Qualitative examination of US and Israeli adults' perceptions of IQOS advertising messages: modified exposure and risk statements, US FDA endorsement, and health warnings.

Introduction: IQOS, a leading heated tobacco product, is advertised as less harmful than cigarettes and received US Food and Drug Administration (FDA) authorization for 'reduced exposure' advertising claims. Perceptions of advertising messages, including reduced exposure/risk claims, FDA endorsements, and health warning labels (HWLs), are understudied.

Methods: Qualitative interviews (N=84) from US and Israeli adults (2022) examined perceptions of advertising messages, specifically: 1) scientific claims that switching completely from cigarettes to IQOS reduces 1a) chemical exposure and 1b) tobacco-related disease risk; 2) FDA endorsement of IQOS as a 2a) better choice for adult smokers and 2b) fundamentally different product (heat-not-burn); and 3) promoting IQOS as cigarette alternatives with a HWL pertaining to cigarettes.

Results: For half of participants, referencing scientific studies or the FDA enhanced credibility; some believed this implied unbiased, rigorous research. Half were skeptical due to lack of research-related details. Half interpreted message 1 (switching) to mean any substitution could be beneficial; half interpreted it as complete substitution was necessary. Most did not perceive differences between message 1a (reduced exposure) vs. 1b (reduced risk). Some believed message 2a (FDA endorsement, not targeting youth) demonstrated IQOS' social responsibility. Some interpreted message 2b (fundamentally different product) as risk reduction; others perceived no difference. The majority paraphrased messages using the terms 'safer', 'healthier', or 'less harmful'. For message 3 (safer alternative), some did not think the HWL applied to IQOS; some believed it promoted IQOS.

Conclusion: Regulators and researchers must monitor harm reduction advertising messaging and take actions to prevent consumer misinterpretations.

Implications: Philip Morris International's IQOS received US Food and Drug Administration (FDA) authorization for 'reduced exposure' advertising claims, which are often misinterpreted, and has exploited FDA authorization to promote IQOS globally. This qualitative study showed that most participants perceived no difference between reduced risk vs. exposure messages in IQOS ads, half believed that references to scientific studies or FDA enhanced credibility, some believed certain messages demonstrated IQOS' social responsibility, and some perceived warnings in IQOS ads to promote IQOS. Product ads using harm reduction messages must be monitored to inform efforts to prevent potentially harmful misinterpretations and mitigate negative population-level impacts.