The study population consisted of young people, 18–26 years old, from Romania, exclusive CC users (n = 5), exclusive HTP users (n = 4), dual CC + HTP users (MIX; n = 5), and non-smokers (n = 5). See Table 1 for participant characteristics.

Table 1 Participant’s characteristics.

We present the results from our thematic analysis in relation to three over-arching themes and 12 sub-themes that impact the decision to start using HTPs. 1. People, places and subjects of marketing; 2. Engagement with risk narratives; and 3. Social body, family bonds and autonomous self. Table 2 shows the complete list of themes and sub-themes.

Table 2 Over-arching themes and sub-themes.

Themes are outlined below with the use of verbatim quotes. Data extracts are tagged with a unique anonymised identifier indicating the sex of the participant (F for female, M for male), the age and the current smoking status (CC – combustible cigarettes, HTP – heated tobacco products users, MIX – users of both combustible cigarettes and heated tobacco products, NS – non-smoker), for example, F26-CC. Because in the case of two participants, the code was identical, we added 1 or 2 at the end of the tag.

People, places and subjects of marketing

In our interviews, young adults experienced elements of almost all the P’s of the tobacco marketing mix: Product, Price, Place, Promotion, People, Process and Physical evidence26.

They consider themselves above marketing influence (the decision to start smoking, they say, is theirs), yet they manifest interest in new devices and news.

“I didn’t pay attention to marketing and advertising, and I don’t think that my peer opinion was important, either. I mean it was something about me, to see what it was about. No, I wasn’t influenced, maybe on an unconscious level this could be possible.” (F25-MIX)

Marketing is nowadays greatly impacted by the social sciences, especially psychology27. There are also de-marketing strategies that discourage smoking28, from all of the smoking continuum (stopping smoking and preventing starting smoking).

In our data, we explore five separate elements of tobacco marketing.

Product as badge

Tobacco has been called the ultimate “badge product”29 for it sends an implicit message, repeated every time young adults join social reunions:

“this is another reason I continued to smoke: I felt it became my thing, my signature.” (F25-CC1)

Moreover, being an early adopter is another way of being distinctive but alike to the’chosen’ ones: the daring and courageous. The HTP devices have nice designs, and many functions that stimulate interaction (i.e. connection with the smartphone). Some are singled out as elegant, this particular quality was believed to “set them apart” (F19-HTP):

“It appeared… 3 years ago, I was among the first ones to buy and use it…it was a pleasant experience from the start. It continued to be pleasant, I am a loyal client. In time there have been different devices …they did not attract me at all, IQOS has a more elegant design” (F26-HTP)

The package design and brand are visible and project a message of power and engagement, which can either turn young adults on or off certain products:

“I don’t like the design of glo, it’s big and ugly” (F19-HTP)

Size, graphics and colour are not a new marketing strategy for transferring symbolised attributes to HTP; it was there to enlist smokers of CC, right from the beginning:

“I remember buying my first pack of cigarettes, they were coloured, each cigarette had its own colour and I think that is what got me hooked.” (F19-HTP)

Price – the financial hook

This is not direct marketing but it is a great hook to start discussing with people to get their attention.

When young adults start experimenting, price is not very important, for they need the image conveyed by the “badge”, but, in time, they are interested in lowering the price by choosing discounts, as “the cost is huge” (F24-MIX):

“Promotions for cartons, there are discounts, devices that are more colourful, look more… more beautiful” (F26-HTP)

Although young adults in our study knew about HTP-related contests and raffles, some “have never participated” (F26-HTP).

Young adults’ main financial hooks were gratuity packages, or buying the HTP device in installments “you can buy it for like 20 RON/month” (F19-HTP):

“the most attractive method is to receive a free package without buying anything… sometimes it’s also interesting to buy a package and get another one for free” (M20-MIX)

Not every participant in our study was susceptible to HTP marketing tactics, some perceived them as inappropriate, encouraging the increased use:

“I felt weird, for they made you buy a package for getting one for free, and I said….”I already have cigarettes”…. I don’t have to stockpile with cartridges right away, it seems inappropriate” (F25-CC2)

Young adults knew they were being manipulated by the idea of getting something for free when, actually, they were just buying in bulk (HTP companies overcome buyer uncertainty by giving HTP devices out for free when young adults buy a certain number of packages).

