‘It’s like if a vape pen and a cigarette had a baby’: a mixed methods study of perceptions and use of IQOS among US young adults Free

Abstract

Young adults’ perceptions and use of heated tobacco products (HTPs) are understudied. This mixed methods study analyzed (i) Fall 2020 survey data from 2470 US young adults (mean_age = 24.67; 19.5% and 25.2% past-month cigarette and e-cigarette use; 4.1% ever HTP use) assessing HTP use intentions and perceptions (1 = not at all to 7 = extremely) and (ii) Spring 2021 interview data regarding IQOS (most widely available HTP) in a subset of 40 e-cigarette users. Among survey participants, HTPs versus cigarettes and e-cigarettes showed lower use intentions (mean = 1.27 vs. mean = 1.73, mean = 2.16) but were perceived as less addictive (mean = 5.11 vs. mean = 6.28, mean = 5.82) and harmful (mean = 5.37 vs. mean = 6.65, mean = 5.62). HTPs were perceived more socially acceptable than cigarettes but less than e-cigarettes (mean = 3.39 vs. mean = 3.13, mean = 4.37). Among interviewees, most reported limited HTP knowledge. A few perceived IQOS as a hybrid of traditional cigarettes and e-cigarettes. Most perceived IQOS as harmful but less harmful than cigarettes and were uncertain in relation to e-cigarettes. Over half reported minimal interest in trying IQOS; common reasons included IQOS containing tobacco, limited flavors and use complexity. The varied perceptions of IQOS versus cigarettes and e-cigarettes underscore the need for continued surveillance of perceptions, use and marketing of IQOS to inform regulatory oversight and potential interventions.

Introduction

The heated tobacco product (HTP) market has expanded globally in recent years, with HTPs being sold in more than 60 countries [1–3]. HTPs are electronic tobacco products that heat tobacco rather than burn it [4]. A recent systematic review indicated that HTPs were addictive and hazardous to health, compared to no smoking [5]. Although current evidence indicates that HTPs may expose consumers to lower levels of toxic chemicals than cigarettes [6–9] and thus may have the potential to reduce health risks typically linked to cigarette use, the health effects and potential public health impacts associated with HTP use remain largely unknown [10].

Globally, the three largest HTP brands include IQOS produced by Philip Morris International (PMI), ‘glo’ by British American Tobacco and ‘Ploom TECH’ from Japan Tobacco International [11]. In the United States, two brands of HTPs, IQOS and Eclipse, are authorized for sale by the US Food and Drug Administration (FDA) [12]. Notably, IQOS emerged in the US market in October 2019 in Atlanta, GA. In July 2020, FDA authorized IQOS to use ‘reduced exposure’, but not ‘reduced risk’, claims in its marketing [13]. By May 2021, IQOS products were sold in four US states, including Georgia, North Carolina, South Carolina, and Virginia [12]. Then, a patent-infringement lawsuit against PMI brought forth by British American Tobacco required that PMI discontinue the sale of IQOS in the United States in November 2021 [14]. Nevertheless, PMI will likely pursue routes to continue IQOS sales in the United States [15], and the HTP market may continue to expand with increasing HTP awareness and use in the United States [16–21].

Empirical evidence suggests that potential predictors of tobacco use behaviors include consumers’ perceptions of tobacco products, which are influenced by marketing and advertising [22–25]. The increasing marketing and availability of HTPs may impact consumers’ HTP awareness, perceptions, use behaviors and use intentions, particularly among young adults who have historically been targeted by the tobacco industry’s marketing campaigns [26–30]. Thus, it is valuable to understand perceptions of HTPs among consumers, particularly young adults who have the highest use prevalence of almost all tobacco products [31].

The examination of perceptions of harm to health, addictiveness and social acceptability of HTPs is especially worthy relative to traditional cigarettes and e-cigarettes—the two most used tobacco products among US young adults [31] and the two products most commonly compared to HTPs in marketing [32, 33]. Globally, IQOS advertising messages promote its potential health benefits (e.g. ‘reduced risk’) [34–36] compared to cigarettes and/or that IQOS is a ‘cleaner’ product (i.e. ‘less ash’ and ‘less odor’), more acceptable to nonsmokers [15, 36] and a satisfactory alternative to cigarettes (e.g. ‘real tobacco’), despite mixed findings on the harm perceptions and sensory experiences in the literature [36–38]. Notably, FDA authorized IQOS’ use only of ‘reduced exposure’ (‘not’ ‘reduced risk’) marketing claims [39], which are often misperceived by consumers as ‘reduced risk’ [40–42]. Also noteworthy are PMI’s efforts to distinguish IQOS from e-cigarettes [32, 33], which has been notable since the outbreak of e-cigarette and vaping-associated lung injuries (EVALI) [43]. Research in the United States has documented a substantial number of IQOS ads featuring text addressing this, for example, ‘It’s not a vape. It’s not an e-cig. It’s real tobacco with less odor and no ash’ [32].

