Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries

Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries Giorgi Mzhavanadze This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7460827/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Since their introduction in 2014, heated tobacco products (HTPs) have entered a growing number of national markets. Despite this expansion, few studies have systematically compared their affordability with that of cigarettes or examined differences in access across income groups. Aims This study assesses the affordability of HTPs relative to combustible cigarettes across 55 countries of varying income levels, with a focus on disparities by socioeconomic status. Methods Using publicly available data from the World Health Organization, World Bank, and industry sources, we compared retail prices, affordability (measured as the share of GDP per capita required to purchase 100 packs), and tax burden (the share of all taxes in the retail price) across 55 countries. Income distribution data were incorporated to assess affordability across different economic strata. Results HTPs were absent from low-income countries. HTP sticks were more expensive than the most-sold cigarette brand in 26 countries and costlier than the cheapest cigarette brand in 48 countries. In all 9 lower-middle-income countries and 11/16 upper-middle-income countries, HTPs were more expensive than the most-sold brand; in 24/30 high-income countries they were cheaper. In lower-middle-income countries, HTPs were on average 1.5 times less affordable than the most-sold brand and 2.3 times less affordable than the cheapest cigarettes; in high-income countries they were 1.2 times more affordable than the most-sold brand. For the lowest-income quintile across countries, purchasing 100 packs of HTPs required 9.2% of annual income compared with 8.0% for cigarettes; for the highest-income quintile the figures were 1.5% and 1.3%, respectively. Including device costs increased annual HTP use costs by 9.2–35.3%. HTPs faced lower tax burden than cigarettes in 52 of 55 countries (mean gap: 24.3 percentage points), but this advantage was not reflected in retail prices. Conclusion Outside high-income countries, higher relative prices for HTPs remain a major barrier to their use as substitutes for cigarettes. Although average HTP tax shares were lower in most countries, observed retail prices did not consistently reflect this difference. Policies that promote pass-through to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to switch away from combustibles where such strategies are pursued. Figures Figure 1 Figure 2 Figure 3 Background Since the introduction in 2014, heated tobacco products (HTPs) have become a significant and rapidly growing category within the global nicotine market. Initially launched in Japan and Italy, HTPs are now legally available in at least 70 countries as of early 2025, according to industry data [ 1 , 2 ]. This expansion has been driven by substantial research and development investments, primarily from major tobacco companies [ 1 ]. Since 2020, the global market value of HTPs, including both consumables and heating devices, has exceeded that of nicotine vaping products, driven by rising prices and increasing consumer adoption. However, even with the number of users projected to increase from 21 million in 2020 to 55 million by 2026 (assuming roughly one device per user per year), HTP adoption still lags behind vaping, which is estimated to have 82 million users in 2024 [ 3 ]. According to market data, the highest growth rates have been observed in Europe and Asia, with some countries experiencing near one-to-one substitution for cigarettes (e.g., Hungary, South Korea, Italy, Germany), while in others, cigarette sales are declining faster than HTP uptake (e.g., Slovakia, Japan, Greece) [ 3 ]. However, this global expansion has been uneven. As of April 2025, HTPs were available in 40 high-income countries (HICs), 21 upper-middle-income countries (UMICs), and only 9 lower-middle-income countries (LMICs) [ 2 ]. Notably, they are not legally available in any low-income countries (LICs), highlighting a significant disparity in access based on national income levels. This study is positioned within the public health framework of tobacco harm reduction, which advocates for providing safer nicotine alternatives to adult smokers who are unable or unwilling to quit. The principle of harm reduction is based on the understanding that the most severe health consequences of smoking arise from the toxicants produced during the combustion of tobacco, not from nicotine itself. HTPs operate by heating tobacco to a temperature sufficient to release a nicotine-containing aerosol, but without burning it. This process means they contain fewer harmful chemicals than tobacco smoke [ 4 ] and significantly reduce the formation of harmful and potentially harmful constituents. Clinical studies have consistently shown that smokers who switch exclusively to HTPs have a significant reduction in exposure to these toxicants [ 5 – 8 ]. Furthermore, switching to HTPs eliminates elevated exhaled carbon monoxide levels, with normalization observed rapidly [ 9 , 10 ]. Recent research suggests that after adjusting for prior smoking history, the odds ratio for chronic obstructive pulmonary disease drops significantly among exclusive HTP users [ 11 ]. Despite a growing body of evidence suggesting that HTPs are a less harmful alternative to combustible cigarettes, both their absolute risk and the extent of relative risk reduction remain subjects of debate and ongoing research. The long-term health and mortality impacts of HTP use remain unknown [ 12 , 13 ]. Also, to the best of our knowledge, no population-level observational studies have demonstrated a decline in smoking-related mortality in countries with high HTP uptake. Given these uncertainties, this paper does not assess the health outcomes of HTPs. Instead, it focuses on the critical role of economic accessibility in realizing any potential public health benefits. Ensuring that less harmful products are accessible to all is a cornerstone of health equity [ 14 ]. If safer alternatives are not affordable for the populations most burdened by smoking-related diseases, often those in lower socioeconomic strata, their potential to reduce harm at a population level is severely limited [ 15 – 18 ]. Affordability, therefore, is not merely an economic consideration but a prerequisite for equitable harm reduction. In this context, the relative price of HTPs compared to cigarettes becomes a critical determinant of consumer behavior. Economic evidence shows that raising cigarette prices through taxation reduces smoking prevalence, despite cigarette demand being relatively inelastic [ 19 – 22 ]. By contrast, emerging research suggests that HTP demand is more price-sensitive and these products function as economic substitutes for cigarettes [ 23 , 24 ]. Alongside price, consumer uptake is also shaped by perceived relative health risks, peer influence, and motivations to quit or cut down [ 25 , 26 ]. Early studies found that HTPs, despite benefiting from lower tax rates, were still priced higher than cigarettes in many countries [ 27 ]. The substantial upfront cost of purchasing a heating device has also been identified as a significant financial barrier, discouraging smokers from switching [ 28 ]. While previous research offered an initial cross-country comparison of HTP affordability, this paper is the first to focus explicitly on income-related disparities. It also considers how tax structures and market pricing shape access. By centering on economic equity, this paper provides evidence to guide fiscal and market interventions that could enhance the harm reduction potential of HTPs. To achieve this, we conducted a cross-country analysis of HTP affordability relative to cigarettes, incorporating both national and within-country income differences, as described in the Methods section below. Methods This cross-sectional study compared the affordability of HTPs and combustible cigarettes across 55 countries. Analyses were conducted by national income level, using the World Bank classification, and across income quintiles within each country. The data for this study were compiled from multiple public and industry sources. Retail prices and tax burdens for the most-sold, premium, and cheapest cigarette brands, along with the most-sold brand of HTP sticks, were obtained from the World Health Organization’s (WHO) Global Health Observatory for 2022 [ 29 ]. As prices for HTP heating devices were not included in this dataset, they were supplemented with industry-reported data as of April 2024 [ 30 ]. Country-level macroeconomic indicators for 2022, including Gross Domestic Product (GDP) per capita and income distribution by quintiles, were sourced from the World Bank, while national income classifications followed the World Bank’s fiscal year 2024 groupings [ 31 , 32 ]. The primary measure of affordability was the Relative Income Price (RIP), defined as the percentage of annual GDP per capita required to purchase 100 packs of a given product, with higher RIP values indicating lower affordability [ 33 ]. RIP was calculated for the general population and each income quintile. The analysis also incorporated the annualized cost of HTP heating devices, using the lowest- and highest-priced devices reported in April 2024, amortized over one year, and added this to HTP stick prices to capture the total annual cost of use. Tax burdens, expressed as the total tax share of the retail price, were also compared between HTP sticks and cigarettes. Descriptive and comparative analyses were supplemented with ordinary least squares linear regression to examine associations between the HTP-cigarette price differential and factors such as cigarette prices, excise tax differentials, and GDP per capita. All calculations and statistical analyses were conducted in Microsoft Excel (Microsoft 365; Microsoft Corporation, Redmond, WA, USA). Results Cross-Country Price Comparison Across the 55 countries analyzed, HTP sticks were more expensive than the most-sold brand of cigarettes in 26 countries and more expensive than the cheapest brand of cigarettes in 48 countries. This pattern varied by national income level: HTP sticks were more expensive than the most-sold cigarette brand in all 9 LMICs and 11 of the 16 UMICs in the sample. In contrast, among the 30 HICs, HTPs were less expensive than the most-sold cigarette brand in 24 countries. Descriptive analysis indicated a negative relationship between absolute cigarette prices and the price differential between HTPs and cigarettes: in countries with higher cigarette prices, HTPs were more likely to be the cheaper option, and vice versa (Fig. 1). Multiple linear regression confirmed this association. For every US $ 1 increase in the price of the most-sold cigarette brand, the price difference between HTPs and cigarettes decreased by approximately US $ 0.49 (95% CI: -0.5474 — -0.4305, p < 0.001). This suggests that HTP prices are not increasing at the same rate as cigarette prices; for every $ 1 rise in cigarette prices, HTP