of Pediatrics FUNDING: Supported by a contract from the California Department of Public Health (CDPH-16- and Susceptibility to Heated Tobacco Products. . 10109). The funding agency had no role in the design and conduct of this study. 2021;148(2):e2020049597

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 148, number 2, August 2021:e2020049597 ARTICLE among US States, although they have no PMTA middle schools (eighth-graders) adolescents has declined authorization from the FDA. were sampled separately. This study significantly in the last decade.1 included high schools only. The However, the decrease in smoking Researchers have found that 5% to sampling design for high schools has been accompanied by a 12% of American adults were aware first divided the state into 35 dramatic increase in e-cigarette of HTPs and that some adults have regions. Eligible schools in each 10–12 use.2 The use of e-cigarettes among tried them. The level of region were then randomly sampled. US high school students increased awareness of HTPs among Public and nonsectarian schools from 1% in 2011 to 27.5% in adolescents appeared to be similar were eligible. Special education, ’ 2019.3,4 The product design for e- to that of adults before IQOS PMTA juvenile court, district and/or 23,24 cigarettes has gone through several authorization. No study, county community, continuation, or other alternative schools were not generations but always with a however, has examined the sampled. Within each high school, plethora of flavors.5 E-cigarettes are awareness or usage of HTPs among adolescents after IQOS received its only 10th- and 12th-graders were now the most prevalent tobacco PMTA authorization. sampled. product used by adolescents,6 although their popularity seems to The current study investigated the The 2019–2020 CSTS approached a have declined in 2020.7,8 awareness and usage of HTPs random sample of 608 schools, and among adolescents after IQOS’ 482 agreed to participate (79.3%). A new line of tobacco products, PMTA authorization. For students Among these, 358 schools however, is ready to compete for who had tried HTPs, the study completed the survey (74.3%) adolescents’ attention: heated assessed the proportion who between September 2019 and March tobacco products (HTPs).7,9 HTPs, continued to use these products. For 2020. A total of 162 675 students in which generate -containing those who had not tried them, it 8th, 10th, and 12th grades aerosols by heating tobacco instead examined their susceptibility to participated, with an overall student of burning it, have already gained using HTPs in the future. response rate of 68.3%. The current some recognition among US Susceptibility to trying particular analyses included data from 311 adults.10–12 With novel and slick tobacco products has been shown to high schools (47 middle schools exterior designs, many HTPs are 25 were excluded). A total of 150 516 13,14 be a useful monitoring strategy. also flavored. Currently, only 1 Because HTPs have not yet become 10th- and 12th-graders answered brand of HTPs, IQOS, has obtained widely available in the United States, the HTP-related questions in the survey (Table 1). The CSTS was premarket tobacco product the susceptibility measure could administered online during class application (PMTA) authorization serve as a warning sign. Toward time. Participation was voluntary. from the US Food and Drug these objectives, we analyzed the 15 The study was approved by the Administration (FDA). With its data from the most recent California University of California San Diego PMTA authorization, IQOS can be Student Tobacco Survey (CSTS) Human Research Protections legally sold in the United States. The (2019–2020), a survey with Program, Institutional Review Board distribution of IQOS so far is still >150 000 high school student 170787. limited, mainly in 2 municipalities: participants. Atlanta, Georgia, and Richmond, Measures Virginia.16,17 However, there are METHODS To add clarity, pictures and online outlets and resellers that sell descriptions of all tobacco products IQOS to US residents. HTPs have Design and Participants were presented before any question been successful in several markets This study used data from the was asked. Students who answered outside of the United States.18–20 – 2019 2020 cycle of the CSTS, an yes to having ever smoked Three tobacco companies dominate ongoing school-based survey that cigarettes were considered ever these markets: Philip Morris provides statewide estimates of smokers. Students who answered International (PMI), tobacco use among middle and high yes to vaping nicotine or just International (JTI), and British school students in California. The flavoring were considered ever e- 20,21 American Tobacco (BAT). In CSTS used a two-stage cluster cigarette users. addition to IQOS, BAT’s Glo and JTI’s sampling design, in which school Ploom Tech (known as Logic was the primary sampling unit and For HTPs, the questionnaire used Vapeleaf in the United States.)22 classroom was the secondary the term “heat-not-burn,” which is have been found in the United sampling unit. The high schools and another common name for these

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 LI et al TABLE 1 Prevalence of Having Heard of HTPs Among High School Students, 2019–2020 CSTS Total Never Used Cigarettes or E-cigarettes Ever Used E-cigarettes Only Ever Used Cigarettes N 5 150 516 n 5 110 880 n 5 29 857 n 5 9369 % (95% CI) % (95% CI) % (95% CI) % (95% CI) Overall 8.9 (8.7–9.1) 8.4 (8.2–8.6) 8.3 (7.9–8.8) 16.6 (15.5–17.7) Sex Male 9.2 (8.8–9.5) 8.5 (8.1–8.8) 9.2 (8.6–9.8) 16.8 (15.3–18.4) Female 8.3 (8.0–8.6) 8.3 (8.0–8.7) 7.2 (6.6–7.7) 12.3 (10.9–13.7) Other 13.5 (12.2–14.9) 9.7 (8.1–11.2) 15.4 (12.8–18.0) 28.7 (24.4–33.1) Undisclosed 10.3 (9.1–11.4) 7.5 (6.3–8.6) 10.2 (8.0–12.5) 29.6 (23.3–35.9) Race and/or ethnicity NH-white 9.6 (9.2–10.0) 9.3 (8.8–9.7) 7.8 (7.1–8.5) 17.1 (15.0–19.2) NH-Black 7.9 (6.9–9.0) 7.2 (6.1–8.3) 9.5 (6.6–12.4) 17.3 (11.0–23.5) Hispanic 8.9 (8.6–9.2) 8.5 (8.1–8.8) 8.5 (7.8–9.1) 15.5 (14.2–16.9) NH-Asian 7.2 (6.8–7.7) 7.0 (6.5–7.5) 7.3 (6.4–8.2) 15.2 (11.7–18.7) NH-other 9.1 (8.0–10.1) 7.7 (6.4–9.0) 8.5 (6.7–10.2) 20.9 (16.8–25.0) NH-multiple 10.1 (9.4–10.7) 9.6 (8.8–10.3) 8.8 (7.6–10.1) 18.2 (15.4–21.0) Grade Grade 10 9.4 (9.1–9.7) 8.9 (8.6–9.2) 9.5 (8.8–10.1) 18.2 (16.3–20.0) Grade 12 8.3 (8.0–8.6) 7.8 (7.4–8.1) 7.4 (6.9–7.9) 15.6 (14.4–16.8) NH-white, non-Hispanic white; NH-Black, non-Hispanic Black or African American; NH-Asian, non-Hispanic Asian; NH-other, non-Hispanic other (including American Indian or Alaskan native, Native Hawaiian, or other Pacific Islander); NH-multiple, non-Hispanic multiple race and/or ethnicity. products. The students were first response options were presented (see known HTP brand were considered presented with a picture of one Table2).TheuseofHTPwas to have used HTP. Those who chose HTP, with the following description: assessed with 2 questions, starting brand Pax (8% of self-reported “Heat-not-burn tobacco products use with “Have you ever used a heat-not- current HTP users) were excluded an electronic device to heat tobacco burn tobacco product?” Those who because Pax is a vaporizer designed sticks (heat-sticks) or capsules answered yes were then asked, “Have for vaping marijuana only. Those instead of burning it. They may also you used a heat-not-burn tobacco who chose