Heated Tobacco Products in South Africa: Harm Perceptions, Use, and Quitting Behaviors Among an Online Sample of Adults

Introduction: Despite the growing sales of heated tobacco products (HTPs) in South Africa (SA), limited information is available on HTP use in SA and generally in Africa. The aim of this study is to describe individuals who currently and formerly used HTPs, including the association between HTP use and perceived relative harm of HTPs to combustible cigarettes (CCs), and CC cessation among an online SA population. Methods: Data were obtained from an online survey conducted in 2021 among SA adults ≥18 years (n =12674). The dependent variables were HTP-use status, past-year quit attempts and cigarettes-per-day (CPD). Primary independent variables were CC-smoking status and relative harm perceptions. Weighted proportions, multivariable logistic, and Poisson regression models were used to examine the association between dependent and independent variables. Results: In this online sample, 2.82% of SA adults indicated current HTP-use. Among current CC-smokers, 6.57% indicated current HTP-use compared to 0.50% among those who have never smoked cigarettes. Current CC-smoking was associated with higher odds of current HTP-use (aOR=2.66; 95% CI=1.11 to 6.39). Conversely, perceiving HTPs as more/equally harmful than CCs was associated with lower odds of current HTP-use (aOR=0.24; 95% CI=0.14 to 0.40). HTP-use was not associated with previous CC quit attempts, and there was no difference in CPD between current and never HTPs users who smoked (aIRR=1.02; 95% CI=0.91 to 1.14). Conclusions HTP users in the studied SA online population were mostly current cigarette smokers who believed HTPs were less harmful than cigarettes. However, HTP-use was not associated with higher previous quit attempts nor smoking fewer CPD. Implications: This study provides early data on the behaviors and beliefs associated with HTPs in SA, a significant yet understudied tobacco market for novel nicotine products. It reveals that individuals with lower harm perceptions, polytobacco use, and individuals who currently smoke CCs are more likely to consume HTPs. However, HTP use was not associated with higher odds of past-year cigarette quit attempts or a reduction in the number of CPD. These findings offer valuable evidence for surveillance and policy efforts aimed at emerging tobacco products and protecting public health.