prices are associated with an increase of only about $ 0.51. The excise tax differential between the products showed no statistically significant association with the price differential. Table 1 Linear Regression Results For Heated Tobacco Products Prices Variable Coefficient Standard Error t-statistic P-value 95% CI Intercept 1.3108*** 0.1625 8.0654 < 0.0001 0.9845–1.6371 Tax differential 0.0052 0.0044 1.1926 0.2385 -0.0036–0.0141 Cigarette price -0.4889*** 0.0291 -16.7861 < 0.0001 -0.5474 – -0.4305 GDP per capita (US $ 1000) 0.0076** < 0.0001 2.4774 0.0166 0.0014–0.0137 Ordinary least squares regression of HTP stick prices (US$) as the dependent variable, using 2022 cross-country data (n = 55). Independent variables: excise tax differential between cigarettes and HTP sticks, price of the most-sold cigarette brand, and GDP per capita (in US$1000). Adjusted R² = 0.8810. Cigarette price was strongly and negatively associated with HTP prices (p < 0.0001), GDP per capita had a small but statistically significant positive association, and the tax differential was not statistically significant. All monetary values are in US$. Coefficients are rounded to four decimal places. ***p < 0.001, **p < 0.05 CI: confidence interval; GDP: gross domestic product. Affordability by National Income Level Affordability varied substantially across income groups (Fig. 2). In LMICs, HTP sticks were, on average, 1.5 times less affordable than the most-sold cigarette brand and 2.3 times less affordable than the cheapest cigarettes. However, compared to premium brands, HTPs were 1.2 times more affordable. In UMICs, HTP affordability was comparable to premium cigarettes but 1.1 times lower than the most-sold brand. In HICs, HTP sticks were, on average, 1.2 times more affordable than the most-sold cigarettes and 1.3 times more affordable than premium brands. Across all groups, the cheapest cigarette brands remained the most affordable option. The affordability gap between HTPs and cigarettes narrowed as national income levels increased, making HTPs relatively more accessible in wealthier countries. No LICs in the dataset had HTP availability. Affordability by Income Quintile Within countries, affordability gaps were most pronounced for lower-income groups (Fig. 3). For the lowest-income quintile across all countries, purchasing 100 packs of HTP sticks would require 9.2% of annual income, compared with 8.0% for the most-sold cigarette brand. Affordability improved steadily with rising income: for the highest-income quintile, the same purchase required 1.5% of annual income for HTPs and 1.3% for cigarettes. This translates to HTPs being 6.3 times less affordable for the poorest quintile compared with the richest. The disparity was particularly stark in LMICs, where the RIP for HTPs among the lowest-income quintile reached 24.9% of annual income (measured in GDP per capita). Impact of Device Costs Including the amortized annual cost of HTP devices increased the total annual cost of HTP use by 9.2–35.3%, depending on device model. When the cost of the cheapest device was included, HTPs became more expensive than the most-sold cigarette brand in 39 of the 55 countries, including all 9 LMICs and 14 of the 16 UMICs. When the most expensive device was factored in, HTPs were more expensive in 53 of 55 countries. The only exceptions where cigarettes remained costlier even with the highest-priced device were the United Kingdom and New Zealand. Tax Burden Analysis The higher price of HTPs did not appear to be driven by higher taxation. On the contrary, HTPs benefited from lower tax rates (measured as the share of total taxes in retail price) than cigarettes in 52 of the 55 countries studied. The average tax gap between cigarettes and HTPs was 24.3 percentage points. This tax advantage was largest in HICs (27.4 percentage points) and smallest in LMICs (16.5 percentage points). The regression analysis suggested that this tax differential was not being passed on to consumers in the form of lower retail prices, as the model found no statistically significant association between the size of the tax differential and the final price difference between HTP sticks and cigarettes (Table 1 ). Discussion This study highlights a substantial equity gap in global accessibility to HTPs. Both an expanding body of evidence and tobacco industry positioning present HTPs as potential harm reduction alternatives to smoking, yet affordability remains a major barrier, particularly for lower-income populations in low- and middle-income countries, which also bear a disproportionate burden of smoking-related disease. The affordability gap appears to be driven primarily by industry pricing strategies rather than taxation. Despite having a lower tax burden than cigarettes in most countries, HTPs are frequently priced above cigarettes, consistent with prior findings that tax advantages are not fully reflected in retail prices [ 23 , 27 ]. Across the major transnational tobacco companies, the highly publicized “transformation” narrative is best understood as a profit-maximizing corporate strategy rather than a genuine global shift away from combustible cigarettes. Evidence from corporate strategy analyses, leaked internal documents, and independent reviews shows that these shifts toward HTPs and other non-combustibles are concentrated in high-income countries where cigarette sales are already declining, regulation is stronger, and investor pressure encourages portfolio diversification [ 1 , 34 – 39 ]. In these markets, alternative products are positioned as central to maintaining long-term profitability and market relevance, supported by marketing that frames them as premium, high-tech lifestyle products [ 34 , 35 , 37 , 39 ]. By contrast, in lower-income countries, where cigarettes remain highly profitable and regulatory pressures are weaker, the industry continues to prioritize and aggressively market the deadliest form of nicotine delivery, combustible cigarettes [ 1 , 38 ]. This dual strategy is consistent with industry commercial objectives and may support harm-reduction efforts in select high-income settings; however, it does not adequately address the needs of the majority of the global smoking population. Another factor, particularly relevant in LMICs, is the relatively low price of cigarettes. In many such markets, taxes are not high enough to make cigarettes sufficiently expensive. In 2022, the average tax share on cigarettes was 73% in HICs versus 59% in LMICs. Our results show that higher cigarette prices are associated with greater relative affordability of HTPs. Where cigarettes remain inexpensive, there is limited scope and incentive for firms to price HTPs competitively. This reduces the financial motivation for consumers to switch. Given these constraints, closing the affordability gap will likely require targeted policy interventions. One option is the use of price ceilings or profit-margin caps for HTPs, drawing on frameworks used in other sectors, such as pharmaceuticals, to improve affordability [ 40 , 41 ]. While such measures may reduce retail prices, economic evaluations warn that price regulation can dampen innovation, risk supply shortages if caps are set too low, and spur illicit markets if controls are overly restrictive [ 42 ]. These trade-offs require careful design and implementation. Conditional tax benefits are another potential tool. Preferential excise rates could be linked to a measurable retail price gap between HTPs and cigarettes, increasing the likelihood that tax advantages are passed on to consumers. Evidence from the investment tax incentive literature suggests that linking tax relief to specific performance outcomes can make such policies effective (43, 44). However, no country has yet applied this conditional approach to tobacco excise. Its implementation would present practical challenges, including monitoring compliance, verifying price information, and enforcing penalties for non-compliance. Alongside fiscal measures, competition policy could also play a critical role in shaping market prices. Promoting competition may offer a more sustainable and economically efficient pathway to reducing HTP prices [ 41 ]. Easing regulatory barriers to entry for HTPs and other tobacco alternatives, and lifting product-specific prohibitions, can expand the number of suppliers, intensify price competition, and increase product variety. In countries where HTPs are either unavailable or limited to premium market segments, competition-oriented strategies may improve their affordability compared to cigarettes. The initial cost of a heating device remains another significant barrier, echoing earlier research [ 28 ]. For smokers with limited disposable income, the upfront investment can represent several weeks or months’ worth of cigarette purchases. Even when stick prices are competitive, this fixed cost can effectively exclude lower-income smokers from trying or adopting HTPs. Finally, our estimates likely understate the affordability gap by not accounting for roll-your-own (RYO) tobacco, which is the cheapest combustible option in many countries. Evidence shows RYO use is concentrated among lower socioeconomic groups because of its price advantage over factory-made cigarettes [ 46 – 50 ]. For smokers who use RYO, the price gap to switch to premium-priced HTPs is even higher than for manufactured cigarette smokers. Lower-income populations are also more price sensitive and more prone to downward substitution [ 48 – 51 ], exacerbating the equity problem: those with the fewest resources are the least exposed to any potential benefits of HTPs. Limitations This study has several limitations that should be acknowledged when interpreting the findings. First, it is based on cross-sectional data from 2022, providing only a single snapshot of market conditions. Tobacco and nicotine product markets are highly dynamic, with prices, taxes, and product availability subject to rapid changes in response to regulation, competition, and industry strategy. As such, the analysis is correlational and cannot establish causal relationships between price, tax structures, and consumer behavior. Second, heating device cost estimates are drawn from a single company for 2024. While this may introduce some distortion, the potential bias is likely modest, as the company is the dominant market leader for HTPs in most observed markets. A comparison of heating device prices between 2024 and 2025 revealed no consistent pattern of price change, further suggesting that the figures used are a reasonable approximation. Third, GDP per capita was used as the primary income indicator. Although it provides a broadly comparable measure across countries, it does not capture intra-country income inequality or differences in disposable income. This limitation was partially mitigated by examining income quintile data, but a more granular household-level analysis of income and expenditure would enable a more precise assessment of affordability and equity impacts. Fourth, the analysis relies on WHO-reported tax share data, which measure the proportion of the retail price accounted for by all taxes on HTP sticks and cigarettes. While this metric provides