“you get a lot of free packs…they’re not really free but it’s the idea.” (F19-HTP).

Some use both CCs and HTPs and needed the advantage of the HTP’s price:

“[HTPs] are more accessible. The price of cigarettes rose… but the prices for these [HTPs] cigarette packages for these devices remained the same, didn’t increase…and for some students this difference counts” (M20-MIX)

Place – the universe

Young adults in our study noticed HTPs advertising in gas stations, kiosks, hypermarkets, neighbourhood stores and coffee houses. This advertising presence aimed to normalise HTP use. It is also in public spaces that sales teams approach potential customers. Young adults described the approach as direct:

“in small shops, there are always tobacco representatives… ‘Do you smoke?’ …and if you say ‘Yes’, they make you different offers” (F19-HTP)

Young adults also compared online versus face-to-face marketing.

“I access the [HTP supplier] internet site… when I need to buy… I order and I get it delivered… I am unsubscribed from receiving emails, I only receive ads” (F26-HTP)

Participants noticed the unequal distribution of supplies:

“in the city (…) I find these products in 95% of the stores, but if I want to go on holiday…in a rural area, we cannot find these packages for respective devices” (M20-MIX)

Promotion – the start of a dialogue

Young adults engage in conversation with tobacco sales teams:

“if you stay and get to answer a questionnaire, they give you small tokens: a lighter, a package of cigarettes or discount to cigarettes…” (F19-HTP)

Young adults observed the subtle ways HTP promoters succeeded in making an impression by sampling tobacco products in restaurants, recreational venues and events (experiential marketing) or through the internet and cartoons:

“I remember that from 3 years ago when I was a minor and I went to a festival… as a minor you are bombarded with ads”. (F19-HTP)

“the problem with this promotion is that it is a very, very subtle one, but has an effect. We don’t see cigarette commercials on TV, because it’s a matter of ethics…but still, we have the internet, lots of ways left…including cartoons” (M21-NS)

Some non-smoker young adults are aware that HTP is presented as less harmful for health, but see this as a marketing strategy.

“From what I have seen, many people have the impression that IQOS is less harmful” (M21-NS)

Improved sensory experience relating to smell and taste represents one of the main promotional messages, thus becoming important for young adults who perceive HTPs as lacking any “ugly smell” (F26-HTP):

“those [HTPs] have no smell, you could use them anywhere, in house, car or any enclosed space and there is no residual smell in the clothes” (F24-MIX)

HTP frees young adults from the problem of smoking in enclosed spaces (that is banned) and allows them the flexibility not to be ‘found out’ if they wanted to conceal a smoking habit from their family.

“it was quite hard and uncomfortable [smoking indoors being banned]… with IQOS we got rid of this problem, since I use [HTP] I’ve almost forgotten this problem that normal cigarettes smokers have” (F26-HTP)

“you can smoke it anywhere and I am hiding from the family…if somebody catches me I close it quickly and put it in my pocket, it’s more flexible somehow” (F24-MIX)

Young adults fall into the trap of Big Tobacco’s promotional themes of independence and rebelliousness:

“when you are a child and you smoke…I am rebellious, I do what I want, look - I am smoking, I don’t care…I was a ‘bad girl’, I smoke, look at me” (F24-MIX)

but also into the belief that tobacco supports stress relief:

“it brings me some moment of quiet, for I take my cigarette and I think of my own problems and while it lasts, for 3 minutes it seems like nothing else matters…It’s just me and my cigarette…me aware of myself” (F24-MIX)

People as influencers

The manner in which promotional teams, mainly represented by teams of two or more advertisers, almost all of them young girls, approached face-to-face encounters induced different reactions amongst young adults:

“all dressed alike and they don’t have the most intelligent faces and all of them, have the same words, for me it is amusing” (F19–CC) “I am impressed by the behaviour of….the ‘girls’, all dressed to the nines, they have elegant suits, behave professionally…they always hire pretty girls, always girls” (F24-MIX)

Phone calls provoke annoyance:

“most of the time [they] talk as if they’re robots….it’s very annoying” (F19–HTP)

Happy customers are excellent advocates and this applies to family and friends but also to huge celebrities or non-public figures.

