Odor Reduction Drives Transition to Heat-Not-Burn Tobacco Products in Poland

Introduction

HNB PRODUCTS:

Despite extensive health promotion initiatives, public information campaigns, and progress in pharmacological treatments, nicotine addiction remains an unresolved social problem.

HnB products may serve as a potential harm reduction tool, aimed not at treating nicotine dependence directly, but at mitigating the adverse health consequences associated with tobacco use [6]. Currently, HnB products are used in more than 70 countries. Although first introduced in the late 1980s., HnB originally did not achieve commercial success [7]. However, since 2014, the HnB market has grown rapidly [8].

These new tobacco products are viewed as a potential means of reducing the burden of tobacco-related diseases among smokers and as a potential mechanism to assist smokers in quitting [9]. Human studies have shown that HnB products, when used by smokers, are associated with significant reductions in blood or urinary biomarkers of tobacco toxicants, particularly when fully switching, and to some extent in case of dual use. While the extent to which these biomarkers represent potential lung toxicity is not entirely clear, several studies have indicated that former smokers who switch to e-cigarettes or HnB products tend to experience lower odds of respiratory outcomes, fewer exacerbations, and improvements in symptoms and physical activity compared to those who continue smoking conventional cigarettes or engage in dual use [10]. In Poland, heated tobacco products have been available since 2017, and within 6 years of market launch, >20% of adults in Poland had ever tried such products [11].

SMOKING PREVALENCE IN POLAND:

A 2019 CBOS study, conducted on a representative random sample of 1077 adult residents of Poland, found that approximately 26% of adults smoke, with 20% smoking regularly and 5% smoking occasionally [12]. The study also revealed that smoking prevalence differs by sex, with 31% of males and 21% of females smoking. More recent data from a 2022 nationwide study on “Poles’ attitudes towards smoking” showed that 28.8% of adults in Poland were daily smokers (30.8% males and 27.1% females), 4.8% used e-cigarettes daily, and 4% were daily heated tobacco users [13]. Between 2022 and 2024, the prevalence of daily heated tobacco use increased from 4% to 4.9% among Polish adults [11]. Over the past 3 years, several factors – including the conclusion of the COVID-19 pandemic, ongoing public discussions, and the introduction of a ban on disposable e-cigarettes – may have affected nicotine consumption patterns in Poland. This highlights the need for continuous monitoring of consumer behaviors and decisions to better understand the influence of these changes on nicotine use and the effectiveness of related health promotion efforts.

HEALTH CONSEQUENCES:

According to the current Health Needs Maps for the years 2022–2026, the most significant health risk factor in Poland is tobacco, which has been in the top position since 1990 [14]. Data from the Global Burden of Disease 2021 study confirm that tobacco, high blood pressure, and dietary risks are leading factors contributing to death and disability in Poland [15]. Smoking is linked to various neurological, cardiovascular, and pulmonary diseases [16]. Most smoking-related deaths are caused by cancers (mainly lung cancer), respiratory disease (mainly chronic obstructive pulmonary disease [COPD]), and cardiovascular disease (mainly coronary heart disease). In addition, smoking increases the risk of stroke, blindness, deafness, back pain, osteoporosis, and peripheral vascular disease, which can lead to amputation. After the age of 40, smokers typically experience greater levels of pain and disability compared to non-smokers [17]. Long-term trends in cancer incidence and mortality in Poland have been determined by both the age structure of the population and changes in exposure to carcinogenic factors, primarily those associated with cigarette smoking. Notably, in 2022, data from Polish National Cancer Registry showed that the number of women who died from lung cancer once again exceeded the number of deaths from breast cancer – by 20% [18].

ROLE OF PRIMARY CARE PHYSICIANS:

According to the CBOS study, only16% of Polish smokers had attempted to quit, and only 13% of conventional cigarette users intended to quit in the near future [12]. Primary care physicians play a critical role in the prevention and control of tobacco dependence, as they are often the first point of contact in advising patients to reduce or cease smoking [19]. However, findings from a survey conducted by the Anti-Nicotine Section of the Polish Society for Lung Diseases among 700 smokers indicated that 90% of doctors advise patients to quit smoking, but offer no more assistance, and only 40% offer guidance on how to quit [20]. A group of Polish experts emphasizes that physicians should combat cigarette smoking using all available methods and proposed a scheme for the treatment of tobacco addiction that includes the use of HnB products (Figure 1) [6]. HnB products could be considered a harm reduction option for individuals who are unable or unwilling to quit smoking, especially in view of the limited long-term success of pharmacological and behavioral treatments.