other were also excluded be called heated tobacco products. product in the last 30 days?” Students (30% of self-reported current HTP They are different from vapes. who had used HTPs in the last 30 users). Popular brands include IQOS, Glo, days were asked, “What brand of and Ploom Tech.” Then, students heat-not-burn tobacco product do you The susceptibility of HTPs was were asked, “Before today, have you use most often?” Students could assessed with a single question, “If heard of heat-not-burn tobacco choose 1 of 9 options: Glo, iFuse, one of your best friends offered you products?” IQOS, Jouz, Lil, Logic Vapeleaf, Pax, a heat-not-burn tobacco product, Ploom Tech, and other. would you use it?” Responses were Those who answered yes were asked, on a 4-point Likert scale, from “Where did you last hear about heat- To reduce false-positives, only those “definitely yes” to “definitely not.” not-burn tobacco products?” Eight current users who identified a Any response other than definitely

TABLE 2 Sources From Which High School Students Have Heard of HTPs, 2019–2020 CSTS Total Never Used Cigarettes or E-cigarettes Ever Used E-cigarettes Only Ever Used Cigarettes N 5 13 549 n 5 9396 n 5 2512 n 5 1615 Source of Information % (95% CI) % (95% CI) % (95% CI) % (95% CI) Internet or social media (eg, Snapchat, 39.1 (38.1–40.1) 41.7 (40.4–42.9) 35.9 (33.8–38.0) 28.8 (25.8–31.8) Instagram, or YouTube) A friend or someone else 32.5 (31.4–33.6) 29.1 (27.9–30.3) 40.4 (37.7–43.2) 40.4 (36.8–43.9) Television or streaming service (eg, Netflix, 9.3 (8.4–10.3) 10.3 (9.2–11.3) 8.2 (6.3–10.1) 5.6 (3.7–7.6) Hulu, or Amazon Prime) Other 7.0 (6.4–7.6) 6.8 (6.1–7.5) 5.2 (4.2–6.3) 10.3 (8.6–12.0) Store (eg, convenience store, smoke shop, or 5.8 (5.3–6.2) 5.8 (5.2–6.4) 5.1 (4.2–5.9) 6.6 (5.3–7.9) vape shop) Bus stop or billboard 2.9 (2.5–3.3) 3.0 (2.5–3.6) 2.3 (1.7–2.9) 3.0 (2.2–3.8) Radio or music streaming service (eg, 1.9 (1.6–2.2) 1.9 (1.5–2.3) 1.6 (1.0–2.2) 2.6 (1.7–3.5) Spotify, Pandora, or SoundCloud) Magazine 1.6 (1.3–1.8) 1.4 (1.1–1.7) 1.3 (0.7–1.8) 2.7 (1.9–3.5)

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 28, 2021 3 not was defined as susceptible in RESULTS male (9.2%) or female (8.3%). White 25 this analysis. Table 1 presents the awareness of students and students of multiple ethnicities had the highest Analyses HTPs among 150 516 high school student survey participants. Overall, awareness, with Asian students All estimates were weighted by the 8.9% of students reported having having the lowest (7.2%). Students school enrollment data from the heard of HTPs. Awareness differed in 10th grade (9.4%) were more California Department of Education. by whether the participants had likely to have heard of HTPs than Point estimates and their 95% smoked cigarettes. Those who had 12th-graders (8.3%). Within each confidence intervals (CIs) were never used cigarettes or e-cigarettes demographic dimension, those who 26 computed. We also calculated the (8.4%) and those who had only used had tried cigarettes consistently had proportion of HTP “continued use” e-cigarettes (8.3%) had heard of greater awareness than those who given that participants had tried it. HTPs. For those who had tried had not. All analyses were performed by cigarettes, approximately twice as using SAS software version 9.4 (SAS many (16.6%) had heard of HTP. Table 2 shows the sources from Institute, Inc, Cary, NC).27 The which students last heard about estimates for prevalence are Students who identified their sex as HTPs. Overall, Internet or social presented with 2 decimal points other than male or female (13.5%) media (39.1%) was the most because these values are small were more likely to have heard of frequently mentioned source of (Table 3). HTPs than those who identified as having heard of HTPs. A friend or