“my father, immediately after I bought the IQOS came to me and asked “what is this?”, and after some days he bought his own device” (F21–HTP)

“using a movie star (…): she’s sexy and very beautiful, with a cigarette, inhaling the steam while you see the IQOS logo…” (M21-NS)

Some non-smoker young adults think that the vulnerable youth are being manipulated through advertising and marketing methods:

“I honestly saw smarter advertising methods in IQOS, more modern methods: influencers, Instagram, ads on social networks frequented by young people; using a movie star or a model…the youth are much easier to manipulate.” (M21-NS)

Some participants in our study felt the pressure and the aggressiveness of sales teams while others perceived this as sales perseverance:

“those promoters are very aggressive…they attack you in gas stations…it will come the moment when they will shove that device down our neck, probably” (F24–MIX)

“the girl needs to work and do her job, for this is the way she gets paid” (M20-MIX)

Engagement with risk narratives

Our analysis found young adults had different types of engagement with risk narratives and this was likely to influence their decision to use HTPs. As no one in our sample started smoking using HTPs, but CCs, and as some of them are using both, we present data also on perceptions of combustion smoking risk.

Smoking is about losing health

For the non-smokers, knowing the smoking risks and/or recognising the harmful effects in family members acted in some cases as reasons for not initiating or continuing smoking.

“… I think I was influenced because I saw my father when he had problems and he was choking or coughing. I was very young when these things happened, it was when he also tried to quit for the first time and I thought I didn’t want to be like him. I don’t know, probably being young the impact was bigger seeing my father so vulnerable”. (F21-NS)

For the smokers, we identified two types of answers: those affirming that smoking had harmful effects on health whilst those who doubted, dismissed, minimised or avoided engagement with risk narratives. One young adult, despite being a smoker, acknowledged smoking as a loss to health:

“Smoking, in general, cannot be healthy”. (M20-MIX)

Awareness of the harmful effects of smoking was based upon living with a long-term chronic respiratory condition, observations of the impact of smoking on their physical fitness and a desire to quit to avoid harm:

“I had asthma during my childhood so I should not smoke”. (F21-HTP)

“Before I start smoking my resistance to physical effort was better…after I started to smoke, I got tired quickly and feel like suffocating”. (M20-MIX)

“[I]considered quitting several times” (M20-MIX)

Harmful effects of smoking - doubted, dismissed, minimised or avoided

However, for one participant, even when the harmful effects of smoking were acknowledged, this was qualified with the expression ‘at least’, used to reduce the effect of the statement of harm or indicate some doubt:

“I am aware it causes harm, at least this is what is said”. (F21-HTP)

Harmful effects of tobacco consumption were linked to the length of time someone had smoked. The expression in time was used to dismiss or minimise a statement of harm:

“Regarding smoking, people should not become dependent because in time addiction to tobacco cannot be healthy”. (M20-MIX)

“In time smoking can cause respiratory diseases, cancers etc”. (F21-HTP)

Similarly, reducing the amount of smoking activity was also seen as one way to minimise risks, with the belief ‘if I am not dependent, I am not at risk’:

“I am careful not to smoke too much…”. (M20-MIX)

Finally, young adults admitted to avoiding any engagement with risk narratives, by turning away from the pictures on packaging as risk reminders:

“In the beginning I saw them, now, after all these years they became normality and I do not feel affected so much, I mean I know that they are there but I cannot say that I see them anymore” (F25-MIX)

Diminishing, doubting, dismissing or even avoiding any engagement with risk narratives are in fact methods of self – rationalisation, well known strategies to diminish the discomfort of being psychologically incongruent when smoking while knowing in fact smoking is damaging health.

The way participants engaged with risk narratives was linked, in part, to the relationship within the family home (which we discuss further below, in relation to the social body, family bonds and a sense of an autonomous self).

Perceptions of addiction

Very few young adults in our study shared knowledge of nicotine’s addictive mechanism:

“Anyway, it’s an addiction, it’s… Honestly, you get moody at some point if you don’t take your dose, so to speak” (F20-HTP)

Smoking was perceived more as a vice, rather than a behaviour related to a disease.