a standardized international proxy, it does not capture the statutory excise tax rates set in national legislation. These rates may be ad valorem (a percentage of retail price), specific (a fixed amount per unit), or mixed. Consequently, HTPs and cigarettes could face identical statutory rates yet differ in measured tax share solely because of differences in retail prices. Under a specific tax, for example, a flat-rate levy will represent a smaller proportion of the price for higher-priced products. This limitation may introduce some imprecision in interpreting tax burdens; however, it should not critically affect our findings. The conclusion that tax advantages for HTPs are largely absorbed by manufacturers rather than passed on to consumers remains valid, regardless of whether measured differences in tax burden arise from statutory rates or underlying price levels. Finally, as stated earlier, this study does not evaluate the health effects of HTPs or their effectiveness for smoking cessation. Its focus is strictly on the economic equity of access. The analysis assumes, based on existing evidence, that HTPs are significantly less harmful than combustible cigarettes and therefore have harm reduction potential. If this assumption were proven incorrect, or if the relative risk differential were minimal, the implications for health equity discussed here would not apply. Conclusions Outside high-income countries, higher relative prices for HTPs remain a major barrier to their use as substitutes for cigarettes. Although average HTP tax shares were lower in most countries, observed retail prices did not consistently reflect this difference. This pattern suggests incomplete pass-through of HTP tax advantages, potentially due to industry pricing strategies, which limits their impact on consumer prices. Policies that promote pass-through of any HTP tax advantages to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to substitute away from combustibles where such strategies are pursued. Without such action, the harm-reduction potential of HTPs may remain unevenly distributed, with lower-income populations continuing to bear the greatest burden of smoking-related disease. The analysis is cross-sectional and does not identify causal effects; results should be interpreted accordingly. Abbreviations GDP Gross Domestic Product HIC High-Income Country HTP Heated Tobacco Product LIC Low-Income Country LMIC Lower-Middle-Income Country RIP Relative Income Price RYO Roll-Your-Own UMIC Upper-Middle-Income Country WHO World Health Organization Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets analysed during the current study are available in the following repositories: WHO Global Health Observatory: National taxes and retail price for 20 sticks of heated tobacco products National taxes on a pack of 20 cigarettes Retail price for a pack of 20 cigarettes World Bank Data: GDP per capita (constant national currency) GDP per capita (current US$) Income shares by quintile: First Second quintile Third quintile Fourth quintile Fifth quintile World Bank country and lending groups classification Industry data (Philip Morris International): Retail selling price database – April 2024 release Retail selling price database – April 2025 release The compiled dataset used for analysis is available from the corresponding author on reasonable request. Competing interests The author works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs. At the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons. In parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases. Both organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products. The charitable gift agreement (the “Pledge Agreement”) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization’s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking’s Certificate of Incorporation states that Global Action was formed to, among other things, “support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.” Global Action’s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website (www.globalactiontoendsmoking.org) and fully disclosed in public materials. This study was conducted as part of the author’s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above. Funding This study was funded with a grant from Global Action to End Smoking (formerly known as the Foundation for a Smoke-Free World), an independent U.S. nonprofit 501(c)(3) grantmaking organization. The funder had no role in the design, implementation, data analysis, interpretation of the study results, or preparation of this manuscript. Authors’ contributions GM contributed to the conceptualization, data collection, data analysis, and drafting of the manuscript. The author read and approved the final manuscript. Acknowledgements The author thanks the Global State of Tobacco Harm Reduction team at Knowledge-Action-Change for their support during the conceptualization and dissemination of this research. In particular, the author is grateful to Professor Gerry Stimson for his valuable feedback and for encouraging the initiation of this research from its earliest stages. The views expressed in this manuscript are solely those of the author. Use of AI-Assisted Technologies The author discloses that AI chatbot ChatGPT was used solely for language editing purposes in the preparation of this manuscript. The model was not used for data analysis, data interpretation, or content generation. All intellectual content, analysis, and conclusions are my own, and I take full responsibility for the integrity and accuracy of the work. References O’Connor RJ, Schneller LM, Felicione NJ, Talhout R, Goniewicz ML, Ashley DL. Evolution of tobacco products: recent history and future directions. Tob Control. 2022;31(Suppl 3):s3–s5. https://doi.org/10.1136/tobaccocontrol-2021-056544. Philip Morris International. Retail selling price database – April 2025 release. 2025. https://www.pmi.com/resources/docs/default-source/investor_relation/apr25---rsps.xlsx [accessed 2025 Aug 4]. The Global State of Tobacco Harm Reduction. The Global State of Tobacco Harm Reduction 2024: A Situation Report. Knowledge-Action-Change. 2024. https://gsthr.org/resources/thr-reports/the-global-state-of-tobacco-harm-reduction-2024-a-situation-report/ [accessed 2025 Aug 4]. Polosa R, Rodu B, Farsalinos K. Health effects of e-cigarettes, heated tobacco, and oral nicotine products. Intern Emerg Med. 2025. https://doi.org/10.1007/s11739-025-04057-4. Haziza C, de La Bourdonnaye G, Merlet S, Benzimra M, Ancerewicz J, Donelli A, Baker G, Picavet P, Lüdicke F. Assessment of the reduction in levels of exposure to harmful and potentially harmful constituents in Japanese subjects using a novel tobacco heating system compared with conventional cigarettes and smoking abstinence: A randomized controlled study in confinement. Regul Toxicol Pharmacol. 2016 Dec;81:489–99. https://doi.org/10.1016/j.yrtph.2016.09.014. Lüdicke F, Ansari SM, Lama N, Blanc N, Bosilkovska M, Donelli A, Picavet P, Baker G, Haziza C, Peitsch M, Weitkunat R. Effects of switching to a heat-not-burn tobacco product on biologically relevant biomarkers to assess a candidate modified risk tobacco product: a randomized trial. Cancer Epidemiol Biomarkers Prev. 2019;28(11):1934-43. https://doi.org/10.1158/1055-9965.EPI-18-0915. Gale N, McEwan M, Camacho OM, Hardie G, Murphy J, Proctor CJ. Changes in biomarkers of exposure on switching from a conventional cigarette to the Glo tobacco heating product: a randomized, controlled ambulatory study. Nicotine Tob Res. 2021 Mar;23(3):584–91. https://doi.org/10.1093/ntr/ntaa135. Gale N, McEwan M, Hardie G, Proctor CJ, Murphy J. Changes in biomarkers of exposure and biomarkers of potential harm after 360 days in smokers who either continue to smoke, switch to a tobacco heating product or quit smoking. Intern Emerg Med. 2022;17:2017–30. https://doi.org/10.1007/s11739-022-03062-1. Adriaens K, Van Gucht D, Baeyens F. IQOSTM vs. e-cigarette vs. tobacco cigarette: a direct comparison of short-term effects after overnight-abstinence. Int J Environ Res Public Health. 2018 Dec 18;15(12):2902. https://doi.org/10.3390/ijerph15122902. Caponnetto P, Maglia M, Prosperini G, Busà B, Polosa R. Carbon monoxide levels after inhalation from new generation heated tobacco products. Respir Res. 2018;19:164. https://doi.org/10.1186/s12931-018-0867-z. Kimura Y, Sugita M. Association between use of heated tobacco products and long-term respiratory effects considering smoking history: internet-based cross-sectional study in Japan. BMC Public Health. 2024;24:2785. https://doi.org/10.1186/s12889-024-20257-7. McNeill AD, Brose LS, Calder R, Bauld L, Robson DJ. Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. Public Health England; 2018. London. https://assets.publishing.service.gov.uk/media/5a981c6740f0b67aa27253cc/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf [accessed 2025 Aug 4]. Polosa R, Farsalinos K, Prisco D. Health impact of electronic cigarettes and heated tobacco systems. Intern Emerg Med. 2019 Jun;14(6):817–20. https://doi.org/10.1007/s11739-019-02167-4. Braveman P, Arkin E, Orleans T, Proctor D, Plough A. What is health equity? Behav Sci Policy. 2018;4(1):1-14. https://doi.org/10.1177/237946151800400102. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, Ricceri F, d’Errico A, Barros H, Bochud M, Chadeau-Hyam M, Clavel-Chapelon F, Costa G, Delpierre C, Fraga S, Goldberg M, Giles GG, Krogh V, Kelly-Irving M, Layte R, Lasserre AM, Marmot MG, Preisig M, Shipley MJ, Vollenweider P, Zins M, Kawachi I, Steptoe A, Mackenbach JP, Vineis P, Kivimäki M; LIFEPATH consortium. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1.7 million men and women. Lancet. 2017 Mar 25;389(10075):1229–37. https://doi.org/10.1016/S0140-6736(16)32380-7. Marmot M. Social determinants of health inequalities. Lancet. 2005 Mar 19;365(9464):1099–104. https://doi.org/10.1016/S0140-6736(05)71146-6. U.S. National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2017. https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-22 [accessed 2025 Aug 4]. Centers for Disease Control and Prevention. People with low socioeconomic status experience a health burden from commercial tobacco. Tobacco – Health Equity. 2024 May 15. https://www.cdc.gov/tobacco-health-equity/collection/low-ses-health-burden.html [accessed 2025 Aug 4]. Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235-8. https://doi.org/10.1136/tc.2010.039982. Levy DT, Boyle RG, Abrams DB. The role of public policies in reducing smoking: the Minnesota SimSmoke tobacco policy model. Am J Prev Med. 2012;43(5 Suppl 3):S179-86. https://doi.org/10.1016/j.amepre.2012.07.037. Chaloupka FJ, Warner KE. The economics of smoking. In: Culyer AJ, Newhouse JP, editors. Handbook of Health Economics. Vol. 1B. Amsterdam: Elsevier; 2000. p. 1539-627. https://doi.org/10.1016/S1574-0064(00)80042-6. DeCicca P, Kenkel DS, Lovenheim MF. The economics of tobacco regulation: a comprehensive review. Cambridge (MA): National Bureau of Economic Research; 2020. (NBER Working Paper No. 26923). https://doi.org/10.3386/w26923. Dauchy E, Shang C. The pass-through of excise taxes to market prices of heated tobacco products (HTPs) and cigarettes: a cross-country analysis. Eur J Health Econ. 2023;24(4):591-607. https://doi.org/10.1007/s10198-022-01499-x. Kenkel DS, Mathios AD, Phillips GN, Suryanarayana R, Wang H, Zeng S. Fear or knowledge: the impact of graphic cigarette warnings on tobacco product choices. Cambridge (MA): National Bureau of Economic Research; 2023. (NBER Working Paper No. 31534). https://doi.org/10.3386/w31534. Sutanto E, Miller C, Smith DM, O’Connor RJ, Quah ACK, Cummings KM, Xu S, Fong GT, Hyland A, Ouimet J, Yoshimi I, Mochizuki Y, Tabuchi T, Goniewicz ML. Prevalence, use behaviors, and preferences among users of heated tobacco products: Findings from the 2018 ITC Japan Survey. Int J Environ Res Public Health. 