Due to the anticipated increases in HTP availability and market expansion, it is important to examine use patterns and perceptions of HTPs, particularly relative to other tobacco products, among US young adults. This study aims to fill this research gap using cross-sectional survey in 2020 to explore HTP use and use intentions and perceived addictiveness, harm and social acceptability of HTPs relative to cigarettes and e-cigarettes. Among young adults, the most commonly used tobacco product is e-cigarettes [31], most e-cigarette users have used other tobacco products [44] and e-cigarette users are more likely to report HTP awareness [21, 45], ever use [21] and use intentions [21, 45]. Thus, we also conducted semi-structured interviews among a subsample of young adult e-cigarette users, as doing so poses a particularly strategic opportunity to gain insights about HTP use and perceptions relative to other tobacco products among this population.

Methods

This study analyzes Fall 2020 data from a sample of US young adults (ages 18–34) in the Vape shop Advertising, Place characteristics and Effects Surveillance (VAPES) study [46], a 2-year, five-wave longitudinal cohort study. Participants were recruited from six metropolitan statistical areas (MSAs) (Seattle, WA; San Diego, CA; Oklahoma City, OK; Minneapolis, MN; Boston, MA; Atlanta, GA), selected based on the differences in state tobacco control environments. This study, detailed elsewhere [46], was approved by the Emory University Institutional Review Board.

Advertisements posted on Facebook and Reddit targeted eligible individuals, specifically those who were (i) 18–34 years old, (ii) living in one of the six MSAs and (iii) English speaking. Purposive, quota-based sampling was used to ensure sufficient representation of e-cigarette and cigarette users (∼1/3 each), sexes and racial/ethnic minorities.

Overall, 65 843 Facebook/Reddit users viewed study ads, 10 433 clicked ads and 9847 consented. Of the 9874, 2751 were not allowed to advance to the baseline survey (1427 ineligible; 1279 excluded to reach recruitment targets). Of the 7096 allowed to advance to the baseline survey, 3460 (48.8%) completed the entire survey and 3636 (51.2%) partially completed it (not enrolled). Participants were required to confirm their participation 7 days post-baseline by clicking a ‘confirm’ button included in an email, after which they were enrolled and emailed their first incentive ($10 e-gift card); participation was confirmed among 3006 (86.9%) participants.

Quantitative survey study

Current quantitative analyses focused on data from the W5 survey (September–December 2020; n = 2476; response rate: 82.4%), specifically among the 2470 participants who provided complete information on HTP awareness and use.

Measures included ‘sociodemographic’ factors (sex, sexual orientation, race, ethnicity and education at baseline and MSA, age and marital status at W5), and ‘past-30-day use of tobacco products’ (cigarettes, e-cigarettes and other tobacco products [hookah/waterpipe, little cigars/cigarillos, traditional cigars and smokeless tobacco]).

We also assessed ‘HTP awareness’ by asking, ‘Have you heard of heat-not-burn products, like IQOS or Eclipse, which heat sticks of tobacco instead of burning it?’ ‘HTP use’ was assessed by asking, ‘In your lifetime, have you ever tried a heat-not-burn product like IQOS or Eclipse?’, with response options of: no; yes, IQOS only; yes, Eclipse only; yes, both IQOS and Eclipse; don’t know and prefer not to answer. Participants were also asked, ‘How many days of the past 6 months did you use a heat-not-burn product?’ and among past 6-month users, ‘How many days of the past 30 days did you use a heat-not-burn product?’ Respondents who reported one day or more were categorized as past 30-day HTP users.

To assess ‘HTP perceptions relative to cigarettes and e-cigarettes’, participants were asked to rate each product on a scale of 1 = not at all to 7 = extremely with respect to the extent they thought they were addictive, harmful to their health and socially acceptable among their peers. We also assessed ‘use intentions’ of each product by asking how likely they were to try or continue to use each product in the next year (scale: 1 = not at all to 7 = extremely).

