Cross-Sectional Survey
POS and participant (manager/owner) characteristics
Table 1 summarizes the POS and participant (manager/owner) characteristics from the retailers’ survey, overall and comparing retailers at Arab vs. Jewish neighborhoods. The surveyed POS were mainly grocery stores (37.7%, n=26) or convenience stores not within a gas station (34.8%, n=24). A higher proportion of POS in Arab neighborhoods were grocery stores (71.4% vs. 22.9%, p=0.001), and all of them (100.0%) were located in low- and medium-SES neighborhoods, compared to 64.6% of POS in Jewish neighborhoods (p=0.009).
Table 1. POS and retailer characteristics, overall and across Arab vs. Jewish neighborhoods
Variable
|
Total (n=69)
n (%)
|
Population group
|
p value†
|
Arab (n=21)
n (%)
|
Jewish (n=48)
n (%)
|
POS characteristics
|
Store Type
|
Convenience store without gas
|
24 (34.8)
|
4 (19.0)
|
20 (41.7)
|
0.001#
|
Convenience store with gas
|
8 (11.6)
|
0 (0.0)
|
8 (16.7)
|
|
Grocery store
|
26 (37.7)
|
15 (71.4)
|
11 (22.9)
|
|
Liquor store
|
5 (7.2)
|
0 (0.0)
|
5 (10.4)
|
|
Tobacco store
|
4 (5.8)
|
1 (4.8)
|
3 (6.2)
|
|
Other (café, kiosk)
|
2 (2.9)
|
1 (4.8)
|
1 (2.1)
|
|
Neighborhood socio-economic status (SES)
|
Non-residential
|
7 (10.1)
|
0 (0.0)
|
7 (14.6)
|
0.009#
|
Low
|
10 (14.5)
|
5 (23.8)
|
5 (10.4)
|
|
Medium
|
42 (60.9)
|
16 (76.2)
|
26 (54.2)
|
|
High
|
10 (14.5)
|
0 (0.0)
|
10 (20.8)
|
|
Participants characteristics
|
Age, mean (SD)
|
39.1 (9.9)
|
39.4 (9.5)
|
38.9 (10.1)
|
0.806^
|
Sex
|
|
|
|
|
Male
|
62 (89.9)
|
17 (81.0)
|
45 (93.8)
|
0.188#
|
Female
|
7 (10.1)
|
4 (19.0)
|
3 (6.2)
|
Position at the POS
|
Owner
|
16 (23.2)
|
4 (19.0)
|
12 (25.0)
|
0.760#
|
Manager
|
53 (76.8)
|
17 (81.0)
|
36 (75.0)
|
|
Cigarette smoking status*
|
Current smoker
|
26 (38.2)
|
7 (33.3)
|
19 (40.4)
|
0.833
|
Past smoker
|
14 (20.6)
|
5 (23.8)
|
9 (19.2)
|
|
Never smoker
|
28 (41.2)
|
9 (42.9)
|
19 (40.4)
|
|
IQOS use status*
|
Current user
|
8 (11.8)
|
1 (4.8)
|
7 (14.9)
|
0.163#
|
Past user
|
9 (13.2)
|
5 (23.8)
|
4 (8.5)
|
|
Never user
|
51 (75.0)
|
15 (71.4)
|
36 (76.6)
|
|
POS – Point-of-sale. †Chi square test, unless stated otherwise. #Fishers exact test. ^Mann-Whitney test. *Missing: Participants characteristics: Cigarette smoking n=1; IQOS use status n=1 (both are retailers in Jewish neighborhoods). Bold indicates between-group statistically significant differences (Bonferroni correction).
|
IQOS marketing strategies
Table 2 summarizes IQOS/HEETS marketing strategies overall, and compares retailers in Arab vs. Jewish neighborhoods. Compared to Jewish neighborhoods, a higher proportion in Arab neighborhoods carried less than 4 HEETS flavors (66.7% vs. 17.4%, p<0.001) and less IQOS special displays (25.0% vs. 53.2%, p=0.034) (Table 2).
Table 2. POS IQOS/HEETS marketing strategies, overall and across Arab vs. Jewish neighborhoods
POS – Point-of-sale. †Chi square test, unless stated otherwise. #Fishers exact test. *Missing: Number of HEETS flavors n=2; Special display n=2; Promotions to POS: free HEETS samples n=8; price discounts for your own purchases n=8; paraphernalia n=3; other gifts n=7; price discounts, rebates, or incentives based on promoting their products n=4; incentives for sales n=4; invitations to parties n=2; Promotions to costumers: free HEETS samples n=9; paraphernalia is zero for all POS; other gifts n=9; price promotions n=10; price discounts n=8; coupons n=12; special prices for members n=11; Special discounts for military/students was zero for all POS; Advertisements: any form of ad n=4 (if all items were missing); online n=4; social media n=6; print media n=5; inside the POS n=6. §Other gifts given to retailers included lighters, lighter stands swimming competitions, and flights abroad. ‡Other gifts given to customers included lighters. $Price promotions offered to customers such as buy one get one free, 2 NIS off the price of HEETS, or buy IQOS and get a free HEETS package. Bold indicates between-group statistically significant differences (Bonferroni correction).