2019;16(23):4630. https://doi.org/10.3390/ijerph16234630. Laverty AA, Vardavas CI, Filippidis FT. Prevalence and reasons for use of heated tobacco products (HTP) in Europe: An analysis of Eurobarometer data in 28 countries. Lancet Reg Health Eur. 2021;8:100159. https://doi.org/10.1016/j.lanepe.2021.100159. Liber AC. Heated tobacco products and combusted cigarettes: comparing global prices and taxes. Tob Control. 2019;28(6):689-691. https://doi.org/10.1136/tobaccocontrol-2018-054602. Jakob J, Joss S, Meier AN, Tal K, Schoeni A, Marti J, Diethelm P, Auer R. The price of nicotine dependence: A comparison of the cost of nicotine across products in Switzerland, Germany, USA, Sweden, France and the UK, in 2019. Tob Prev Cessat. 2022;8:42. https://doi.org/10.18332/tpc/156052. World Health Organization. WHO Global Health Observatory: National taxes and retail price for 20 sticks of heated tobacco products; National taxes on a pack of 20 cigarettes; Retail price for a pack of 20 cigarettes. 2025. https://www.who.int/data/gho [accessed 2025 Aug 1]. Philip Morris International. Retail selling price database – April 2024 release. https://www.pmi.com/resources/docs/default-source/investor_relation/may_2024---rsps.xlsx [accessed 2025 Aug 1]. The World Bank. World Development Indicators. Washington, DC: World Bank; 2025 . https://databank.worldbank.org/source/world-development-indicators [accessed 2025 Aug 1]. The World Bank. World Bank country and lending groups. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups [accessed 2025 Aug 1]. Blecher EH, van Walbeek CP. An international analysis of cigarette affordability. Tob Control. 2004;13(4):339-46. https://doi.org/10.1136/tc.2003.006726. Triossi MN, Cloos TA. Disrupting the Tobacco Industry: How Tobacco Companies Seek to Stay in Business – A Case Study on the Strategic Transformation of Philip Morris International [master’s thesis]. Copenhagen: Copenhagen Business School; 2022. 99 p. https://research-api.cbs.dk/ws/portalfiles/portal/76442875/1390284_Thesis_Philip_Morris.pdf [accessed 2025 Aug 4]. Edwards R, Hoek J, Karreman N, Gilmore A. Evaluating tobacco industry ‘transformation’: a proposed rubric and analysis. Tob Control. 2022;31(3):365-371. https://doi.org/10.1136/tobaccocontrol-2021-056687. Mehegan J, Gallagher A, Elmitwalli S, Edwards R, Gilmore A. Analysis of Philip Morris International’s ‘aspirational’ target for its 2025 cigarette shipments. Tob Control. 2024;33(e1):e11–e18. https://doi.org/10.1136/tc-2023-058511. Levy DT, Thirlway F, Sweanor D, Liber A, Sanchez-Romero LM, Meza R, Douglas CE, Cummings KM. Do tobacco companies have an incentive to promote “harm reduction” products?: The role of competition. Nicotine Tob Res. 2023;25(12):1810–21. https://doi.org/10.1093/ntr/ntad014. Hendlin YH, Han EL, Ling PM. Pharmaceuticalisation as the tobacco industry’s endgame. BMJ Glob Health. 2024;9:e013866. https://doi.org/10.1136/bmjgh-2023-013866. Mathers A, Hawkins B, Lee K. Transnational tobacco companies and new nicotine delivery systems. Am J Public Health. 2019;109(2):227–235. https://doi.org/10.2105/AJPH.2018.304813. Basu K, Pitsuwan F, Zhang P. The economics of profit-cap policy: Big Pharma, Big Tech, and the duopoly rule. J Econ Behav Organ. 2023;215:120-33. https://doi.org/10.1016/j.jebo.2023.08.027. Lee KS, Kassab YW, Taha NA, Zainal ZA. A systematic review of pharmaceutical price mark-up practice and its implementation. Explor Res Clin Soc Pharm. 2021;2:100020. https://doi.org/10.1016/j.rcsop.2021.100020. Guenette JD. Price controls: good intentions, bad outcomes. Policy Research Working Paper No. 9212. Washington, DC: World Bank; 2020. http://hdl.handle.net/10986/33606. Platform for Collaboration on Tax (IMF, OECD, UN, World Bank). Tax Incentives Principles. Washington, DC: IMF; 2025. https://www.tax-platform.org/sites/pct/files/publications/Tax-Incentives-Principles.pdf [accessed 2025 Aug 4]. OECD. Countering harmful tax practices more effectively, taking into account transparency and substance (BEPS Action 5 — Final Report). Paris: OECD Publishing; 2015. https://doi.org/10.1787/9789264241190-en [accessed 2025 Aug 4]. Bresnahan TF, Reiss PC. Entry and competition in concentrated markets. J Polit Econ. 1991;99(5):977-1009. https://doi.org/10.1086/261786. Young D, Borland R, Hammond D, Cummings KM, Devlin E, Yong HH, O'Connor RJ, ITC Collaboration. Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15(Suppl 3):iii76-82. https://doi.org/10.1136/tc.2005.013268. Gallus S, Lugo A, Ghislandi S, La Vecchia C, Gilmore AB. Roll-your-own cigarettes in Europe: use, weight and implications for fiscal policies. Eur J Cancer Prev. 2014;23(3):186-92. https://doi.org/10.1097/CEJ.0000000000000010. Rothwell L, Britton J, Bogdanovica I. The relation between cigarette price and hand-rolling tobacco consumption in the UK: an ecological study. BMJ Open. 2015;5(6):e007697. https://doi.org/10.1136/bmjopen-2015-007697. Brown AK, Nagelhout GE, van den Putte B, Willemsen MC, Mons U, Guignard R, Thompson ME. Trends and socioeconomic differences in roll-your-own tobacco use: findings from the ITC Europe Surveys. Tob Control. 2015;24(Suppl 3):iii11-9. https://doi.org/10.1136/tobaccocontrol-2014-051986. Mzhavanadze G. Illicit cigarette market in Georgia: potential impacts on smoking prevalence and tax revenues. Public Health. 2023;223:223-9. https://doi.org/10.1016/j.puhe.2023.08.010. Fuchs A, Gonzalez Icaza MF, Paz DP. Distributional effects of tobacco taxation: a comparative analysis. World Bank Policy Research Working Paper No. 8805. Washington, DC: World Bank; 2019 Apr 8. https://ssrn.com/abstract=3368579/. Additional Declarations Competing interest reported. The author works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs. At the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons. In parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases. Both organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products. The charitable gift agreement (the “Pledge Agreement”) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization’s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking’s Certificate of Incorporation states that Global Action was formed to, among other things, “support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.” Global Action’s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website ( www.globalactiontoendsmoking.org ) and fully disclosed in public materials. This study was conducted as part of the author’s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 16 Apr, 2026 Reviewers invited by journal 23 Sep, 2025 Editor assigned by journal 26 Aug, 2025 Submission checks completed at journal 26 Aug, 2025 First submitted to journal 26 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7460827","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":524049188,"identity":"53a34b16-5e42-4d39-be1f-70d1b525527d","order_by":0,"name":"Giorgi Mzhavanadze","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACZhBhYGPAwMBDmpY0UrRAwGEStMi7Mx/7+KXgvDF/+9mDnwt+2TDwSyTg12J4mC15tozBbTOJM3nJ0jP70hgkZxDS0sxjzCxhcNuG4QaPgTRvz2EGgxvEaTlnI3+Dx/g3b89/BntCWuSZeYwZPxgcMDO4wWMmzfPjAIMBIb8YMLMlMzMYJBsbnskxs+ZtSOaROPOAgC39hw8z/vhjZzjv+Bnj2zx/7OT42wnZcgAYm/AYYWwjInbkG4AKf8C5fwhqGAWjYBSMghEIANR5PHwab+TKAAAAAElFTkSuQmCC","orcid":"","institution":"Knowledge-Action-Change","correspondingAuthor":true,"prefix":"","firstName":"Giorgi","middleName":"","lastName":"Mzhavanadze","suffix":""}],"badges":[],"createdAt":"2025-08-26 08:53:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7460827/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7460827/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92918563,"identity":"5416d09c-4469-42d7-b5b9-e0855024c4a2","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":57105,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/c6be88f108c4732227f21a40.docx"},{"id":92919417,"identity":"d8bd5196-1561-4058-ad8c-c11da377b391","added_by":"auto","created_at":"2025-10-07 06:35:55","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":9420,"visible":true,"origin":"","legend":"","description":"","filename":"fb5503ec191a46c99026ff6f27c3674f.json","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/ae05d45507d14af205121289.json"},{"id":92919177,"identity":"ac265053-0439-4648-a9ff-5f9019803a62","added_by":"auto","created_at":"2025-10-07 06:27:55","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":189653,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/e60e3214189fd96ba7d6c622.jpg"},{"id":92918570,"identity":"4bf8d487-c934-4179-9c11-9b8f8e952ec1","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":251071,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/178c5bbc54269a9fb6343337.jpg"},{"id":92918573,"identity":"dbc73c14-42a2-4984-bb4f-450ef89d56c7","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":262208,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/f3d90458578349952acc0b9a.jpg"},{"id":92918571,"identity":"6d7e5546-d0eb-4121-a656-20ce70053c92","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":132135,"visible":true,"origin":"","legend":"","description":"","filename":"fb5503ec191a46c99026ff6f27c3674f1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/2d6fca38a5e15a8a013f8393.xml"},{"id":92919179,"identity":"5254867d-2996-4f37-b213-963cb17605ee","added_by":"auto","created_at":"2025-10-07 06:27:55","extension":"xml","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":123032,"visible":true,"origin":"","legend":"","description":"","filename":"fb5503ec191a46c99026ff6f27c3674f1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/9b82f7a5c9255828955dac35.xml"},{"id":92918574,"identity":"78c6602f-39f6-49a9-9135-afeb5dce7c1e","added_by":"auto","created_at":"2025-10-07 06:19:56","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":142797,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/40ca9ce01bcc8da5f3eac836.html"},{"id":92918569,"identity":"e82fa537-c1f1-4a1d-a1d6-b5529476cc8c","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":189653,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrice Comparison Between Heated Tobacco Products And Cigarettes Across 55 Countries, 2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEach point represents one country. Red squares plot the price of heated tobacco product (HTP) sticks against the price of the most-sold cigarette brand; purple diamonds plot HTP stick price against the cheapest cigarette brand (US$). The 45° parity line indicates equal prices; points above the line denote HTPs priced higher than the comparator cigarette brand and points below denote HTPs priced lower.. HTP device costs are not included in this figure.