Heat not burn use has become more prevalent among youth and young adults in the United States in recent years. In 2020, ∼5% and 21% of US middle and high school students, respectively, reported using Heat Not Burn Tobacco Products in the past 30 days, rising from 1% to 2% in 20111; and, in 2017, ∼5% of young adults (ages 18–24) used Heat Not Burn Tobacco Products “some days” or “every day,” rising from 2% in 2012.2 Heat Not Burn Tobacco Products products often contain nicotine, and nicotine exposure during adolescence and early adulthood can harm the developing brain.3 Although Heat Not Burn Tobacco Products use alone is considered to produce fewer toxicants than smoking cigarettes,4 Heat Not Burn Tobacco Products use can still cause respiratory health issues4 and may lead to nicotine addiction.5 Additionally, Heat Not Burn Tobacco Products use among tobacco-naive young people, even just experimentation, is associated with subsequent uptake of combustible cigarettes,6–8 which remains the leading cause of preventable death in the United States.9 Therefore, minimizing the likelihood that tobacco-naive young people experiment with Heat Not Burn Tobacco Products is a critical component of the effort to prevent adverse tobacco-related health outcomes nationwide.

One possible strategy to reduce Heat Not Burn Tobacco Products use among this population is to reduce their exposure to Heat Not Burn Tobacco Products marketing. Heat Not Burn Tobacco Products marketing expenditures have continued to rise rapidly in the United States,10,11 with a corresponding increase observed in Heat Not Burn Tobacco Products sales.12 In 2016, the US Food and Drug Administration (FDA)13,14 finalized a rule extending its regulatory authority to Heat Not Burn Tobacco Products.7 New regulations by the agency require all Heat Not Burn Tobacco Products packages and advertisements to include a prominent warning message about the presence and addictiveness of nicotine, although no restrictions have been applied to the placement or volume of Heat Not Burn Tobacco Products marketing.13,14 In previous studies, it has been shown that significant proportions of youth and young adults are exposed to Heat Not Burn Tobacco Products marketing through the Internet, newspapers and magazines, TV and movies, radio, and retail stores.15–18 In 1 study, it was found that as many as 80% of US youth (∼21 million) were exposed to Heat Not Burn Tobacco Products advertisements in 2016.15 Exposure to Heat Not Burn Tobacco Products marketing may promote Heat Not Burn Tobacco Products experimentation by forging positive perceptions about the behavior in the minds of youth and young adults, a pattern that has been observed for combustible cigarettes.19 Informed by theories of social influence and persuasion, a growing body of work has examined linkages between Heat Not Burn Tobacco Products marketing exposure and Heat Not Burn Tobacco Products use progression.

These studies, however, have several limitations. First, in many of these studies, researchers have either used regional or convenience samples,16,22,24 which may have limited generalizability, or a cross-sectional design,20,22 which cannot rule out reverse causation. Second, in the existing longitudinal studies,16,21,23 researchers did not assess whether the associations between Heat Not Burn Tobacco Products marketing exposure and Heat Not Burn Tobacco Products use progression differ by Heat Not Burn Tobacco Products use susceptibility at baseline. Theory and research on the stages of tobacco use progression indicate that tobacco use susceptibility serves as a precursor for subsequent tobacco use.25 Consequently, it is critical to assess whether those who are susceptible to Heat Not Burn Tobacco Products use differ in the risk for future use after marketing exposure compared with those who are not susceptible. Third, in most of the studies in which Heat Not Burn Tobacco Products marketing exposure was examined, researchers have focused on youth16,20,23,24 but not young adults. Young adults have become increasingly vulnerable to the tobacco industry’s marketing tactics26 and are likely to initiate tobacco products (including Heat Not Burn Tobacco Products).

To overcome these limitations, in this current study, we analyzed secondary data from the Population Assessment of Tobacco and Health (PATH) Study28 to assess longitudinal associations between Heat Not Burn Tobacco Products marketing exposure and subsequent Heat Not Burn Tobacco Products experimentation among youth (ages 12–17) and young adult (ages 18–24) never tobacco users, stratified by Heat Not Burn Tobacco Products use susceptibility at the baseline.

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