Japan represents an amazing example of capitalism and consumer choice resulting in an unprecedented decrease in the number of cigarettes smoked, without the need for government funding or intervention.

In Japan, vapes (or “e-cigarettes”) with nicotine are effectively banned. They are considered a “pharmaceutical product,” and cannot be marketed without a pharmaceutical license.

Heat-Not-Burn (HNB) devices are allowed and regulated in a similar way to cigarettes. In some cases, they are subject to less strict rules. For example, in some locations, they are allowed while combustible cigarettes are not.

What is a heat-not-burn device?

HNB devices use a small sachet of tobacco that is warmed to release a vapour that the user inhales. The tobacco is never heated enough for it to burn, so the thousands of toxic chemicals produced by burning tobacco leaves are either absent or present in much lower concentrations.

There is general agreement that HNB products produce fewer toxic chemicals than cigarette smoking, but more than vaping. Smokers who have switched to HNB products have reduced biomarkers of toxicity compared to people who continue smoking.

In the USA, the Food and Drug Administration (FDA) states: “Scientific studies have shown that switching completely from conventional cigarettes to the IQOS system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.”

The FDA has authorized the marketing of iQOS as a modified risk tobacco product (MRTP). It is the first tobacco product to receive “exposure modification” orders, which permits the marketing of a product as containing a reduced level of or presenting a reduced exposure to a substance, or as being free of a substance when the issuance of the order is expected to benefit the health of the population.

As an additional bonus, conventional cigarettes are the leading cause of household fires in Japan and HNB devices are much less likely to cause fires.

PMI started a pilot for iQOS in Japan in 2014. In the two years, 2016 and 2017 HNB products took over 16.5% of the total Japanese tobacco market. By mid-2020, iQOS alone had 18.7% of the market, and Blu, its main competitor, had an additional 4.5%. In the first quarter of 2021 “Reduced risk products” (mainly HNB devices) made up 31.7% of the Japanese tobacco market.

What do these changes mean in terms of the number of actual cigarettes sold? According to the official publications of Japan Tobacco, in the first three months of 2016 43.6 billion cigarettes were sold in Japan. In the first quarter of 2021, only 25 billion sticks were sold, a decline of 42.7% in half a decade. That is 18.6 billion fewer cigarettes sold in one quarter, or 74.4 billion fewer cigarettes sold every year.

In 2019 Japan’s male smoking rate fell below 30 percent for the first time, slipping to 28.8 percent, down 2.3 points from the previous study in 2016, according to a health ministry survey.

Is the decrease in cigarette consumption due to national changes in Japan, such as an increase in smoke-free areas, or can it be attributed to iQOS? Independent research confirms that decreased tobacco sales in Japan are likely due to IQOS. The product was introduced into 11 areas of Japan at different times, with the decline in cigarette sales following the introduction of IQOS.

The availability and advertising of HNB devices have not resulted in an “epidemic” of use by teenagers. In Japanese High Schools, only 1% of students use a HNB device or a vape on a monthly basis, and only 1:1,000 use HNB devices or vapes every day.

Canadian tobacco control expert David Sweanor said: “All Japan has done, really, is not obstruct the efforts for this single category, and still we have the most rapid decline in cigarette sales that we’ve ever seen.

Could HNB devices produce a similar dramatic decrease in tobacco smoking in other countries?

As of the second quarter of 2019, PMI reported that IQOS was offered in 52 countries and that it has an estimated 13.6 million users.

In South Korea, HNB sales rose from 79 million packs in 2017 to 332 million packs in 2018 while cigarette sales decreased by 8.9% in the same time period. PMI claims that HNB products are also reducing tobacco sales in Italy, Latvia, and Lithuania.

211,700 of Japan’s roughly 20 million smokers die every year. In theory, a 42.7% decline in cigarette sales caused by smokers switching to iQOS could eventually result in 90,400 fewer deaths, if iQOS was harmless, or over 80,00 if iQOS carries 10% of the health risk of smoking. However, there has only been a small decrease in the prevalence of smoking in Japan, from about 19% in 2016 to about 17% in 2019. It seems that people are decreasing the number of cigarettes they smoke, perhaps by using iQOS in public and cigarettes at home, rather than quitting. In some places in Japan, one can use a HNB product even though smoking is not allowed.

So far there have been no studies done to determine if there are any measurable population health benefits of a large-scale switch from smoking to HNB products.

Japan has seen a huge reduction in the number of cigarettes smoked as PMI has successfully marketed its iQOS brand of heat-not-burn product. This was driven almost entirely by market forces and the choice of informed consumers, with minimal public health intervention.