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/5fb60a2353f95160dc87127e.jpg"},{"id":92919175,"identity":"4385d60d-9ea2-4ca7-b9c6-cf0a4c21c718","added_by":"auto","created_at":"2025-10-07 06:27:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":251071,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAffordability of Cigarettes and Heated Tobacco Products by Country Income Group, 2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBars show affordability as the Relative Income Price - the percentage of gross domestic product per capita required to purchase 100 packs. Product categories include the cheapest, most-sold, and premium cigarette brands; HTP sticks alone; HTP sticks + lowest-priced device; and HTP sticks + highest-priced device. Device costs are annualized over one year. Country groups are lower-middle-, upper-middle-, and high-income. Low-income countries had no legal HTP availability in the dataset.\u003cbr\u003e\nGDP: gross domestic product; HTP: heated tobacco product.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/1f829012b49090005713c33a.jpg"},{"id":92918567,"identity":"b09b5549-fc39-4cd6-b25c-f11187774385","added_by":"auto","created_at":"2025-10-07 06:19:55","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":262208,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAffordability of Cigarettes and Heated Tobacco Products Across Income Quintiles, 2022\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBars show affordability as the Relative Income Price (the percentage of gross domestic product per capita required to purchase 100 packs) for income quintiles within countries (Q1 = poorest 20%, Q5 = richest 20%).\u003c/em\u003e \u003cem\u003eValues reflect averages across the 55-country sample. Product categories include the cheapest, most-sold, and premium cigarette brands; HTP sticks alone; HTP sticks + lowest-priced device; and HTP sticks + highest-priced device. Device costs are annualized over one year. Country groups are lower-middle-, upper-middle-, and high-income. Low-income countries had no legal HTP availability in the dataset.\u003cbr\u003e\nGDP: gross domestic product; HTP: heated tobacco product.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/fc186a66bb596accdcaf7873.jpg"},{"id":92920077,"identity":"4b1e5fed-2256-4035-b170-47800e74e7de","added_by":"auto","created_at":"2025-10-07 06:43:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1415970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7460827/v1/0f6fb40c-8067-4163-a1f4-da9aae038af8.pdf"}],"financialInterests":"Competing interest reported. The author works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs.\nAt the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons.\nIn parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases.\nBoth organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products.\nThe charitable gift agreement (the “Pledge Agreement”) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization’s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking’s Certificate of Incorporation states that Global Action was formed to, among other things, “support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.” Global Action’s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website (www.globalactiontoendsmoking.org) and fully disclosed in public materials.\nThis study was conducted as part of the author’s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above.","formattedTitle":"Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries","fulltext":[{"header":"Background","content":"\u003cp\u003eSince the introduction in 2014, heated tobacco products (HTPs) have become a significant and rapidly growing category within the global nicotine market. Initially launched in Japan and Italy, HTPs are now legally available in at least 70 countries as of early 2025, according to industry data [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This expansion has been driven by substantial research and development investments, primarily from major tobacco companies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since 2020, the global market value of HTPs, including both consumables and heating devices, has exceeded that of nicotine vaping products, driven by rising prices and increasing consumer adoption. However, even with the number of users projected to increase from 21\u0026nbsp;million in 2020 to 55\u0026nbsp;million by 2026 (assuming roughly one device per user per year), HTP adoption still lags behind vaping, which is estimated to have 82\u0026nbsp;million users in 2024 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. According to market data, the highest growth rates have been observed in Europe and Asia, with some countries experiencing near one-to-one substitution for cigarettes (e.g., Hungary, South Korea, Italy, Germany), while in others, cigarette sales are declining faster than HTP uptake (e.g., Slovakia, Japan, Greece) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, this global expansion has been uneven. As of April 2025, HTPs were available in 40 high-income countries (HICs), 21 upper-middle-income countries (UMICs), and only 9 lower-middle-income countries (LMICs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Notably, they are not legally available in any low-income countries (LICs), highlighting a significant disparity in access based on national income levels.\u003c/p\u003e\u003cp\u003eThis study is positioned within the public health framework of tobacco harm reduction, which advocates for providing safer nicotine alternatives to adult smokers who are unable or unwilling to quit. The principle of harm reduction is based on the understanding that the most severe health consequences of smoking arise from the toxicants produced during the combustion of tobacco, not from nicotine itself. HTPs operate by heating tobacco to a temperature sufficient to release a nicotine-containing aerosol, but without burning it. This process means they contain fewer harmful chemicals than tobacco smoke [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and significantly reduce the formation of harmful and potentially harmful constituents. Clinical studies have consistently shown that smokers who switch exclusively to HTPs have a significant reduction in exposure to these toxicants [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, switching to HTPs eliminates elevated exhaled carbon monoxide levels, with normalization observed rapidly [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Recent research suggests that after adjusting for prior smoking history, the odds ratio for chronic obstructive pulmonary disease drops significantly among exclusive HTP users [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite a growing body of evidence suggesting that HTPs are a less harmful alternative to combustible cigarettes, both their absolute risk and the extent of relative risk reduction remain subjects of debate and ongoing research. The long-term health and mortality impacts of HTP use remain unknown [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Also, to the best of our knowledge, no population-level observational studies have demonstrated a decline in smoking-related mortality in countries with high HTP uptake.\u003c/p\u003e\u003cp\u003eGiven these uncertainties, this paper does not assess the health outcomes of HTPs. Instead, it focuses on the critical role of economic accessibility in realizing any potential public health benefits. Ensuring that less harmful products are accessible to all is a cornerstone of health equity [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. If safer alternatives are not affordable for the populations most burdened by smoking-related diseases, often those in lower socioeconomic strata, their potential to reduce harm at a population level is severely limited [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Affordability, therefore, is not merely an economic consideration but a prerequisite for equitable harm reduction.\u003c/p\u003e\u003cp\u003eIn this context, the relative price of HTPs compared to cigarettes becomes a critical determinant of consumer behavior. Economic evidence shows that raising cigarette prices through taxation reduces smoking prevalence, despite cigarette demand being relatively inelastic [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. By contrast, emerging research suggests that HTP demand is more price-sensitive and these products function as economic substitutes for cigarettes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Alongside price, consumer uptake is also shaped by perceived relative health risks, peer influence, and motivations to quit or cut down [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEarly studies found that HTPs, despite benefiting from lower tax rates, were still priced higher than cigarettes in many countries [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The substantial upfront cost of purchasing a heating device has also been identified as a significant financial barrier, discouraging smokers from switching [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile previous research offered an initial cross-country comparison of HTP affordability, this paper is the first to focus explicitly on income-related disparities. It also considers how tax structures and market pricing shape access. By centering on economic equity, this paper provides evidence to guide fiscal and market interventions that could enhance the harm reduction potential of HTPs. To achieve this, we conducted a cross-country analysis of HTP affordability relative to cigarettes, incorporating both national and within-country income differences, as described in the Methods section below.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional study compared the affordability of HTPs and combustible cigarettes across 55 countries. Analyses were conducted by national income level, using the World Bank classification, and across income quintiles within each country.\u003c/p\u003e\u003cp\u003eThe data for this study were compiled from multiple public and industry sources. Retail prices and tax burdens for the most-sold, premium, and cheapest cigarette brands, along with the most-sold brand of HTP sticks, were obtained from the World Health Organization\u0026rsquo;s (WHO) Global Health Observatory for 2022 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. As prices for HTP heating devices were not included in this dataset, they were supplemented with industry-reported data as of April 2024 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Country-level macroeconomic indicators for 2022, including Gross Domestic Product (GDP) per capita and income distribution by quintiles, were sourced from the World Bank, while national income classifications followed the World Bank\u0026rsquo;s fiscal year 2024 groupings [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary measure of affordability was the Relative Income Price (RIP), defined as the percentage of annual GDP per capita required to purchase 100 packs of a given product, with higher RIP values indicating lower affordability [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. RIP was calculated for the general population and each income quintile. The analysis also incorporated the annualized cost of HTP heating devices, using the lowest- and highest-priced devices reported in April 2024, amortized over one year, and added this to HTP stick prices to capture the total annual cost of use. Tax burdens, expressed as the total tax share of the retail price, were also compared between HTP sticks and cigarettes.