Qualitative interview study

In February–April 2021, VAPES W5 participants who reported past 30-day e-cigarette use were recruited via email to participate in a semi-structured interview. We applied quota-based sampling and established eligibility criteria to get representation across the racial/ethnic backgrounds, sexes and sexual orientations to the extent possible. Of the past 30-day e-cigarette users recruited via email (n = 139), 105 (75.5%) began the eligibility screener, of whom 94 (89.5%) completed the screener. Of the 94, 60 (63.8%) were eligible and consented to participate in the semi-structured interview. Of the 60, 40 (66.7%) were successfully scheduled for and participated in an interview, at which point, saturation had been reached. The Consolidated Criteria for Reporting Qualitative Research guidelines were used to guide interview implementation and analyses [47].

The study team developed a semi-structured interview guide to explore experiences with tobacco product use. The initial interview guide was piloted through mock interviews among a sample of four graduate research assistants. We assessed the clarity of the questions, potential probes needed and whether the phrasing of the questions allowed participants to expand on their answers. Interview guide topics explored in the current analyses focused on IQOS perceptions. We began by asking, ‘Have you heard of IQOS? If so, how did you learn about it? What do you know about IQOS?’ In order for participants to respond to the remainder of the questions with similar information, we then said, ‘IQOS is an electronic heated tobacco product, with 3 main parts: the heatsticks that contain tobacco, the device into which the heatsticks are inserted and heated, and a charger for the device. If you’d like to see images of IQOS, you can google it’. We then asked, ‘Given what I shared with you just now, tell me what you think about IQOS? What do you find appealing about IQOS, if anything? How do you think it compares with cigarettes (probes: harmful to health, addictive, clean, technology, etc.)? How do you think it compares with e-cigarettes (probes: harmful to health, addictive, clean, technology, etc.)? Have you tried IQOS? Can you tell me about that (probes: Why did you try it? Where did you get it? What did you think of it?)? Would you try IQOS? Why or why not?’

Four female graduate research assistants (never tobacco users) trained in qualitative data collection obtained consent and then facilitated Webex-based, audio-recorded interviews, lasting about 45 min. Upon interview completion, participants were debriefed and compensated ($30 Amazon e-gift card). All audio-recorded interviews were uploaded to a secure, password-protected computer, and the recordings were transcribed verbatim by a contracted professional transcription service.

Data analysis

Descriptive statistical analyses were used to characterize the survey sample and interview subsample, using Stata 15.1. Paired t-tests were used to compare survey data regarding perceptions and use intentions of HTPs versus cigarettes and e-cigarettes, with a significance level of P < 0.05.

Qualitative data were analyzed using QRS Software NVivo v12 and thematic analyses. Transcripts were systematically coded using NVivo and cross-checked for agreement about the application of the codes. Team discussions took place regularly where the codebook themes were redefined, inclusion and exclusion criteria set and representative passages identified. Discrepancies about code choices were resolved through discussion in a process of constant comparison until consensus was reached (Kappa = 93.3%). Inter-rater reliability was calculated for each code through use of an intra-class correlation coefficient and was deemed acceptable if the coefficient was in the 0.80 range. Content codes were used to thematically group similar interview text; themes were organized into overarching domains compiled with representative quotations, which were edited for readability. Balancing the controversy in qualitative research regarding whether to quantify qualitative results, we chose to indicate the frequency with which themes were provided by participants by categorizing them as ‘all’, ‘almost all’, ‘most’, ‘the majority’, ‘some’ and ‘a few’ [48, 49].

Results

Survey results

At W5 (Fall 2020), survey participants represented the six MSAs (with 23.6% moving outside these MSAs by W5), were on average 24.67 years old (SD = 4.70) and were 55.8% female, 31.3% sexual minority, 71.3% White and 11.0% Hispanic, with past-month use prevalence of 19.5% for cigarettes, 25.2% for e-cigarettes and 12.4% for other tobacco products (Table I). Overall, 19.1% (n = 471) reported having ever heard of HTPs (n = 138 for IQOS only; n = 108 for Eclipse only; n = 225 for both, data were not shown in tables), and 4.1% (n = 101) reported ever using HTPs (n = 43 for IQOS only; n = 31 for Eclipse only; n = 27 for both, data were not shown in tables). Additionally, 2.5% (n = 61) reported past 6-month use of HTPs, and 2.3% (n = 57) reported past 30-day use of HTPs.