TABLE 3 Prevalence of Ever and Current Use of HTPs Among High School Students, 2019–2020 CSTS Total Never Used Cigarettes or E-cigarettes Ever Used E-cigarettes Only Ever Used Cigarettes % (95% CI) % (95% CI) % (95% CI) % (95% CI) Ever use N 5 150 560 n 5 110 909 n 5 29 862 n 5 9374 Overall 0.67 (0.61–0.73) 0.11 (0.08–0.14) 1.30 (1.13–1.47) 5.22 (4.65–5.80) Sex Male 0.59 (0.51–0.67) 0.10 (0.07–0.12) 1.19 (0.96–1.41) 4.63 (3.74–5.51) Female 0.48 (0.42–0.53) 0.09 (0.05–0.13) 1.11 (0.93–1.29) 3.34 (2.70–3.98) Other 3.30 (2.63–3.97) 0.52 (0.00–1.04) 4.96 (3.34–6.58) 13.54 (10.38–16.69) Undisclosed 1.81 (1.37–2.25) 0.22 (0.03–0.41) 2.28 (1.15–3.40) 12.52 (8.98–16.06) Race and ethnicity NH-white 0.65 (0.54–0.75) 0.07 (0.03–0.10) 0.94 (0.72–1.16) 4.58 (3.58–5.57) NH-Black 0.72 (0.41–1.02) 0.19 (0.00–0.44) 1.33 (0.52–2.14) 9.34 (4.08–14.60) Hispanic 0.67 (0.59–0.75) 0.13 (0.09–0.16) 1.39 (1.13–1.65) 4.94 (4.15–5.73) NH-Asian 0.37 (0.27–0.46) 0.08 (0.02–0.13) 1.12 (0.71–1.53) 4.94 (2.76–7.12) NH-other 1.09 (0.80–1.39) 0.05 (0.00–0.12) 1.49 (0.78–2.20) 8.19 (5.64–10.75) NH-multiple 0.70 (0.54–0.87) 0.07 (0.02–0.12) 1.39 (0.94–1.84) 5.10 (3.48–6.71) Grade Grade 10 0.58 (0.51–0.66) 0.08 (0.06–0.11) 1.43 (1.19–1.68) 5.74 (4.60–6.89) Grade 12 0.76 (0.68–0.84) 0.14 (0.10–0.18) 1.18 (1.00–1.37) 4.90 (4.21–5.59) Current use n 5 15 0551 n 5 11 0908 n 5 29 858 n 5 9370 Overall 0.20 (0.17–0.23) 0.01 (0.00–0.02) 0.26 (0.20–0.32) 2.24 (1.82–2.65) Sex Male 0.14 (0.09–0.20) 0.00 (0.00–0.00) 0.20 (0.11–0.28) 1.58 (0.84–2.32) Female 0.09 (0.07–0.12) 0.01 (0.00–0.03) 0.16 (0.10–0.22) 0.93 (0.56–1.29) Other 1.89 (1.46–2.32) 0.06 (0.00–0.15) 1.83 (0.99–2.67) 10.19 (7.64–12.73) Undisclosed 0.94 (0.64–1.23) 0.04 (0.00–0.10) 1.14 (0.18–2.09) 7.10 (4.62–9.57) Race and ethnicity NH-white 0.12 (0.08–0.16) 0.00 (0.00–0.01) 0.15 (0.05–0.25) 1.01 (0.59–1.44) NH-Black 0.32 (0.15–0.48) 0.02 (0.00–0.06) 0.53 (0.00–1.06) 5.86 (2.25–9.48) Hispanic 0.21 (0.16–0.26) 0.01 (0.00–0.03) 0.26 (0.19–0.34) 2.40 (1.73–3.07) NH-Asian 0.06 (0.03–0.10) 0.01 (0.00–0.02) 0.12 (0.01–0.23) 1.48 (0.63–2.34) NH-other 0.44 (0.26–0.63) — 0.35 (0.00–0.70) 3.99 (2.24–5.74) NH-multiple 0.25 (0.16–0.35) — 0.39 (0.16–0.61) 2.47 (1.30–3.63) Grade Grade 10 0.19 (0.14–0.25) 0.01 (0.00–0.03) 0.33 (0.23–0.43) 2.71 (1.75–3.68) Grade 12 0.21 (0.17–0.25) 0.01 (0.00–0.02) 0.20 (0.13–0.27) 1.94 (1.53–2.35) NH-white, non-Hispanic white; NH-Black, non-Hispanic Black or African American; NH-Asian, non-Hispanic Asian; NH-other, non-Hispanic other (including American Indian or Alaskan native, Native Hawaiian, or other Pacific Islander); NH-multiple, non-Hispanic multiple race and/or ethnicity; —, not applicable.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 LI et al someone else (32.5%) was the Among those who had never were still using HTPs at the time of second. When these categories are smoked cigarettes or used e- survey among those who had ever combined, more than two-thirds cigarettes, only 0.01% had used an tried one). Overall, 30.2% of (71.6% 5 39.1% 1 32.5%)of HTP in the last 30 days. However, students who had ever used HTPs students reported having heard of among students who had ever used were current users (ie, had used HTPs from the Internet or from e-cigarettes (but not cigarettes), HTPs in the last 30 days). The ratio someone they knew. The remaining 0.26% were current users. Among was 9.9% among those who had one-third had heard of HTPs from those who had ever smoked never tried cigarettes or various sources: television (9.3%), cigarettes, 2.24% were current users. e-cigarettes. It increased to 20.0% store (5.8%), bus stop or billboard Again, these differences across among those who had ever used (2.9%), radio or music streaming tobacco use status are much greater e-cigarettes (but not cigarettes) and (1.9%), magazine (1.6%), and other than the variation across 42.8% among those had ever tried (7.0%). demographic variables. cigarettes.