\u003c/p\u003e\u003cp\u003eDescriptive and comparative analyses were supplemented with ordinary least squares linear regression to examine associations between the HTP-cigarette price differential and factors such as cigarette prices, excise tax differentials, and GDP per capita. All calculations and statistical analyses were conducted in Microsoft Excel (Microsoft 365; Microsoft Corporation, Redmond, WA, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eCross-Country Price Comparison\u003c/h2\u003e\u003cp\u003eAcross the 55 countries analyzed, HTP sticks were more expensive than the most-sold brand of cigarettes in 26 countries and more expensive than the cheapest brand of cigarettes in 48 countries. This pattern varied by national income level: HTP sticks were more expensive than the most-sold cigarette brand in all 9 LMICs and 11 of the 16 UMICs in the sample. In contrast, among the 30 HICs, HTPs were less expensive than the most-sold cigarette brand in 24 countries.\u003c/p\u003e\u003cp\u003eDescriptive analysis indicated a negative relationship between absolute cigarette prices and the price differential between HTPs and cigarettes: in countries with higher cigarette prices, HTPs were more likely to be the cheaper option, and vice versa (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eMultiple linear regression confirmed this association. For every US\u003cspan\u003e$\u003c/span\u003e1 increase in the price of the most-sold cigarette brand, the price difference between HTPs and cigarettes decreased by approximately US\u003cspan\u003e$\u003c/span\u003e0.49 (95% CI: -0.5474 \u0026mdash; -0.4305, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This suggests that HTP prices are not increasing at the same rate as cigarette prices; for every \u003cspan\u003e$\u003c/span\u003e1 rise in cigarette prices, HTP prices are associated with an increase of only about \u003cspan\u003e$\u003c/span\u003e0.51. The excise tax differential between the products showed no statistically significant association with the price differential.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLinear Regression Results For Heated Tobacco Products Prices\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et-statistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntercept\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.3108***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.1625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.0654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.9845\u0026ndash;1.6371\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTax differential\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.0052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.0044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.1926\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.2385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.0036\u0026ndash;0.0141\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCigarette price\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.4889***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.0291\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-16.7861\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.5474 \u0026ndash; -0.4305\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGDP per capita (US\u003cspan\u003e$\u003c/span\u003e1000)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.0076**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.4774\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.0166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.0014\u0026ndash;0.0137\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eOrdinary least squares regression of HTP stick prices (US$) as the dependent variable, using 2022 cross-country data (n\u0026thinsp;=\u0026thinsp;55). Independent variables: excise tax differential between cigarettes and HTP sticks, price of the most-sold cigarette brand, and GDP per capita (in US$1000). Adjusted R\u0026sup2; = 0.8810. Cigarette price was strongly and negatively associated with HTP prices (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), GDP per capita had a small but statistically significant positive association, and the tax differential was not statistically significant. All monetary values are in US$. Coefficients are rounded to four decimal places. ***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, **p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eCI: confidence interval; GDP: gross domestic product.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAffordability by National Income Level\u003c/h3\u003e\n\u003cp\u003eAffordability varied substantially across income groups (Fig.\u0026nbsp;2). In LMICs, HTP sticks were, on average, 1.5 times less affordable than the most-sold cigarette brand and 2.3 times less affordable than the cheapest cigarettes. However, compared to premium brands, HTPs were 1.2 times more affordable. In UMICs, HTP affordability was comparable to premium cigarettes but 1.1 times lower than the most-sold brand. In HICs, HTP sticks were, on average, 1.2 times more affordable than the most-sold cigarettes and 1.3 times more affordable than premium brands. Across all groups, the cheapest cigarette brands remained the most affordable option. The affordability gap between HTPs and cigarettes narrowed as national income levels increased, making HTPs relatively more accessible in wealthier countries. No LICs in the dataset had HTP availability.\u003c/p\u003e\n\u003ch3\u003eAffordability by Income Quintile\u003c/h3\u003e\n\u003cp\u003eWithin countries, affordability gaps were most pronounced for lower-income groups (Fig.\u0026nbsp;3). For the lowest-income quintile across all countries, purchasing 100 packs of HTP sticks would require 9.2% of annual income, compared with 8.0% for the most-sold cigarette brand. Affordability improved steadily with rising income: for the highest-income quintile, the same purchase required 1.5% of annual income for HTPs and 1.3% for cigarettes. This translates to HTPs being 6.3 times less affordable for the poorest quintile compared with the richest. The disparity was particularly stark in LMICs, where the RIP for HTPs among the lowest-income quintile reached 24.9% of annual income (measured in GDP per capita).\u003c/p\u003e\n\u003ch3\u003eImpact of Device Costs\u003c/h3\u003e\n\u003cp\u003eIncluding the amortized annual cost of HTP devices increased the total annual cost of HTP use by 9.2\u0026ndash;35.3%, depending on device model. When the cost of the cheapest device was included, HTPs became more expensive than the most-sold cigarette brand in 39 of the 55 countries, including all 9 LMICs and 14 of the 16 UMICs. When the most expensive device was factored in, HTPs were more expensive in 53 of 55 countries. The only exceptions where cigarettes remained costlier even with the highest-priced device were the United Kingdom and New Zealand.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTax Burden Analysis\u003c/h2\u003e\u003cp\u003eThe higher price of HTPs did not appear to be driven by higher taxation. On the contrary, HTPs benefited from lower tax rates (measured as the share of total taxes in retail price) than cigarettes in 52 of the 55 countries studied. The average tax gap between cigarettes and HTPs was 24.3 percentage points. This tax advantage was largest in HICs (27.4 percentage points) and smallest in LMICs (16.5 percentage points). The regression analysis suggested that this tax differential was not being passed on to consumers in the form of lower retail prices, as the model found no statistically significant association between the size of the tax differential and the final price difference between HTP sticks and cigarettes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights a substantial equity gap in global accessibility to HTPs. Both an expanding body of evidence and tobacco industry positioning present HTPs as potential harm reduction alternatives to smoking, yet affordability remains a major barrier, particularly for lower-income populations in low- and middle-income countries, which also bear a disproportionate burden of smoking-related disease.\u003c/p\u003e\u003cp\u003eThe affordability gap appears to be driven primarily by industry pricing strategies rather than taxation. Despite having a lower tax burden than cigarettes in most countries, HTPs are frequently priced above cigarettes, consistent with prior findings that tax advantages are not fully reflected in retail prices [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Across the major transnational tobacco companies, the highly publicized \u0026ldquo;transformation\u0026rdquo; narrative is best understood as a profit-maximizing corporate strategy rather than a genuine global shift away from combustible cigarettes. Evidence from corporate strategy analyses, leaked internal documents, and independent reviews shows that these shifts toward HTPs and other non-combustibles are concentrated in high-income countries where cigarette sales are already declining, regulation is stronger, and investor pressure encourages portfolio diversification [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In these markets, alternative products are positioned as central to maintaining long-term profitability and market relevance, supported by marketing that frames them as premium, high-tech lifestyle products [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. By contrast, in lower-income countries, where cigarettes remain highly profitable and regulatory pressures are weaker, the industry continues to prioritize and aggressively market the deadliest form of nicotine delivery, combustible cigarettes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This dual strategy is consistent with industry commercial objectives and may support harm-reduction efforts in select high-income settings; however, it does not adequately address the needs of the majority of the global smoking population.\u003c/p\u003e\u003cp\u003eAnother factor, particularly relevant in LMICs, is the relatively low price of cigarettes. In many such markets, taxes are not high enough to make cigarettes sufficiently expensive. In 2022, the average tax share on cigarettes was 73% in HICs versus 59% in LMICs. Our results show that higher cigarette prices are associated with greater relative affordability of HTPs. Where cigarettes remain inexpensive, there is limited scope and incentive for firms to price HTPs competitively. This reduces the financial motivation for consumers to switch.