More retailers in Arab vs. Jewish neighborhoods received invitations to IQOS events/parties (47.6% vs. 21.7%, p=0.032) and paraphernalia (30.0% vs. 2.2%, p=0.002). The most prevalent form of promotions targeting customers were price discounts (18.8% and 44.4% of POS in Arab and Jewish neighborhoods, respectively, p=0.069) (Table 2). Only retailers in Arab neighborhoods mentioned receiving lighter stands (n=2), flights abroad (n=1), swimming competitions (n=1), and receiving points when referring customers (n=1). More than half of all POS carried IQOS promotional materials (Table 2); these were mainly electronic and/or non-electronic signs that said “here you can buy heated tobacco products” or “heated tobacco units”, small flags that say the same or advertise a price promotion, and/or special display cases for IQOS/HEETS. A few retailers mentioned that PMI sent saleswomen to set up a small stand and promote IQOS directly to customers (6 in Arab neighborhoods and 3 in Jewish neighborhoods).
Open-ended questions
Retailers from POS in Arab neighborhoods emphasized their part in promoting the product to their customers and connecting the customers with sales representatives. For example, one participant used her personal experience as a promotional strategy: “When people come to my shop and see me use it they get curious and start asking me about it, I tell them about my personal experience and how I used to smoke Marlboro but when I switched to IQOS I stopped coughing in the morning and it doesn't stink your clothes or furniture”.
Another participant stated that the POS was acting as a “middle man” by connecting the customer with a PMI sales representative: “the shop was the intermediary; the company's representative asked us to connect him with the customers if anyone asks about IQOS or was interested in trying it”, and mentioned collecting ID numbers and phone numbers to register customers for a user database, and received points for each person. Others referred to the representative’s direct interaction with customers; “the representative and I try to tell customers about IQOS, that it can meet their requirements and is less harmful and smoke-free”.
Retailers’ attitudes towards IQOS and interactions with PMI representatives
More retailers from POS in Arab neighborhoods stated that IQOS is an e-cigarette (61.9% vs. 27.1%, p=0.006) and found its flavors to be appealing (42.9% vs. 12.5%, p=0.009) (figure 1: retailers’ attitudes towards IQOS). Overall, 42.0% of retailers stated that IQOS is less harmful compared to cigarettes (43.8% and 38.1% among retailers from POS in Jewish and Arab neighborhoods, respectively).
Table 3 lists the retailers’ interactions with a PMI representative and PMI’s reaction to the POS display ban. More retailers from POS in Arab than Jewish neighborhoods reported having any form of interaction with a PMI representative (80.0% vs. 51.2%, p=0.029) with no statistically significant differences in regards to the detailed nature of those interactions.
Table 3. Interactions with a PMI representative and PMI’s reaction to the POS display ban, overall and across POS in Arab vs. Jewish neighborhoods
Variable
|
Total (n=69)
n (%)
|
Population group
|
p value†
|
Arab (n=21)
n (%)
|
Jewish (n=48)
n (%)
|
Specific IQOS/HEETS salesperson*
|
25 (37.9)
|
6 (28.6)
|
19 (42.2)
|
0.287
|
Interaction with PMI salesperson*
|
Any interaction
|
38 (60.3)
|
16 (80.0)
|
22 (51.2)
|
0.029
|
Provided direction on placement
|
32 (50.0)
|
13 (65.0)
|
19 (43.2)
|
0.106
|
Provided information on the target market
|
16 (25.8)
|
2 (10.0)
|
14 (33.3)
|
0.050
|
Provided direction how to communicate with consumers
|
21 (35.0)
|
7 (35.0)
|
14 (35.0)
|
1.000
|
Provided information on IQOS/HEETS vs. other tobacco products
|
31 (51.7)
|
13 (65.0)
|
18 (45.0)
|
0.144
|
PMI’s reaction to the POS display ban
|
Any interference*
|
51 (81.0)
|
17 (89.5)
|
34 (77.3)
|
0.318
|
Provided education regarding the tobacco legislation
|
26 (37.7)
|
11 (57.9)
|
15 (34.1)
|
0.096
|
Advised on how to work around the tobacco legislation
|
8 (11.6)
|
5 (26.3)
|
3 (6.8)
|
0.050#
|
Provided free cabinets, display cases and/or signage to address the tobacco legislation
|
36 (52.2)
|
12 (63.2)
|
24 (54.5)
|
0.585
|
Changed their promotional strategies for products such as e-cigarettes and/or IQOS/HEETS
|
7 (10.1)
|
3 (15.8)
|
4 (9.1)
|
0.667#
|
Minimized the importance of compliance with the tobacco legislation
|
4 (5.8)
|
1 (5.3)
|
3 (6.8)
|
1.000#
|
Sold cabinets, display cases and/or signage to address the tobacco legislation
|
8 (11.6)
|
0 (0.0)
|
8 (18.2)
|
0.095#
|
POS – Point-of-Sale. PMI – Philip Morris International. $Includes ticking at least one statement from a-g. †Chi square test, unless stated otherwise #Fisher's exact test. *Missing: Specific IQOS/HEETS salesperson n=3; Interaction with a PMI salesperson: Any interaction n=6; provide direction on placement n=5; target market n=7; communicate with consumers n=9; information on product n=9; PMI’s reaction to the POS display ban: All items n=6.