As shown in Fig. 1, intent to use in the next year was significantly (P < 0.05) lower for HTPs than for cigarettes and e-cigarettes (mean [M] = 1.27 vs. M = 1.73 and M = 2.16, P < 0.05). HTPs were perceived as less addictive than cigarettes and e-cigarettes (M = 5.11 vs. M = 6.28 and M = 5.82, P < 0.05) and less harmful (M = 5.37 vs. M = 6.65 and M = 5.62, P < 0.05). HTPs were perceived as more socially acceptable than cigarettes (M = 3.39 vs. M = 3.13, P < 0.05) but less so than e-cigarettes (M = 3.39 vs. M = 4.37, P < 0.05).

Interview results

Semi-structured interview participants (n = 40) were from across MSAs (range: 3 [7.5%] in Oklahoma City to 10 [25.0%] in Minneapolis-St. Paul); had an average age of 26.30 (SD = 4.39); were 35.0% female, 55.0% heterosexual, 45.0% sexual minority, 57.5% White, 5.0% Black, 22.5% Asian, 15.0% other race and 12.5% Hispanic; 75.0% had a bachelor’s degree and 30.0% married/living with a partner (Table I). Among 40 participants who reported past 30-day e-cigarette use, 7.5% (n = 3) reported past 30-day HTP use, 55.0% (n = 22) reported past 30-day cigarette use and 30.0% (n = 12) reported past 30-day other tobacco use. Table II provides themes, subthemes and representative quotations.

Knowledge/awareness of IQOS

Most participants reported limited knowledge of IQOS—reporting limited exposure to or information about the product. Based on the information that was provided at the outset of the interview, some participants indicated that IQOS seemed like a hybrid of a traditional cigarette and an e-cigarette, as stated by one participant (Seattle, never IQOS user, former cigarette user): ‘So it’s like if a vape pen and a cigarette had a baby kind of.’

Common sources of information for IQOS included mailed coupons, social media advertising and retail vape shop advertising, as noted in Table II.

Perceived health benefits of IQOS

Perhaps because most participants indicated minimal knowledge about IQOS, many reported uncertainty about IQOS’ health effects. For example, one participant (Seattle, never IQOS user, current cigarette user) said: ‘Slim chances that it’s any better than what’s already on the market. They’re probably like, siblings to one another. You know, they’re one and the same’.

Moreover, many asked questions about their benefits and utility. For instance, one participant (Atlanta, never IQOS user, current cigarette user) said: ‘Does the stick have tobacco leaves in it? Or is it kind of a liquidated or liquefied version of tobacco? Like what else is in it?’

Perceived risks compared to cigarettes

Some participants were uncertain about the risks (i.e. harm to health and addiction) of IQOS relative to cigarettes or thought IQOS posed similar risk. For example, one participant (Minneapolis, never IQOS user, former cigarette user) said: ‘I feel like it would still pretty much have the same ability to cause an addictive or to cause an addiction as much as like vaping or regular cigarettes’.

However, most perceived less risk associated with using IQOS versus cigarettes. One participant (San Diego, never IQOS user, former cigarette user) said: ‘It seems like it would be not as harmful as a regular cigarette because you’re not actually burning the tobacco’.

Perceived risks compared to e-cigarettes

There was a broad range of perceived health impacts of IQOS compared to e-cigarettes. Some reported being uncertain, while others believed they were likely similarly harmful. One participant (Seattle, never IQOS user, former cigarette user) said: ‘It sounds cleaner but I don’t know enough about it. Then again, it could also have more chemicals in it than the average vape or e-cigarette or who knows what’s in it…’.

However, some reported that they believed IQOS was more harmful than e-cigarettes generally because IQOS contains tobacco. On the other hand, some reported that they thought IQOS was less harmful than e-cigarettes, given that e-cigarette e-liquids also contain harmful components. For example, one participant (Boston, never IQOS user, former cigarette user) said: ‘I’m sure it’s probably tenfold better (than e-cigarettes), because it doesn’t have rat poison—and God knows what else—in it’.