\u003c/p\u003e\u003cp\u003eGiven these constraints, closing the affordability gap will likely require targeted policy interventions. One option is the use of price ceilings or profit-margin caps for HTPs, drawing on frameworks used in other sectors, such as pharmaceuticals, to improve affordability [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. While such measures may reduce retail prices, economic evaluations warn that price regulation can dampen innovation, risk supply shortages if caps are set too low, and spur illicit markets if controls are overly restrictive [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. These trade-offs require careful design and implementation.\u003c/p\u003e\u003cp\u003eConditional tax benefits are another potential tool. Preferential excise rates could be linked to a measurable retail price gap between HTPs and cigarettes, increasing the likelihood that tax advantages are passed on to consumers. Evidence from the investment tax incentive literature suggests that linking tax relief to specific performance outcomes can make such policies effective (43, 44). However, no country has yet applied this conditional approach to tobacco excise. Its implementation would present practical challenges, including monitoring compliance, verifying price information, and enforcing penalties for non-compliance.\u003c/p\u003e\u003cp\u003eAlongside fiscal measures, competition policy could also play a critical role in shaping market prices. Promoting competition may offer a more sustainable and economically efficient pathway to reducing HTP prices [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Easing regulatory barriers to entry for HTPs and other tobacco alternatives, and lifting product-specific prohibitions, can expand the number of suppliers, intensify price competition, and increase product variety. In countries where HTPs are either unavailable or limited to premium market segments, competition-oriented strategies may improve their affordability compared to cigarettes.\u003c/p\u003e\u003cp\u003eThe initial cost of a heating device remains another significant barrier, echoing earlier research [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. For smokers with limited disposable income, the upfront investment can represent several weeks or months\u0026rsquo; worth of cigarette purchases. Even when stick prices are competitive, this fixed cost can effectively exclude lower-income smokers from trying or adopting HTPs.\u003c/p\u003e\u003cp\u003eFinally, our estimates likely understate the affordability gap by not accounting for roll-your-own (RYO) tobacco, which is the cheapest combustible option in many countries. Evidence shows RYO use is concentrated among lower socioeconomic groups because of its price advantage over factory-made cigarettes [\u003cspan additionalcitationids=\"CR47 CR48 CR49\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. For smokers who use RYO, the price gap to switch to premium-priced HTPs is even higher than for manufactured cigarette smokers. Lower-income populations are also more price sensitive and more prone to downward substitution [\u003cspan additionalcitationids=\"CR49 CR50\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], exacerbating the equity problem: those with the fewest resources are the least exposed to any potential benefits of HTPs.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations that should be acknowledged when interpreting the findings. First, it is based on cross-sectional data from 2022, providing only a single snapshot of market conditions. Tobacco and nicotine product markets are highly dynamic, with prices, taxes, and product availability subject to rapid changes in response to regulation, competition, and industry strategy. As such, the analysis is correlational and cannot establish causal relationships between price, tax structures, and consumer behavior.\u003c/p\u003e\u003cp\u003eSecond, heating device cost estimates are drawn from a single company for 2024. While this may introduce some distortion, the potential bias is likely modest, as the company is the dominant market leader for HTPs in most observed markets. A comparison of heating device prices between 2024 and 2025 revealed no consistent pattern of price change, further suggesting that the figures used are a reasonable approximation.\u003c/p\u003e\u003cp\u003eThird, GDP per capita was used as the primary income indicator. Although it provides a broadly comparable measure across countries, it does not capture intra-country income inequality or differences in disposable income. This limitation was partially mitigated by examining income quintile data, but a more granular household-level analysis of income and expenditure would enable a more precise assessment of affordability and equity impacts.\u003c/p\u003e\u003cp\u003eFourth, the analysis relies on WHO-reported tax share data, which measure the proportion of the retail price accounted for by all taxes on HTP sticks and cigarettes. While this metric provides a standardized international proxy, it does not capture the statutory excise tax rates set in national legislation. These rates may be ad valorem (a percentage of retail price), specific (a fixed amount per unit), or mixed. Consequently, HTPs and cigarettes could face identical statutory rates yet differ in measured tax share solely because of differences in retail prices. Under a specific tax, for example, a flat-rate levy will represent a smaller proportion of the price for higher-priced products. This limitation may introduce some imprecision in interpreting tax burdens; however, it should not critically affect our findings. The conclusion that tax advantages for HTPs are largely absorbed by manufacturers rather than passed on to consumers remains valid, regardless of whether measured differences in tax burden arise from statutory rates or underlying price levels.\u003c/p\u003e\u003cp\u003eFinally, as stated earlier, this study does not evaluate the health effects of HTPs or their effectiveness for smoking cessation. Its focus is strictly on the economic equity of access. The analysis assumes, based on existing evidence, that HTPs are significantly less harmful than combustible cigarettes and therefore have harm reduction potential. If this assumption were proven incorrect, or if the relative risk differential were minimal, the implications for health equity discussed here would not apply.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOutside high-income countries, higher relative prices for HTPs remain a major barrier to their use as substitutes for cigarettes. Although average HTP tax shares were lower in most countries, observed retail prices did not consistently reflect this difference. This pattern suggests incomplete pass-through of HTP tax advantages, potentially due to industry pricing strategies, which limits their impact on consumer prices. Policies that promote pass-through of any HTP tax advantages to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to substitute away from combustibles where such strategies are pursued. Without such action, the harm-reduction potential of HTPs may remain unevenly distributed, with lower-income populations continuing to bear the greatest burden of smoking-related disease. The analysis is cross-sectional and does not identify causal effects; results should be interpreted accordingly.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eGDP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGross Domestic Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHigh-Income Country\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHTP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeated Tobacco Product\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow-Income Country\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLMIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLower-Middle-Income Country\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eRIP\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRelative Income Price\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eRYO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRoll-Your-Own\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUMIC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUpper-Middle-Income Country\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study are available in the following repositories:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eWHO Global Health Observatory:\u003col\u003e\n\u003cli\u003eNational taxes and retail price for 20 sticks of heated tobacco products\u003c/li\u003e\n\u003cli\u003eNational taxes on a pack of 20 cigarettes\u003c/li\u003e\n\u003cli\u003eRetail price for a pack of 20 cigarettes\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003cli\u003eWorld Bank Data:\u003col\u003e\n\u003cli\u003eGDP per capita (constant national currency)\u003c/li\u003e\n\u003cli\u003eGDP per capita (current US$)\u003c/li\u003e\n\u003cli\u003eIncome shares by quintile: First\u003c/li\u003e\n\u003cli\u003eSecond quintile\u003c/li\u003e\n\u003cli\u003eThird quintile\u003c/li\u003e\n\u003cli\u003eFourth quintile\u003c/li\u003e\n\u003cli\u003eFifth quintile\u003c/li\u003e\n\u003cli\u003eWorld Bank country and lending groups classification\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003cli\u003eIndustry data (Philip Morris International):\u003col\u003e\n\u003cli\u003eRetail selling price database \u0026ndash; April 2024 release\u003c/li\u003e\n\u003cli\u003eRetail selling price database \u0026ndash; April 2025 release\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe compiled dataset used for analysis is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs.\u003c/p\u003e\n\u003cp\u003eAt the time this research was conducted, the author had a service agreement as a data scientist with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy. KAC has over forty years of experience working on drug use, HIV, smoking, sexual health, and prisons.\u003c/p\u003e\n\u003cp\u003eIn parallel, the author has a service agreement with the Ukraine-based NGO Healthy Initiatives as an economist. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases.\u003c/p\u003e\n\u003cp\u003eBoth organizations receive grants from Global Action to End Smoking. Global Action to End Smoking, formerly known as Foundation for a Smoke-Free World, is an independent, U.S. nonprofit 501(c)(3) grantmaking organization accelerating science-based efforts worldwide to end the smoking epidemic. Its mission is to end combustible tobacco use, which remains the leading preventable cause of death globally. The organization collaborates with academic and research centers and others to accelerate life-saving research and educational projects. Global Action does not seek or accept funding from companies that produce tobacco or non-medicinal nicotine products.\u003c/p\u003e\n\u003cp\u003eThe charitable gift agreement (the \u0026ldquo;Pledge Agreement\u0026rdquo;) between the organization and its prior funder, PMI Global Services Inc., was terminated in September 2023. To complement the termination of the Pledge Agreement, the organization\u0026rsquo;s Board of Directors established a new policy to not accept or seek any tobacco or non-medicinal nicotine industry funding. Global Action to End Smoking\u0026rsquo;s Certificate of Incorporation states that Global Action was formed to, among other things, \u0026ldquo;support independent scientific research free from the influence of any commercial entity that may be affected by the research outcome.