|
PMI representatives assisted the majority of POS implement the display ban (89.5% in Arab and 77.3% in Jewish neighborhoods), the only borderline significant difference was more POS in Arab neighborhoods being advised on how to navigate and overcome regulatory restrictions, (26.3% vs. 6.8%, p=0.05) (Table 3). This included, for example, being given instructions on how to arrange the products behind the cover to make it easier to access and sell them, being directly informed about new campaigns and promotions, and repeatedly given information about the products.
POS audits
POS characteristics
Table 4 summarizes the POS characteristics, marketing material, placement, promotion and regulatory compliance data from all audited POS, and across Arab vs. Jewish neighborhoods. The audited POS were mainly convenience stores not within a gas station (45.0%, n=58) or convenience stores within a gas station (31.0%, n=40). Significantly more POS in Arab neighborhoods were located in areas of low SES (75.0%, n=36), compared to only 2.4% (n=2) of POS in Jewish neighborhoods (p<0.001) (Table 4).
Table 4. POS characteristics, marketing material, placement, promotions and regulatory compliance, overall and across Arab vs. Jewish neighborhoods
Variable
|
Total (n=129) n (%)
|
Population group
|
p value†
|
Arab (n=48)
n (%)
|
Jewish (n=81)
n (%)
|
POS characteristics
|
Type of store
|
Convenience store with gas
|
40 (31.0)
|
11 (22.9)
|
29 (35.8)
|
0.440
|
Convenience store without gas
|
58 (45.0)
|
23 (47.9)
|
35 (43.2)
|
Grocery store/ supermarket
|
21 (16.2)
|
9 (18.8)
|
12 (14.8)
|
Other Ÿ
|
10 (7.8)
|
5 (10.4)
|
5 (6.2)
|
Neighborhood socioeconomic status (SES)
|
<0.001
|
Non-residential
|
17 (13.2)
|
4 (8.3)
|
13 (15.9)
|
|
Low
|
37 (28.7)
|
36 (75.0)
|
2 (2.4)
|
|
Medium
|
56 (43.4)
|
7 (14.6)
|
49 (59.8)
|
|
High
|
19 (14.7)
|
1 (2.1)
|
18 (21.9)
|
|
Marketing materials (any)
|
103 (79.8)
|
35 (72.9)
|
68 (82.9)
|
0.131
|
IQOS/HEETS
|
Any ad/sign¶
|
59 (57.3)
|
20 (57.1)
|
39 (57.4)
|
0.475
|
Special display‡
|
39 (66.1)
|
11 (55.0)
|
28 (71.8)
|
0.142
|
Brand colors‡
|
45 (76.3)
|
14 (70.0)
|
31 (79.5)
|
0.111
|
Cigarettes
|
Any ad/sign¶
|
84 (81.6)
|
26 (74.3)
|
58 (85.3)
|
0.162
|
Brand names*
|
25 (29.8)
|
12 (46.2)
|
13 (22.4)
|
0.024
|
Price stickers*
|
60 (71.4)
|
17 (65.4)
|
43 (74.1)
|
0.044
|
Visibility**
|
IQOS
|
16 (76.2)
|
4 (66.7)
|
11 (68.8)
|
1.000#
|
HEETS
|
70 (54.3)
|
19 (39.6)
|
51 (62.2)
|
0.010
|
Cigarettes
|
81 (62.8)
|
27 (56.3)
|
54 (65.9)
|
0.237
|
HEETS flavors; M (SD)
|
4.2 (1.8)
|
3.5 (1.9)
|
4.6 (1.6)
|
0.001^
|
IQOS/HEETS Placement
|
Within 30 cm of toys or candy
|
20 (15.5)
|
5 (10.4)
|
15 (18.3)
|
0.219
|
Within 1 m of the floor
|
10 (7.8)
|
0 (0.0)
|
10 (12.2)
|
0.013#
|
Price promotion
|
IQOS/HEETS
|
14 (10.9)
|
4 (8.3)
|
10 (12.2)
|
0.479
|
Other tobacco product
|
33 (25.6)
|
9 (18.8)
|
24 (29.3)
|
0.171
|
Prices; M (SD)
|
|
|
|
|
HEETS
|
30.2 (1.7)
|
29.5 (1.2)
|
30.7 (1.9)
|
<0.001^
|
Cheapest PMI cigarette
|
25.4 (2.1)
|
24.5 (1.5)
|
26.1 (2.3)
|
<0.001^
|
Most expensive PMI cigarette
|
38.5 (3.2)
|
38.4 (1.4)
|
38.9 (4.0)
|
0.004^
|
Regulatory compliance
|
Minimum age signage
|
75 (58.1)
|
23 (47.9)
|
52 (63.4)
|
0.070
|
No smoking sign
|
37 (28.7)