“Honestly, I don’t know…whether or not I will give up this vice” (F20-HTP)

Subsequently, smoking cessation was perceived as a matter of a “very big will” (M20-MIX) and not suitable for medical treatment and cessation support:

“Only the will, the iron will.” (F20-HTP)

Being considered a matter of will, none of the young adults mentioned the relevance of the combined cessation support in improving quitting effectiveness, which some seem to confuse with that offered by a friend:

“Yes, and my friend is trying to support me, “Leave it, leave it, leave it!”. (F20-HTP)

Some young adults considered they were not addicted:

“I do not smoke much, nor often”. (F21-HTP)

For others, the lack of withdrawal symptoms led them to believe they were not addicted:

“If I do not smoke [for a while] nothing happens to my body”. (M20-MIX)

Risk narratives surrounding HTPs

When specifically asked about HTP smoking, most of the young adults acknowledged the same health risks whether they were tobacco smokers, HTPs users or non-smokers:

“They might contain fewer substances but they are equally causing harm”. (F21-HTP)

“Smoking, in general, cannot be healthy even if IQOS producers claim that it could be a healthier option”. (M20-MIX)

Others (smokers and non-smokers) considered that HTPs might present fewer health risks, or might be perceived as such:

“I understood they are less harmful”. (F20-HTP)

“People think they are somehow better than the others (traditional ones) and less harmful”. (F21-NS)

One participant declared that smoking HTPs seems different in terms of perceived harmful effects compared to regular cigarettes.

“No negative effects with IQOS until now. I do not cough at all. When I used to smoke traditional cigarettes, my teeth were yellow, with IQOS they look normal. IQOS leaves no specific taste and I do not think it affects taste as much as the traditional tobacco”. (M20-MIX)

Very few young adults in our study (2 of 9) described HTPs as being less harmful as their reason to switch from CCs to HTPs. One example is a participant who even perceived HTPs as enabling more physical activity:

“I suffered from Tetralogy of Fallot …This is the main reason I switched to HTPs…I couldn’t even run for 30 metres, but now I can even do sports” (F19-HTP)

Social body, family bonds and autonomous self

One of the main themes of our research is how young adults’ risk behaviours and their engagement or resistance to marketing are influenced by their peer groups, family unit and/or individual sense of self. The latter self-concept fluctuated between a presentation of an autonomous self, unaffected by others, and a description of a social [not individual] body – in which the self is perceived as intricately bound and governed by cultural and social norms and the expectations of others.

Individuality – autonomous self

Participants in our study saw HTPs as an opportunity to express and develop their felt sense of individuality, by seeking out novel experiences:

“The first time I tried IQOS…I received it when I celebrated my 18th birthday; it had just appeared and everyone was wow!” (F20-HTP)

Novel experiences that challenged authority were seen as even more attractive:

“It was something ‘wow’ for me that I could hide from my parents”, therefore the thrill of being “afraid of getting caught” (F19-HTP)

Sensation seeking and curiosity are frequently expressed by many young adults as reasons to try smoking:

“I started smoking a little too early for what I should, more out of curiosity, somewhere around the age of 15” (F24-MIX)

“[Starting]…out of curiosity about the effect. Everyone felt more relaxed after smoking a cigarette. Everyone went out after school, before school, and they smoked. I say, what’s going on?” (F25-CC2)

Looking for new sensations and exploring what one’s self likes or dislikes can sometimes end either in fear of use or in rejection:

“[IQOS]…it seemed to be dangerous because it was heated… almost where the smoke was drawn, I always had the feeling that I’m going to get burned”. (F25-CC2)

“HTPs… I don’t even want to hear. The cigarette is a cigarette. I like the inhalation itself, but I still don’t like the smell. [HTP], that’s a steam device; how to like hot steam entering my throat?” (F26-CC)

Impulsive curiosity is frequently remembered:

“…it was just on the spur of the moment, an impulse of being young, but from that moment…it never stopped.” (F25-CC1)

Yet, a current non-smoker student in our study, educated and raised by non-smoking parents, described experimenting with smoking “just in order not to die stupid” (M18-NS). His behaviour was suggestive of a more cerebral, informed, or censored curiosity compared to the impulsive curiosity tied up with challenging authority figures. He, therefore, was able to override temptation and did not become a smoker.

