Commentary on Gravely et al (2019): Beginning a new era of nicotine products-beyond the four national-level determinants of nicotine vaping products (NVPs) use.

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Recently, tobacco companies have increased their ownership of alternative tobacco products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs). In addition to the examination of essential national-level characteristics, including regulation of both NVPs and conventional cigarettes, future studies should also consider HTPs, which are already popular in some countries. Gravely and colleagues have updated their study estimating the prevalence of nicotine vaping product (NVP) use among current and recent ex-smokers in 14 countries 1, 2. In the updated paper 1, the status of NVP use in each country was assessed on four national-level characteristics: (1) regulatory policies for NVPs, (2) whether countries are classed as high- or middle-income, (3) attitudes towards harm reduction by NVPs and (4) the regional location of each country. With a few exceptions, considerable differences between countries in ever-use, and current/daily use of NVPs were observed such that NVP use patterns vary according to the combination of the four national-level characteristics. Lower prevalence of NVP use was observed in countries with strong regulations (e.g. where NVPs are prohibited from sale and regulations are strongly enforced), such as Australia, Brazil and Uruguay, regardless of whether these were high- or middle-income countries. Conversely, the highest prevalence of NVP use was observed in England, where regulation is weak and NVPs are promoted for harm reduction. Compared with middle-income countries, high-income countries had a higher prevalence of NVP use and the interaction between national-level environments and NVP use is also further complicated by the interaction of the above-mentioned four factors. However, we must also take some additional points into account in any future study. First, we need to consider the associations between NVP use and national-level tobacco control policy status, i.e. whether countries have implemented the measures recommended by the World Health Organization (WHO) MPOWER policy package, such as tobacco taxation and smoke-free policies. This matters, because the price of tobacco cigarettes, as influenced by taxation, may affect NVP use, or a strict smoke-free policy in schools may encourage students to use NVPs, which can be easily concealed 3. However, the 2017 MPOWER report suggests that taxation levels in each country, defined as the share of total taxes or the affordability of cigarettes, do not have a straightforward association with the prevalence of NVP use among the 14 countries analysed by Gravely et al. 4. More investigation into the relative prices of cigarettes and NVPs and the way this influences NVPs use is needed 5, as people may be more likely to choose NVPs if they are much cheaper than cigarettes. Secondly, in order to monitor usage of all nicotine-containing products in addition to NVPs, we should also consider heated tobacco products (HTPs) such as IQOS and PloomTECH, developed by the tobacco companies Philip Morris International and Japan Tobacco, respectively. IQOS is currently sold in more than 40 countries or regions world-wide, particularly in high-income countries 6. After becoming popular and widely used in Japan 7, IQOS has also gained widespread acceptance in the Republic of Korea 8. Given the marketing strategies of the big tobacco companies, the world-wide market share of nicotine-containing products accounted for by HTPs is likely to grow, increasing the potential for public health concern. Thirdly, the big tobacco companies have also bought electronic cigarette (e-cigarette) companies. For example, the tobacco company Altria (the parent company of Philip Morris International) recently took a 35% stake in the e-cigarette company JUUL, the makers of the most popular e-cigarette brand in the United States 9. As a result, all major nicotine-containing products, including conventional cigarettes, other tobacco products such as snus, NVPs (e-cigarettes) and HTPs, have now become part of the big tobacco companies’ range of products. This is concerning, because the use of NVPs and/or HTPs is strongly influenced by the marketing strategies of tobacco companies 10, 11. The time-period since the first appearance of NVPs and HTPs on the market has been relatively short, and thus our knowledge of the dissemination of these new products and our appropriate responses in relation to their regulation are limited and a consensus has not yet been reached. We should continue to gather information and evidence on these products to objectively judge the best approach for our society, and carefully determine our attitudes towards each nicotine-containing product. In order to carry out basic epidemiological data monitoring of health behaviour, HTPs, which are increasingly widely used, should be included in future analysis, either separately or jointly with NVPs. Ultimately, we need to recognize that our society has already entered a ‘new era of new nicotine-containing products diffusion’ following the ‘era of the conventional cigarette epidemic’. None.