Background: A significant number of people who smoke have adopted heated tobacco products (HTPs), either concurrently with cigarettes or exclusively through switching. This study investigates the influence of social norms on the transition between cigarette and HTP use.
Methods: Data were collected from people who used tobacco products in at least two consecutive waves of ITC Japan study (2018 – 2021). The association between social norms at baseline wave and tobacco product use in the follow-up wave were assessed using mixed effect multinominal logistic regressions on weighted data, controlling for demographics.
Results: While most perceive HTP use as less harmful than cigarettes, 29.6% of those who use cigarette exclusively lack awareness of HTP harm. Across groups (exclusive cigarette, exclusive HTP, dual product uses), many have smoking friends (84.7%, 83.3%, 85.3%) and perceive disapproval of smoking from close circles (49.3%, 52.5%, 57.2%) and society (67.2%, 67%, 65.5%). Those who use HTP exclusively more often have friends using HTPs (78.16%) and perceive disapproval of HTP use from friends (39.1%) and society (38.9%). While most continue product use in the follow-up wave, those who use HTP exclusively were more likely transition to non-current users. Perceived positive social norms towards cigarette use were significantly associated with continued exclusive cigarette use in the next wave. Having friends using HTPs increased the likelihood of using HTP in the next wave, either exclusively or concurrently with cigarettes, or reducing tobacco product use to non-current level, relative to exclusive cigarette use. However, perceiving that the public was approved of or being neutral towards HTP use was also associated with increased likelihood of continued cigarette use in the next wave, mostly concurrently with HTP.
Implications: To address these dynamics, public health interventions should focus on clear communication, targeted education, and promoting healthier social norms, while simultaneously dispelling misconceptions about HTP harm and creating supportive environments for smoking cessation.