For one participant, experiencing smoking is a facilitator for self-change - to become “stronger but more determined, more assumed” (F25-CC1):

“I thought that a certain category of kids was smoking and I would have liked to be like them. Personally, I am quite introverted and they were not like that;… they were more, I don’t know, popular, full of excitement” (F25-CC1)

For another young adult in our study, being authentic and living passionately, enjoying life experiences were important values she attributed to the experience of smoking. She described “smoking - a familiar companion of her childhood - a way of living”. (F19-CC)

Family bonds

The family dynamic was clearly impacting upon young adults in our study and their smoking choices, including their engagement with marketing practices. Parents who smoked acted as role models: both positively and negatively. Young adults reported that if they had parents who smoked, despite their declared concern regarding the harmful health-related effects, their parents were ‘pretty understanding’ regarding their child starting smoking:

“The idea that I had started smoking - was not good news for them but, in the end, they didn’t try very much to talk me out of it”. (F25-CC1)

“at 14 years old I didn’t tell them that I smoked, they found out eventually and it wasn’t all that good but it wasn’t all that bad either” (F19-CC)

Even more, parents purchased HTPs as birthday gifts for their adult children, illustrating the symbolic gift value attributed to a tobacco product for strengthening family bonds. For example,

“And I can remember that my mother gave it to me for my birthday, I remember it vividly” (F26-HTP)

Smoking together with parents, smoking the same tobacco brand at home or sharing cigars whilst having deep, reflective conversations, was mentioned by some of the young adults as significant events in their lives. For young adults, burdened by the uncertainty of their quests for the true self, such rituals facilitated a glimpse of real adulthood:

“doing what grown-ups do and feel” (F19-HTP).

These moments of child-parent bonding facilitated a perceived feeling of being seen and accepted as true individuals whilst also re-creating a feeling of safety and acceptance:

“I am good friends with my father and, in a very stupid way, when I sit at a cigarette with him I have the feeling that our friendship is strengthening …yes sharing and connecting” (F19-CC)

Daughters seem especially rewarded by smoking with their fathers - a sort of confirmation at the end of a rite of passage into adulthood:

“My dad told me that the first time we will smoke together will be on my 18th birthday” (F19-HTP).

For another female in our study, sharing the same CCs with her father was a bonding experience. This created a shared adult space, thus HTP marketing messages, designed to boost youthful social image, were of no interest to her, considering HTPs as a poor “surrogate”. (F19-CC)

Young adults who smoke, having parents who were smokers, demonstrate they remember their parents’ educational messages and mirror them by providing similar messages to their siblings:

“Don’t do it, it’s not OK [smoking], it’s not for you! I want the best for you and I’ll tell you what conclusion I came to - it’s not OK and it’s a waste of time, money, health” (F21-HTP)

Non-smoking parents were perceived by their non-smoking children not only as good role models but as authentic educators, succeeding in conveying pro-non-smoking messages that last:

“I was never interested in smoking. Honestly speaking, I think the reason has to do a lot with the education I received at home. With my parents being non-smokers, I was taught since I was little not to touch cigarettes as they are not pleasant… What also matters is how this educational message is delivered.” (M21-NS)

Social body

Mirroring and adopting peer group behaviours was viewed by young adults in our study as a modality to anticipate acceptance, and the first step to bonding and belonging to a social group:

“Everybody was smoking, I needed to be there, along with my crowd. I have no idea what happened in my subconscious because I remember that I didn’t like to smoke, but… I kept going. It was something I needed to do because that was the reality, that was the thing that everybody did”. (F25-MIX)

Peer pressure is one of the most frequently cited reasons to give in to the temptation of smoking:

“At the beginning, I felt weird going out with them and not smoking; … They were asking me: why don’t you smoke? Give it a try! … It was mostly the pressure: see how it is, try it… plus a sort of curiosity to see how it is.” (F22-MIX)

At the same time, peer pressure was enough to override unpleasant first smoking experiences:

“First experience was terrible…the sensation, the taste, choking…and friends pressuring: try more, you are not inhaling deep inside…” (F19-HTP)

Therefore, peer pressure becomes a sort of instrument of giving up on the individual self to become part of the new (social body) entity. Similarly, pressure (via aggressive marketing) becomes an instrument of adherence towards the new culture- smoking in a group.

The power of the group and the importance of bonding with it was strengthened for young adults in our study by sharing CCs:

“I felt the need to offer my cigars to others; I like to share … because it’s not normal to smoke by yourself; the people around have to smoke as well” (F19-HTP)

Interestingly, in our data, HTP was not perceived as the ideal instrument for achieving the social body:

“… now I use HEETS and it’s not an option because not everyone has the device.” (F19-HTP)