Educational gradients in the use of electronic cigarettes and heat-not-burn tobacco products in Japan

OBJECTIVES In addition to electronic cigarettes (e-cigarettes), tobacco companies have recently begun to sell heat-not-burn tobacco products, Ploom and iQOS in Japan. Previous research has reported an inverse association between combustible cigarette smoking and educational attainment, but little is known about the association for e-cigarettes, especially heat-not-burn tobacco products. Our objective was to analyze the relationship between educational attainment and e-cigarette and heat-not-burn tobacco use. SETTING An internet survey (randomly sampled research agency panelists) in Japan. PARTICIPANTS A total of 7338 respondents aged 18-69 years in 2015 (3632 men and 3706women). PRIMARY MEASURES Adjusted odds ratios (ORs) of educational attainment for current smoking (combustible cigarettes), e-cigarette ever-use, and heat-not-burn ever-use were calculated by multivariable logistic regression models using covariates including socio-demographic factors. Stratified analyses according to smoking status (combustible cigarettes) were additionally performed for e-cigarette ever-use and heat-not-burn tobacco product ever-use. RESULTS Associations between educational attainment and e-cigarette ever-use or heat-not-burn tobacco ever-use are not straightforward, although these associations are not statistically significant except for one cell. For example, using "graduate school" education as a reference category, adjusted ORs for "high school" were 1.44 (95% confidence interval [CI]: 0.85-2.44) for e-cigarettes ever-use and 0.75 (95% CI:0.19-2.97) for heat-not-burn tobacco product ever-use. Among current smokers, compared with "graduate school" (reference), those with lower educational attainment showed 0.6 to 0.7 ORs for e-cigarette ever-use: e.g.,"4-year university"(OR = 0.54, 95% CI:0.24-1.24) and "high school" (OR = 0.69, 95% CI: 0.30-1.60). Among former smokers, lower education indicated higher ORs for both e-cigarettes and heat-not-burn tobacco ever-use. CONCLUSIONS This study provides baseline information on educational gradients of e-cigarette and heat-not-burn tobacco products, ever-use. As heat-not-burn tobacco products are increasing their market share in Japan, continuous monitoring of these products will be necessary.