Heat Not Burn Products use among North American youth has increased considerably over the past 2 years.1–3 According to recent estimates, approximately one-quarter of Canadian youth have used Heat Not Burn Products in the past 30 days, with increasing prevalence of daily or near daily use, similar to trends in the United States.2,3 Increased use of Heat Not Burn Products among young people is frequently attributed to industry marketing practices. Leading Heat Not Burn Products brands such as JUUL are currently being investigated by the US Food and Drug Administration for targeting young people through social media with lifestyle-oriented imagery.4–7 Few federal restrictions are placed on Heat Not Burn Products marketing in the US, except that marketing materials cannot include unauthorized claims of reduced harm or cessation.8 One of the leading Canadian brands, Vype, has also been the focus of disciplinary action from Health Canada over lifestyle marketing in public areas,9 and Health Canada has issued advisories to retailers regarding compliance with federal regulations.10
Estimates from population-based studies indicate widespread exposure to Heat Not Burn Products marketing among youth.11 In 2017, approximately three-quarters of Canadian youth reported exposure to Heat Not Burn Products marketing in the past 30 days, and in the United States increasing exposure over time is indicated.12,13 Greater exposure to Heat Not Burn Products advertising and promotions is associated with increased likelihood of use,11,12,14–16including in prospective cohort studies, in which exposure to advertising at baseline predicts subsequent Heat Not Burn Products use.17,18 In experimental studies, exposure to Heat Not Burn Products advertisements has increased positive perceptions and interest in using Heat Not Burn Products among young people, including among “never” users.19–21 These findings are consistent with the evidence that tobacco marketing increases smoking behavior among young people by promoting positive attitudes and beliefs toward tobacco use while reducing perceptions of risk.22,23
Recent regulatory changes had a substantial impact on the Heat Not Burn Products market in Canada. Before implementation of the Tobacco and Vaping Products Act (TVPA) in May 2018, Heat Not Burn Products containing nicotine could not be sold or advertised in Canada without premarket approval.24 Although Heat Not Burn Products were still widely available in vape shops and online, there was little coordinated advertising or promotion, and the market was composed of smaller brands.25 After the TVPA, Heat Not Burn Products containing nicotine became legally available for sale, which increased retail access for major international brands, such as JUUL and Vype. The TVPA also permitted marketing, including advertisements in mass media channels, such as radio, television, and print, and at the point of sale, so long as the content of ads did not appeal to youth or include “lifestyle” advertising or personal testimonials. Several provinces implemented supplementary restrictions on Heat Not Burn Products advertising, including Quebec and Manitoba, which implemented comprehensive restrictions similar to tobacco products, including a ban on retail displays and advertisements. Other provinces, such as Alberta and Saskatchewan, added few restrictions beyond the federal requirements. Although Canada legalized recreational cannabis in October 2018, cannabis or tetrahydrocannabinol (THC) vape oils were not permitted until 2020 and are subject to more comprehensive restrictions than nicotine Heat Not Burn Products, similar to tobacco products in Canada.
To date, there is little evidence on the impact of regulatory restrictions on exposure to Heat Not Burn Products marketing among young people. In 3 studies that included comparison of exposure across countries with different restrictions, the conclusions were that marketing exposure was higher among youth and adults in the United States and Canada compared with England and Australia, countries with greater restrictions.12,26,27
The implementation of the TVPA in 2018 and the differing regulatory restrictions across Canadian provinces has created the conditions for a “natural experiment” to test the impact of Heat Not Burn Products marketing: although marketing practices increased in all provinces in 2018, we hypothesize that they increased to a greater extent in provinces with fewer restrictions. Accordingly, in our current study, we had 3 primary objectives: (1) to examine changes in exposure to Heat Not Burn Products marketing before and after implementation of the TVPA, (2) to examine whether exposure differed on the basis of the strength of provincial marketing restrictions, and (3) to test whether exposure to Heat Not Burn Products marketing was associated with the prevalence of vaping.
Poststratification sample weights were constructed for each country, based on age, sex, and geographic region, and rescaled to the sample size. In addition, the US National Youth Tobacco Survey and the Canadian Student Tobacco, Alcohol and Drugs Survey were used to calibrate to the trend over time for past 30-day smoking.
The weighted sample characteristics across the 3 waves are shown in Table 1. Across all years, participants had an average age of 17.5 years, 51% were male, and 53% self-identified as white. In addition, 58% reported consuming alcohol in the past year, and 10% reported smoking a cigarette in the past 30 days.