IQOS use intentions

Most participants reported minimal interest in trying IQOS. The most common reasons for low interest included the risks associated with IQOS containing tobacco, limited flavors available (e.g. ‘If it was flavored and legal, then it might be intriguing. But if it’s not flavored, then to me, it’s like, “what’s the point? If I’m, if I’m going to be smoking or vaping something that tastes like a cigarette, then I might as well just smoke a cigarette?”’—Boston, never IQOS user, former cigarette user) and complexity of use (e.g. ‘Seems like a lot of work. And like it wouldn’t be enjoyable.’—San Diego, never IQOS user, former cigarette user).

Some participants reported interest if e-cigarette regulations became stricter and if there were no or minimal costs of trying IQOS (‘If it was free, maybe, but I’m not gonna go out of my way or anything.’—San Diego, never IQOS user, current cigarette user) or to fulfill their curiosity (e.g. ‘I might try it just to see the you know, to fulfill that curiosity of like, “How the hell does this thing work?”’—Atlanta, never IQOS user, current cigarette user).

Prior experiences using IQOS

Among those who had tried IQOS, most reported negative experiences, including harsh taste, strong nicotine hit and complexity to use. One participant (Minneapolis, ever IQOS user, current cigarette user) said: ‘I’m not really thrilled with it. I have tried one. It seems to be it seems to be a harsher device than was intended. It gives you a more aggressive hit of straight nicotine’. However, the same participant also reported positive aspects of IQOS use, including available flavors: ‘The flavors are surprisingly good. Okay, they’re actually not terrible. They’re a lot better than some of the other heating element devices I’ve seen’.

Discussion

This mixed methods study found that HTP awareness, use and intention to use HTPs were low in both the survey and interview samples of US young adults. This 2020 data indicated higher rates of HTP awareness and ever use relative to those documented in other national probability samples prior to IQOS’ launch in the United States [18, 19]. Current findings also indicate higher rates of awareness and use in this sample in 2020 (19.1% and 4.1%) compared to 2019 (9.7% and 3.5%) [21, 50], which may be due to study participants being exposed to descriptions of HTPs in prior surveys in this longitudinal study. However, these increases in awareness and use may also be due to IQOS market expansion in 2019–2020 and potential targeted marketing to young adults [26, 51–53]. Based on what interview participants did know, some perceived IQOS as a hybrid of a traditional cigarette and an e-cigarette. This common perception may be related to ways in which they perceived IQOS as being similar versus dissimilar to each product.

Regardless, across the survey and interview samples, there was low interest in using IQOS. Intention to use was lower than for cigarettes and e-cigarettes overall and among cigarette and e-cigarette users in the survey sample. Among interview participants (i.e. e-cigarette users) who had tried IQOS, most had negative experiences (e.g. harsh taste). Interview findings indicated that common reasons for low interest in using IQOS included complexity of use, limited flavors available and IQOS containing tobacco. The former reasons may reflect young adult e-cigarette users’ level of savviness about the broad range of e-cigarette products available, their technology and customization and their flavors and other attributes that appeal to youth [54–56].

Concerns about IQOS containing tobacco may relate to perceived harm. Consistent with previous studies [57–60], almost all interview participants perceived IQOS as harmful to health, and most perceived IQOS as a reduced-harm product relative to cigarettes. However, most were uncertain about the health impacts of IQOS compared to e-cigarettes. Survey findings echoed these findings; while IQOS was perceived as less harmful than cigarettes and e-cigarettes, the difference was greater relative to cigarettes. Participants’ perceptions of HTPs’ reduced harm could be at least partially attributable to IQOS’ marketing, which emphasizes the health benefits and uses ‘reduced exposure’ claims. Notably, some of the authorized languages are concerning because (i) reduced exposure claims may be interpreted as reduced risk [40–42] and (ii) consumers often misinterpret messaging about ‘switching completely’ from traditional cigarettes to IQOS [40–42]. However, despite PMI’s efforts to distinguish IQOS from e-cigarettes [33], participants were uncertain about the relative harms of these two tobacco products, which may be due to the novelty of HTPs in the US market with the debut of IQOS in October 2019 [15]. In addition, e-cigarette may have been perceived as more harmful in recent years, particularly after the EVALI epidemic [61, 62]. Therefore, participants may perceive IQOS as less harmful than e-cigarettes. As the HTP market continues to expand, further longitudinal studies are needed to monitor HTP harm perceptions in relation to both cigarettes and e-cigarettes among more diverse populations, which may have implications on the transitions across products among consumers.