|
18 (37.5)
|
19 (23.2)
|
0.088
|
Plain packaging
|
95 (73.6)
|
30 (62.5)
|
65 (79.3)
|
0.027
|
Display ban&
|
19 (15.1)
|
12 (25.5)
|
7 (8.8)
|
0.011
|
POS – Point-of-Sale. †Chi square test, unless stated otherwise. #Fisher’s exact test. ^Mann-Whitney test. ŸOther: Liquor store n=1; Tobacco shop n=3; Coffee shop n=3; Candy store n=2; Spice shop n=1. ¶Out of those with any internal ad (n=103; Arab n=35 and Jewish n=68). ‡Out of those with any IQOS ads (n=59; Arab n=20 and Jewish n=39). *Out of those with any cigarette ads (n=84; Arab n=26 and Jewish n=58). **Not sold: IQOS device n=108 (n=42 Arab and n=66 Jewish). &Excluding n=3 tobacco shops (Arab n=1 and Jewish n=2) that the display ban does not apply to. Bold indicates between-group statistically significant differences (Bonferroni correction).
|
Marketing materials, prices and price promotions
The vast majority of POS (79.8%, n=103) had internal and/or external ads for any tobacco or nicotine product (72.9% Arab, n=35 and 82.9% Jewish, n=68); of which more than half was IQOS-indirect internal signage (57.1% Arab, n=20/35 and 57.4% Jewish, n=39/68), such as signs that said “heated tobacco units”, or “here you can buy heated tobacco”. The majority of POS that had any IQOS/HEETS signage included HEETS brand colors (70.0% Arab, n=14/20 and 79.5% Jewish, n=31/39), and IQOS/HEETS special displays (55.0% Arab, n=11/20 and 71.8% Jewish, n=28/39) (Table 4). Some of the special display cases provided by PMI were “discreet”; they had a light switch that makes the product visible only when turned on (figures 2A and 2B: IQOS special displays in Arab and Jewish neighborhoods, respectively).
The majority of POS in Arab (74.3%, n=26/35) and Jewish neighborhoods (85.3%, n=58/68) had cigarettes-specific internal signage, such as signs that said “cigarettes”. In contrast, significantly more POS in Arab neighborhoods mentioned a specific cigarette brand name (46.2%, n=12/26 vs. 22.4% in Jewish neighborhoods, n=13/58; p=0.024).
On average, POS in Arab neighborhoods carried fewer HEETS flavors (3.5 vs. 4.6, p=0.001), and sold them at a lower price (29.5 NIS vs. 30.7 NIS, p<0.001). Similarly, POS in Arab neighborhoods sold PMI cigarettes at a lower price on average (cheapest PMI cigarette: 24.5 NIS vs. 26.1 NIS, p<0.001; most expensive PMI cigarette: 38.4 NIS vs. 38.9 NIS, p=0.004). Price stickers that either indicated the advertised price or a price promotion were found at significantly more POS in Jewish neighborhoods (74.1%, n=43/58 vs. 65.4% in Arab neighborhoods, n=17/26; p=0.044).
Placement, visibility and regulatory compliance
IQOS/HEETS were placed within 1 m of the floor only in POS in Jewish neighborhoods (12.2%, n=10). IQOS was highly visible in the POS that sold it (68.8% in Jewish and 66.7% in Arab neighborhoods), but the visibility of HEETS was higher among POS in Jewish neighborhoods (62.2% vs. 39.6% in Arab neighborhoods, p=0.010).
A significantly higher proportion of POS in Arab neighborhoods had products in their original packaging (i.e., not in plain packaging as required by law) compared to Jewish neighborhoods’ POS (37.5% vs. 20.7%, p=0.027), but a higher proportion were compliant with the display ban (25.5% vs. 8.8%, p=0.011).