RESEARCH GAP:

Although the growth of HnB products use prevalence is already well documented, there is limited information on the factors that drive switching from conventional cigarette smoking. For instance, a UK-based study (2018–2019) identified 6 key factors influencing the initiation and use of HnB products: health, financial, physical, practical, psychological, and social [21]. Similarly, a cross-sectional study from Japan indicated that the most common reasons for regularly using HnB products are beliefs that HnB are less harmful than cigarettes to themselves or to others, enjoyment, and social acceptability [22]. In South Korea, research revealed that the primary reasons for initiating HnB use among all users are curiosity, use by family and friends, and appreciation of the HnB technology. Continued use was most commonly motivated by the perception that HnB products emit less odor than cigarettes, are less harmful to one’s health, and help reduce stress [23]. Despite these insights, there remains a need for further research to better understand the specific motivations, beliefs, and social dynamics that contribute to the shift from conventional smoking to HnB use.

OBJECTIVE AND LIMITATIONS:

The primary objective of this study was to identify the key factors influencing the use of HnB products among smokers in Poland. Accordingly, we sought to identify the reasons and motivations behind participants’ decisions to use or avoid HnB products. Although the sample size of 35 interviewees does not allow for broad generalization, it is important to recognize that qualitative research, particularly with smaller groups, is valuable for exploring complex phenomena in depth. Detailed exploration of individual perspectives and the identification of emerging patterns and trends offers valuable insights for future studies.

FINDINGS:

The primary motivation for switching from conventional cigarettes to HnB products among users was the desire to eliminate the characteristic odor, with perceived health benefits cited as the second most important factor. Notably, respondents did not spontaneously mention potential health risks associated with HnB use, which may reflect either a reduced risk perception or limited awareness. HnB products also were associated with modernity and technological appeal, which could lead to broader adoption, especially among young tech-savvy populations. Meanwhile, a subgroup of “traditionalist” smokers rejects new nicotine delivery systems, indicating cultural resistance that may require tailored interventions.

In conclusion, while HnB products may appear to offer a safer alternative to conventional cigarettes, there are significant gaps in users’ awareness of the potential risks. Public health efforts should focus on increasing risk awareness, addressing misconceptions, and conducting further research on the long-term health impacts of these products. Understanding the social factors driving their adoption will also be crucial for developing effective public health strategies and interventions.

Material and Methods

ETHICS:

The study was approved by the Ethical Review Board of the Medical University of Warsaw (KB/193/2021) and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Each respondent provided informed consent to participate. The interviews were anonymized upon completion, with each identified by number only. Respondents received a reward for their participation in the form of a book on healthy eating. No other material or financial rewards were offered.

RESEARCH TEAM:

Three out of 4 authors conducted the interviews (1 female, 2 males). One of them was a PhD student, 2 had PhDs. All were researchers and academic teachers at time of the study, with a strong background in public health, epidemiology, and social studies. There were no connections between researchers and the subjects.

STUDY DESIGN:

This qualitative study used the semi-structured interview technique. Interviews were conducted between June and August 2022. Each interview lasted between 20 and 60 minutes. Study participants were purposively recruited through social media and interest groups. A recruitment announcement was posted in these groups. Eligibility criteria included the use of a nicotine-containing product (conventional cigarettes, HnB, e-cigarettes) and meeting the study’s age requirements. Individuals who responded to the announcement first participated in a brief screening interview to confirm eligibility, followed by the full in-depth interview.

Face-to-face interviews (at the respondent’s place of residence) and online (using MS Teams or Zoom, depending on the respondent’s preference) interviews were conducted without third parties present. Audio recordings were made of each interview and later transcribed to text using professional transcription software. The transcripts were verified by researchers. Due to the nature of the study, they were not reviewed or modified by the participants after the transcription stage. No follow-up interviews were conducted, and participants did not provide feedback on the findings. All participants were informed about the study’s purpose and structure prior to participation and gave their consent to take part. The study design did not account for dropouts.

PARTICIPANTS:

The participants were 35 individuals smoking various tobacco-containing products. They were all residents of Poland living in different regions to provide a broad perspective. Quota sampling was used based on age group and exposure to nicotine-containing products. The following quotas were employed:

The respondents were selected based on their availability and compliance with the age criterion and exposure to nicotine-containing products. Pregnancy was an exclusion criterion. Participants had no prior relationship with the researchers. The researchers’ motivation for conducting this study was to continue the work analyzing the consumption of both conventional and new forms of tobacco products in Poland. A descriptive phenomenological approach was employed to explore the lived experiences and decision-making processes of participants regarding the use of nicotine-containing products. This approach was chosen to remain close to the participants’ own words and perspectives, minimizing researcher interpretation. Data saturation was discussed between researchers.