Additional findings regarding other risk perceptions, specifically perceived addictiveness, should be of interest. IQOS was deemed less addictive than both cigarettes and e-cigarettes in the survey sample, which is noteworthy, as all tobacco products must contain the warning ‘This product contains nicotine. Nicotine is an addictive chemical’. Moreover, IQOS has not historically focused on this aspect of the product in its advertising [32]. Thus, it is valuable to determine why young adult consumers perceive HTPs as being less addictive than cigarettes and e-cigarettes.

The reported sources of IQOS-related information included social media, retail stores and coupons. Indeed, prior research has documented that, in addition to traditional tobacco marketing approaches (e.g. discounts and coupons, retailing outlets, etc.), IQOS has been marketed via relatively innovative forms (e.g. online/mobile, social media platforms, point-of-sale events, etc.) [33, 63, 64]. The wide range of marketing approaches may make IQOS more appealing to young adults [26, 51, 52]. Moreover, these novel efforts may be aimed at advancing the product’s social appeal, which might be in response to findings such as ours that, in some consumer groups, HTP use is perceived as less socially acceptable than e-cigarette use and is rated similarly to cigarette use in this regard.

Implications for research and practice

Further studies are needed to clarify the effects of IQOS marketing on the harm perceptions relative to cigarette and e-cigarette use, particularly as ‘reduced exposure’ messages continue to evolve—once IQOS is sold in the United States again. Future research might also probe to distinguish harm perceptions regarding HTPs relative to various types of tobacco products, such as earlier generation versus more recent e-cigarette devices [65]. Beyond IQOS, however, as other products obtain FDA authorization to use ‘reduced exposure’ or ‘reduced risk’ messaging in their marketing, the same implication holds true—we must document the impacts of these messages on consumers’ product perceptions. Research is also needed to understand other risk perceptions, particularly for addiction, and how these products are perceived differently, especially across different populations. Young adults may weigh certain product risks, like addictiveness, as more important deterrents to tobacco and substance use [66–69]. As HTPs become increasingly available, it is important to monitor their marketing and its impact among both tobacco-using and tobacco-naïve young adults to inform preventive and regulatory efforts and to reduce potential HTP-related public health harms.

Limitations

First, these samples have limited generalizability: the survey sample resulted from social media-based recruitment that oversampled cigarette and e-cigarette users, and the interview sample composed of e-cigarette users from this survey sample. Thus, estimates of awareness, perceptions and use of HTPs and other tobacco among survey participants should be interpreted with caution, and qualitative findings must be interpreted appropriately as drawn from e-cigarette users. Second, self-reported awareness and use of HTPs and other tobacco products may introduce recall bias and social desirability bias [70], and it is important to note that survey and interview participants were exposed to descriptions of HTPs in the longitudinal surveys beginning in 2019.

Conclusions

Current findings contribute to the growing literature on HTP awareness and use among US young adults. We found that HTP awareness, use and use intentions were low in this sample—lower than for cigarettes and e-cigarettes. Furthermore, participants predominantly viewed IQOS as less harmful than cigarettes, equally harmful as e-cigarettes, less addictive than both cigarettes and e-cigarettes and less socially acceptable than both cigarettes and e-cigarettes. As the HTP market in the United States and globally expands, marketing is likely to impact young adult perceptions of HTPs, particularly as HTP marketing strategies continue to innovate and use ‘reduced exposure’ messaging.

Funding

US National Cancer Institute [grant numbers R01CA215155-01A1 to C.J.B., R01CA215155-04S1 to D.L.]; National Cancer Institute [grant numbers R01CA239178-01A1 to C.J.B. and H.L., R01CA179422-01 to C.J.B, R21CA261884-01A1 to C.J.B.); Fogarty International Center [grant number R01TW010664-01 to C.J.B.]; National Institute of Environmental Health Sciences/Fogarty [grant number D43ES030927-01 to C.J.B.]; National Institute on Drug Abuse [grant number R01DA054751-01A1 to C.J.B., F32DA055388-01; PI: Romm; R25DA054015; MPIs: Obasi, Reitzel to K.F.R.].

Conflict of interest statement

Yael Bar-Zeev has received fees for lectures from Pfizer Ltd, Novartis NCH, and GSK Consumer Health (distributors of smoking cessation pharmacotherapy in Israel) in the past (2012–July 2019). Hagai Levine had received fees for lectures from Pfizer Israel Ltd (distributor of a smoking cessation pharmacotherapy in Israel) in 2017. Lorien Abroms receives royalties from the sale of Text2Quit from Wellpass Inc.

References