The source of information appears Students who reported having used The second row showed to differ by students’ tobacco use HTPs in the last 30 days were asked susceptibility among those who had status. Internet or social media was about the brands they used most never tried HTPs but were the number one source mentioned often. Among the students who were susceptible to it. Overall, 18.3% of by students who had never used able to identify a known HTP brand, never-using HTP participants were cigarettes or e-cigarettes (41.7%). the top 3 brands were Logic susceptible to future HTP use. Among those who had used Vapeleaf, iFuse, and Jouz (see Table Approximately 11.2% of those who e-cigarettes or cigarettes, however, 4). Logic Vapeleaf (name used in the had never tried cigarettes or the most frequently mentioned United States) and Ploom Tech e-cigarettes were susceptible. source of information was a friend (name used in Japan) are identical Susceptibility increased to 35.5% or someone else (40.4%), whereas products22; both are owned by JTI.28 among students who had ever used Internet or social media ranked If they were combined, the e-cigarettes only. For those who had second. proportion would be 31.6% (24.8% ever tried cigarettes, almost half 1 6.8%). Similarly, iFuse is a (49.4%) were susceptible to future Table 3 presents the prevalence of modified version of Glo,29 with both HTP use. ever use and current use of HTPs. owned by BAT. The combined The top half shows the results on proportion is 29.1% (19.1% 1 DISCUSSION ever use. Overall, 0.67% of students 10.0%). Jouz and IQOS are devices In this study, we found that 9% of reported having ever used an HTP. that use Marlboro HeatSticks30,31 California high school students Among those who had never used owned by PMI. Thus, their combined reported having heard of HTPs. cigarettes or e-cigarettes, only 0.11% proportion is 25.8% (17.0% 1 8.8%). Some (0.67%) had even tried had tried HTPs. However, among Finally, 13.5% of students who used HTPs. Among the brands reported students who had tried e-cigarettes HTPs in the last 30 days indicated by the current users, 87% were (but not cigarettes), 1.30% had tried they used Lil, owned by Korea affiliated with the top 3 tobacco HTPs. For those who had ever Tobacco & Ginseng Corporation.32 companies: PMI, BAT, and JTI. smoked cigarettes, 5.22% had tried HTPs. Table 5 presents 2 statistics. The The limited number of brands for first row shows the continuation HTP contrasts with the large The prevalence of ever use of HTPs varies by demographic variables. ratio (the proportion of those who number of brands for However, the variation across TABLE 4 – demographic variables is much Brands of Current Use of HTPs Among High School Students, 2019 2020 CSTS smaller than the variation across Total, N 5 314 tobacco use status (ie, whether the Tobacco Company Brand % (95% CI) students had already tried JTI Logic Vapeleaf 24.8 (3.0–18.9) e-cigarettes or cigarettes). Ploom Tech 6.8 (1.8–3.2) BAT Glo 10.0 (1.8–6.5) iFuse 19.1 (2.3–14.6) The bottom half of Table 3 shows PMI iQOS 8.8 (1.7–5.4) the current use of HTPs. Overall, Jouza 17.0 (5.0–7.1) 0.20% of students reported having Korea Tobacco & Ginseng Corporation Lil 13.5 (2.1–9.3) used an HTP in the last 30 days. aJouz uses Marlboro HeatSticks owned by PMI, but Jouz is not owned by PMI.

PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 28, 2021 5 TABLE 5 Continuation Ratio Among Ever Users and Susceptibility Among Never Users, 2019–2020 CSTS Total Never Used Cigarettes or E-cigarettes Ever Used E-cigarettes Only Ever Used Cigarettes % (95% CI) % (95% CI) % (95% CI) % (95% CI) HTP ever user N 5 1031 n 5 109 n 5 395 n 5 526 Continuation ratio 30.2 (26.3–34.1) 9.9 (3.2–16.6) 20.0 (15.5–24.5) 42.8 (36.8–48.8) HTP never user N 5 149 464 n 5 110 761 n 5 29 454 n 5 8837 Susceptibility 18.3 (17.9–18.8) 11.2 (10.9–11.6) 35.5 (34.8–36.3) 49.4 (47.5–51.4)

e-cigarettes.5,33 Compared with Given that promotion for HTP was experimenters resembles the e-cigarettes, HTPs are more difficult still limited to date, the fact that 9% continuation ratio for adolescent e- to manufacture and are owned of high school students had already cigarette experimenters, 36%,as mainly by large tobacco companies. heard about HTPs is remarkable. shown from another CSTS.39 These companies have released Social media were a key source of HTPs under a small number of information. Promotion on social It appears, therefore, that HTP could brands.20 Early generations of HTPs media was likely initiated by HTP be attractive to adolescents. (such as Eclipse) were sold users themselves, although some Similarity to e-cigarette is sporadically in the 1990s and content might have been concerning given the recent – 2000s.34 36 New HTPs introduced sponsored.14,38 dramatic uptake of e-cigarettes after August 8, 2016, the date of among adolescents. Currently, the FDA's deeming regulations for Interestingly, the levels of HTP promotion of HTPs is still limited. tobacco products,37 can only be awareness and use among California With more advertising for HTPs, legally sold in the United States after high school students in this more adolescents will learn of these receiving their PMTA authorization 2019–2020 survey were similar to new products and may experiment – from the FDA. To date, only iQOS those for US adults found in a recent with them.40 42 A new product, had received its PMTA authorization national survey, conducted from IQOS3, received its PMTA (in April 2019). The other brands November 2019 to February 2020.12 authorization in December 2020.43 reported by users had no PMTA The cited study revealed that 8% of As such, promotion for a series of authorization. American adults had heard of HTPs, IQOS products may increase 0.55% had tried HTPs, and 0.10% significantly in the near future. The current survey was conducted were current users.12 In other from September 2019 to March words, 7% of the adults who had Asubgroupofadolescentsmaybe 2020. This was after IQOS received heard of HTPs experimented with particularly at risk if advertising of PMTA authorization. However, the them (0.55/8 5 6.8%). The current HTPs or the availability of new authorization did not seem to have study found a similar percentage: products increases. Nearly 1 in 5 an immediate impact on the among those who had heard of (18%) students who had never awareness of HTPs among HTPs, 7.4% (0.67/9 5 7.4%) used an HTP were susceptible to adolescents. Surveys that preceded reported having experimented with future use, as measured by the PMTA authorization revealed these products. openness to a friend’s offering of that 9% to 13% of adolescents were the product (Table 5). Given the aware of HTPs.23,24 This study found However, the adolescents appeared strong peer influence on 9% awareness. In fact, the to differ from the adults in the adolescents’ tobacco use,44 the risk prevalence of HTP use (0.67%) likelihood of continuing to use the of increased HTP initiation could found in this study was lower than products once they had be high if these products become that reported in an earlier 2019 experimented with them. For adults, widely promoted. National Youth Tobacco Survey the cited study revealed that 18% of (2.4%).24 One explanation is that the those who had tried HTPs were still Not surprisingly, the susceptibility current study had a stricter current users at the time of to HTPs was even higher among definition of HTP use: this survey survey.12 For adolescents in the those students who had already asked respondents for the brands current study, 30% of experimented with e-cigarettes or they used; those whose reported experimenters continued to use the cigarettes. For those who had brands mismatched with known products at the time of survey experimented with cigarettes, HTP products were coded as non- (Table 5). This continuation ratio for almost half of them were susceptible HTP users. HTPs among adolescent to using HTPs (Table 5). There are

Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 LI et al personal characteristics that render risk perception of these new continued to use HTPs. In addition, certain subgroups more liable for products compared with a significant proportion of students drug use than others.45 The students e-cigarettes was not assessed. The appear to be susceptible to using who have already used some study is also limited in that it is a these attractively designed tobacco products, such as cross-sectional survey, making it products in the future. The public e-cigarettes or cigarettes, are more difficult to assess the time course of health community needs to likely to possess those behavior change. For example, monitor HTP developments, characteristics associated with a although it is logically clear that especially related promotional higher propensity to use similar students have to be aware of the activities, and the impact they may tobacco products, such as HTPs, in products before they will have on youth. the future.46 In previous studies, experiment with them and that they researchers have found that tobacco will first have to experiment before ACKNOWLEDGMENTS users are more interested in a novel becoming regular users, it is We thank the CSTS team for their tobacco product compared with difficult to accurately assess the contributions to questionnaire 2 nontobacco users. With this study, timing of these transitions without design and data collection. We also we confirm previous research in a longitudinal design. It is possible thank Julian Ong for providing help- finding that students who have used that some of the current HTP users ful feedback for an earlier draft of e-cigarettes or cigarettes are much only started to experiment with the the article. more susceptible to using HTPs. product in the last 30 days before the survey, which would have Although those who had never tried inflated the computation of the ABBREVIATIONS e-cigarettes or cigarettes were less continuation ratio. Finally, the BAT: British American Tobacco susceptible to future HTP use, the survey was conducted with % CI: confidence interval risk was still substantial at 11 . students in the state of California. CSTS: California Student Tobacco Moreover, this group is the largest The results may not generalize to % Survey subgroup, consisting of 74 of all other states. students. Prevention strategies need FDA: Food and Drug to be developed to reduce Administration CONCLUSIONS adolescents’ chance of HTP: experimenting with HTPs because This study, based on a large PMTA: premarket tobacco the risk of becoming regular users is representative sample, found that product application substantial once the students have 9% of high school students were PMI: Philip Morris International experimented with them. aware of HTPs despite their JTI: Japan Tobacco International restricted market availability. A This study is limited in that it only small number of students had even inquired about HTPs with a few experimented with HTPs. More questions. For example, the relative importantly, 30% of experimenters

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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PEDIATRICS Volume 148, number 2,Downloaded August 2021 from www.aappublications.org/news by guest on September 28, 2021 9 Adolescent Use of and Susceptibility to Heated Tobacco Products Shuwen Li, Katherine Braden, Yue-Lin Zhuang and Shu-Hong Zhu Pediatrics originally published online July 26, 2021;

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Adolescent Use of and Susceptibility to Heated Tobacco Products Shuwen Li, Katherine Braden, Yue-Lin Zhuang and Shu-Hong Zhu Pediatrics originally published online July 26, 2021;

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