MEASUREMENT:

The questions were developed by the authors. The study utilized an original interview framework consisting of 10 thematic sections: i) introduction; ii) family history of tobacco use (childhood); iii) use of nicotine-containing products; iv) nicotine in the household (currently); v) initiation to tobacco – cigarettes; vi) initiation to novel nicotine-containing products; vii) attempts to quit smoking conventional cigarettes; viii) attempts to limit the use of novel nicotine-containing products; ix) attitude to HnB products; x) source of information about HnB products and assessment of their reliability. The aim of the sections was to understand the history, transitions patterns, and the dynamics of product use. The questions were adjusted based on each respondent’s (the product they were using at the time of the interview and those they had used previously). The interview framework was pilot-tested before the study commenced.

The study also employed a conventional questionnaire to collect the sociodemographic data of the respondents. There was 1 data coder. Any points of disagreement or ambiguity were addressed and clarified among the researchers. In case of disagreement, a consensus was reached within the group.

DATA ANALYSIS:

All interviews were transcribed. The initial analysis involved a content analysis of the complete interviews. This was followed by classifying individual fragments of the interviews and assigning each to appropriate categories developed by the research team. The fragments were then transferred to a shared Excel table. The third stage of the analysis involved comparing the responses of individual respondents within each category. The research team held regular detailed discussions at each stage of the analysis.

Results

SOCIODEMOGRAPHIC CHARACTERISTICS OF THE STUDIED POPULATION:

The study enrolled a total of 35 participants, with males accounting for 71.4%. The average age was 38 years (SD 13.2). More than half (51.4%) of the participants lived in cities with a population exceeding 500 000. The detailed data are shown in Table 1.

PARTICIPANTS’ OPINION ABOUT THE ODOR OF HNB PRODUCTS:

The study found that 17 out of 20 HnB users believed that HnB products reduce their discomfort associated with the odor and smell of conventional cigarettes. The odor of conventional cigarette smoke interfered with their daily lives, and the alternative solution in the form of HnB products was found to be attractive to them. The participants cited odor reduction as the main reason for switching from conventional cigarette smoking to HnB products. In the absence of the characteristic smell of cigarettes, they could more easily smoke in various, often closed, spaces. The second most important factor after odor reduction was the health benefits of using HnB products. This preference for odorless or less-smelly options suggests that users are not only seeking a healthier alternative but also aiming for a more socially acceptable smoking experience. The ability to smoke in various environments, including closed spaces, without the stigma of cigarette odor, may reflect a desire for greater convenience and flexibility in their smoking habits.

With regard to non-HnB users (conventional cigarette smokers or e-cigarette users), 7 out of 15 participants found the odor of HnB to be a source of discomfort. That was cited as a key reason for rejecting the tobacco product. Two smokers of conventional cigarettes and e-cigarettes compared the HnB aerosol to the smell of roasted popcorn, which discouraged them from using HnB products. Additionally, 2 smokers of conventional cigarettes acknowledged disliking the odor but described continued use as driven by dependency and habit strength. The results suggest that the smell plays an important role in the decision to accept or reject tobacco products. For some users, the smell of both conventional cigarettes and HnB products is unpleasant enough to be the main reason for rejecting them. The detailed responses from user groups are presented in Table 2.

PARTICIPANTS’ OPINIONS ON HEALTH ASPECTS OF USING HNB PRODUCTS:

Two-thirds of the HnB users mentioned their desire to limit the negative health consequences of smoking as a factor in transitioning from conventional cigarettes smoking to HnB products. Thirteen out of 20 interviewees reported a tangible improvement in their health status after making the switch. Issues related to their previous use of conventional cigarettes were clearly resolved, including a reduction in the intensity coughing (including morning cough), improved respiratory fitness, absence of headaches, reduced dry throat, and an overall improvement in well-being. All HnB product users stated that these products were less harmful than conventional cigarettes. The adverse effects of using HnB products were not perceived as a barrier to their use. These findings may indicate that concerns about health play a significant role in motivating the shift from conventional cigarettes to HnB products. The reported improvements in well-being appear to validate users’ decisions to switch and may contribute to their continued use of HnB. The lack of notable adverse effects may suggest that HnB products are perceived as a practical and less harmful substitute, making them a viable option for individuals seeking to reduce the negative health impacts of smoking conventional cigarettes.

In contrast, participants who used conventional cigarettes found it difficult to accept HnB products; 8 out of 9 users of conventional cigarette reported that these products did not meet their expectations for smoking harm reduction and that they experienced negative health effects while using HnB products, such as stuffiness, coughing, or headaches. These findings may suggest that conventional cigarette smokers have established expectations for nicotine products that HnB does not fulfill – both in terms of physical sensations and perceived health benefits. This may also indicate that the effectiveness of HnB products in facilitating smoking behavior change is highly dependent on individual experiences and subjective evaluations of their effects. The detailed responses from user groups are presented in Table 3.

OPINIONS OF CONVENTIONAL CIGARETTE USERS ABOUT THEIR OWN SMOKING HABITS AND PERCEPTION OF HNB:

Conventional cigarette smokers were not convinced to use HnB products. Six out of 9 interviewees declared that they were satisfied with smoking conventional cigarettes. They accepted the risks associated with smoking conventional cigarette and held a negative attitude toward novel forms of nicotine delivery, such as HnB products. These findings suggest that for some smokers, the psychological and cultural attachment to conventional cigarettes outweighs the perceived benefits of switching to new products such as HnB. Their satisfaction with smoking and acceptance of its associated health risks may reflect a resistance to change, rooted more in habit, identity, or skepticism toward alternatives.

HnB product users are perceived as modern, open to novelties, tech-savvy, and gadgets enthusiasts. The interviewees’ opinions (10 out of 35) suggest that using HnB products has become a trend, particularly among young adult tobacco users. This may suggest that HnB users perceive these products as a modern alternative, aligning with their interest in technology and innovation. It may also imply that using these products is not only associated with the desire to switch to a healthier smoking alternative, but also with the aspiration to be part of a modern, technological subculture. The detailed responses on this matter are presented in Table 4. Key differences/similarities in opinions about odor and health effects between HnB users, e-cigarette users, and CC smokers (Table 5).

Discussion

LIMITATIONS:

The main limitation of this study was its degree of representativeness. A group of 35 interviewees is too small be considered as representative. This issue is common in most qualitative studies with small samples. Such studies are conducted to gain deeper insights into a phenomenon, such as the motives for switching from conventional cigarettes to heated tobacco. Compared to questionnaire-based research, qualitative studies (using free and partially structured interviews) are more in-depth and offer greater potential for exploration. Another limitation was the overrepresentation of males in the study (Table 1). Gender was not a factor in participant selection, as the quotas were based on age and type of tobacco product. This may be related to the confluence of behavioral patterns, cultural influences, and physiological reasons, as highlighted by a study conducted on a large population in India, which found that females had much lower odds of tobacco consumption than males [35]. Neuroimaging research shows that smoking stimulates men’s reward circuits more than women’s, suggesting that males smoke for the psychological benefits of nicotine, whereas women smoke to control their mood or in reaction to stimuli associated with cigarettes.

The limited sample size and demographic representation may influence the generalizability of our findings. To enhance generalizability, future studies could enroll larger and more diverse samples, further enriching the exploration of consumer perceptions and behaviors across different demographic groups. Additionally, future research could build on these findings by examining evolving consumer attitudes towards HnB products in varied socio-cultural contexts, thereby offering more comprehensive guidance for public health and tobacco policy.

Conclusions

POLICY IMPLICATION AND RECOMMENDATIONS:

The results of the study suggest that sensory and social factors, such as the elimination of unpleasant odors, can significantly influence consumer decisions regarding the choice of nicotine products. For many users, it was the absence of the characteristic cigarette smell that served as the main motivation for switching to these products – more so than concerns about health. This may indicate a shift in consumer motivations – from health concerns towards convenience and social acceptance.

From a public health perspective, this creates significant challenges. Communication strategies are needed that, on one hand, address these motivations, while on the other hand, accurately inform that HnB products still pose a source of exposure to harmful substances and can maintain nicotine dependence. The lack of spontaneous references to health risks may indicate insufficient awareness of these dangers.

The results also suggest the need for monitoring changing patterns of nicotine use, including emerging user identities and the factors influencing their choices. The emergence of new categories, such as “traditionalists” (those preferring conventional cigarettes) versus individuals open to innovative technological products (choosing HnB) highlights the need to adapt public health actions to the diverse attitudes and values of users.

Health policy can no longer rely solely on the binary opposition of “smokers versus non-smokers.” A more nuanced approach is needed, one that takes into account various identities, motivations, and lifestyles of nicotine users. Different groups require distinct communication strategies – different messages should be directed at those attached to conventional cigarettes, and others to those who prefer alternative, technologically advanced forms of consumption.

Further research should focus on the social perception of HnB products, their long-term health impact, and their potential role in the renormalization of nicotine use. This knowledge is crucial for designing effective preventive and regulatory strategies.