\u0026rdquo; Global Action\u0026rsquo;s organizational documents, including the Certificate of Incorporation and bylaws, are publicly available on its website (www.globalactiontoendsmoking.org) and fully disclosed in public materials.\u003c/p\u003e\n\u003cp\u003eThis study was conducted as part of the author\u0026rsquo;s collaboration with Knowledge-Action-Change. The author declares no financial or non-financial competing interests beyond the affiliations disclosed above. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded with a grant from Global Action to End Smoking (formerly known as the Foundation for a Smoke-Free World), an independent U.S. nonprofit 501(c)(3) grantmaking organization. The funder had no role in the design, implementation, data analysis, interpretation of the study results, or preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGM contributed to the conceptualization, data collection, data analysis, and drafting of the manuscript. The author read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author thanks the Global State of Tobacco Harm Reduction team at Knowledge-Action-Change for their support during the conceptualization and dissemination of this research. In particular, the author is grateful to Professor Gerry Stimson for his valuable feedback and for encouraging the initiation of this research from its earliest stages. The views expressed in this manuscript are solely those of the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUse of AI-Assisted Technologies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author discloses that AI chatbot ChatGPT was used solely for language editing purposes in the preparation of this manuscript. The model was not used for data analysis, data interpretation, or content generation. All intellectual content, analysis, and conclusions are my own, and I take full responsibility for the integrity and accuracy of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eO\u0026rsquo;Connor RJ, Schneller LM, Felicione NJ, Talhout R, Goniewicz ML, Ashley DL. Evolution of tobacco products: recent history and future directions. Tob Control. 2022;31(Suppl 3):s3\u0026ndash;s5. https://doi.org/10.1136/tobaccocontrol-2021-056544.\u003c/li\u003e\n\u003cli\u003ePhilip Morris International. Retail selling price database \u0026ndash; April 2025 release. 2025. https://www.pmi.com/resources/docs/default-source/investor_relation/apr25---rsps.xlsx [accessed 2025 Aug 4].\u003c/li\u003e\n\u003cli\u003eThe Global State of Tobacco Harm Reduction. The Global State of Tobacco Harm Reduction 2024: A Situation Report. Knowledge-Action-Change. 2024. https://gsthr.org/resources/thr-reports/the-global-state-of-tobacco-harm-reduction-2024-a-situation-report/ [accessed 2025 Aug 4].\u003c/li\u003e\n\u003cli\u003ePolosa R, Rodu B, Farsalinos K. Health effects of e-cigarettes, heated tobacco, and oral nicotine products. Intern Emerg Med. 2025. https://doi.org/10.1007/s11739-025-04057-4. \u003c/li\u003e\n\u003cli\u003eHaziza C, de La Bourdonnaye G, Merlet S, Benzimra M, Ancerewicz J, Donelli A, Baker G, Picavet P, L\u0026uuml;dicke F. Assessment of the reduction in levels of exposure to harmful and potentially harmful constituents in Japanese subjects using a novel tobacco heating system compared with conventional cigarettes and smoking abstinence: A randomized controlled study in confinement. Regul Toxicol Pharmacol. 2016 Dec;81:489\u0026ndash;99. https://doi.org/10.1016/j.yrtph.2016.09.014.\u003c/li\u003e\n\u003cli\u003eL\u0026uuml;dicke F, Ansari SM, Lama N, Blanc N, Bosilkovska M, Donelli A, Picavet P, Baker G, Haziza C, Peitsch M, Weitkunat R. Effects of switching to a heat-not-burn tobacco product on biologically relevant biomarkers to assess a candidate modified risk tobacco product: a randomized trial. Cancer Epidemiol Biomarkers Prev. 2019;28(11):1934-43. https://doi.org/10.1158/1055-9965.EPI-18-0915. \u003c/li\u003e\n\u003cli\u003eGale N, McEwan M, Camacho OM, Hardie G, Murphy J, Proctor CJ. Changes in biomarkers of exposure on switching from a conventional cigarette to the Glo tobacco heating product: a randomized, controlled ambulatory study. Nicotine Tob Res. 2021 Mar;23(3):584\u0026ndash;91. https://doi.org/10.1093/ntr/ntaa135. \u003c/li\u003e\n\u003cli\u003eGale N, McEwan M, Hardie G, Proctor CJ, Murphy J. Changes in biomarkers of exposure and biomarkers of potential harm after 360 days in smokers who either continue to smoke, switch to a tobacco heating product or quit smoking. Intern Emerg Med. 2022;17:2017\u0026ndash;30. https://doi.org/10.1007/s11739-022-03062-1. \u003c/li\u003e\n\u003cli\u003eAdriaens K, Van Gucht D, Baeyens F. IQOSTM vs. e-cigarette vs. tobacco cigarette: a direct comparison of short-term effects after overnight-abstinence. Int J Environ Res Public Health. 2018 Dec 18;15(12):2902. https://doi.org/10.3390/ijerph15122902. \u003c/li\u003e\n\u003cli\u003eCaponnetto P, Maglia M, Prosperini G, Bus\u0026agrave; B, Polosa R. Carbon monoxide levels after inhalation from new generation heated tobacco products. Respir Res. 2018;19:164. https://doi.org/10.1186/s12931-018-0867-z. \u003c/li\u003e\n\u003cli\u003eKimura Y, Sugita M. Association between use of heated tobacco products and long-term respiratory effects considering smoking history: internet-based cross-sectional study in Japan. BMC Public Health. 2024;24:2785. https://doi.org/10.1186/s12889-024-20257-7.\u003c/li\u003e\n\u003cli\u003eMcNeill AD, Brose LS, Calder R, Bauld L, Robson DJ. Evidence review of e-cigarettes and heated tobacco products 2018: a report commissioned by Public Health England. Public Health England; 2018. London. https://assets.publishing.service.gov.uk/media/5a981c6740f0b67aa27253cc/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf [accessed 2025 Aug 4]. \u003c/li\u003e\n\u003cli\u003ePolosa R, Farsalinos K, Prisco D. Health impact of electronic cigarettes and heated tobacco systems. Intern Emerg Med. 2019 Jun;14(6):817\u0026ndash;20. https://doi.org/10.1007/s11739-019-02167-4. \u003c/li\u003e\n\u003cli\u003eBraveman P, Arkin E, Orleans T, Proctor D, Plough A. What is health equity? Behav Sci Policy. 2018;4(1):1-14. https://doi.org/10.1177/237946151800400102. \u003c/li\u003e\n\u003cli\u003eStringhini S, Carmeli C, Jokela M, Avenda\u0026ntilde;o M, Muennig P, Guida F, Ricceri F, d\u0026rsquo;Errico A, Barros H, Bochud M, Chadeau-Hyam M, Clavel-Chapelon F, Costa G, Delpierre C, Fraga S, Goldberg M, Giles GG, Krogh V, Kelly-Irving M, Layte R, Lasserre AM, Marmot MG, Preisig M, Shipley MJ, Vollenweider P, Zins M, Kawachi I, Steptoe A, Mackenbach JP, Vineis P, Kivim\u0026auml;ki M; LIFEPATH consortium. Socioeconomic status and the 25 \u0026times; 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1.7 million men and women. Lancet. 2017 Mar 25;389(10075):1229\u0026ndash;37. https://doi.org/10.1016/S0140-6736(16)32380-7. \u003c/li\u003e\n\u003cli\u003eMarmot M. Social determinants of health inequalities. Lancet. 2005 Mar 19;365(9464):1099\u0026ndash;104. https://doi.org/10.1016/S0140-6736(05)71146-6. \u003c/li\u003e\n\u003cli\u003eU.S. National Cancer Institute. A socioecological approach to addressing tobacco-related health disparities. National Cancer Institute Tobacco Control Monograph 22. NIH Publication No. 17-CA-8035A. Bethesda (MD): U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2017. https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-22 [accessed 2025 Aug 4]. \u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. People with low socioeconomic status experience a health burden from commercial tobacco. Tobacco \u0026ndash; Health Equity. 2024 May 15. https://www.cdc.gov/tobacco-health-equity/collection/low-ses-health-burden.html [accessed 2025 Aug 4]. \u003c/li\u003e\n\u003cli\u003eChaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235-8. https://doi.org/10.1136/tc.2010.039982.\u003c/li\u003e\n\u003cli\u003eLevy DT, Boyle RG, Abrams DB. The role of public policies in reducing smoking: the Minnesota SimSmoke tobacco policy model. Am J Prev Med. 2012;43(5 Suppl 3):S179-86. https://doi.org/10.1016/j.amepre.2012.07.037. \u003c/li\u003e\n\u003cli\u003eChaloupka FJ, Warner KE. The economics of smoking. In: Culyer AJ, Newhouse JP, editors. Handbook of Health Economics. Vol. 1B. Amsterdam: Elsevier; 2000. p. 1539-627. https://doi.org/10.1016/S1574-0064(00)80042-6. \u003c/li\u003e\n\u003cli\u003eDeCicca P, Kenkel DS, Lovenheim MF. The economics of tobacco regulation: a comprehensive review. Cambridge (MA): National Bureau of Economic Research; 2020. (NBER Working Paper No. 26923). https://doi.org/10.3386/w26923. \u003c/li\u003e\n\u003cli\u003eDauchy E, Shang C. The pass-through of excise taxes to market prices of heated tobacco products (HTPs) and cigarettes: a cross-country analysis. Eur J Health Econ. 2023;24(4):591-607. https://doi.org/10.1007/s10198-022-01499-x. \u003c/li\u003e\n\u003cli\u003eKenkel DS, Mathios AD, Phillips GN, Suryanarayana R, Wang H, Zeng S. Fear or knowledge: the impact of graphic cigarette warnings on tobacco product choices. Cambridge (MA): National Bureau of Economic Research; 2023. (NBER Working Paper No. 31534). https://doi.org/10.3386/w31534. \u003c/li\u003e\n\u003cli\u003eSutanto E, Miller C, Smith DM, O\u0026rsquo;Connor RJ, Quah ACK, Cummings KM, Xu S, Fong GT, Hyland A, Ouimet J, Yoshimi I, Mochizuki Y, Tabuchi T, Goniewicz ML. Prevalence, use behaviors, and preferences among users of heated tobacco products: Findings from the 2018 ITC Japan Survey. Int J Environ Res Public Health. 2019;16(23):4630. https://doi.org/10.3390/ijerph16234630. \u003c/li\u003e\n\u003cli\u003eLaverty AA, Vardavas CI, Filippidis FT. Prevalence and reasons for use of heated tobacco products (HTP) in Europe: An analysis of Eurobarometer data in 28 countries. Lancet Reg Health Eur. 2021;8:100159. https://doi.org/10.1016/j.lanepe.2021.100159. \u003c/li\u003e\n\u003cli\u003eLiber AC. Heated tobacco products and combusted cigarettes: comparing global prices and taxes. Tob Control. 2019;28(6):689-691. https://doi.org/10.1136/tobaccocontrol-2018-054602. \u003c/li\u003e\n\u003cli\u003eJakob J, Joss S, Meier AN, Tal K, Schoeni A, Marti J, Diethelm P, Auer R. The price of nicotine dependence: A comparison of the cost of nicotine across products in Switzerland, Germany, USA, Sweden, France and the UK, in 2019. Tob Prev Cessat. 2022;8:42. https://doi.org/10.18332/tpc/156052. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Global Health Observatory: National taxes and retail price for 20 sticks of heated tobacco products; National taxes on a pack of 20 cigarettes; Retail price for a pack of 20 cigarettes. 2025. https://www.who.int/data/gho [accessed 2025 Aug 1]. \u003c/li\u003e\n\u003cli\u003ePhilip Morris International. Retail selling price database \u0026ndash; April 2024 release. https://www.pmi.com/resources/docs/default-source/investor_relation/may_2024---rsps.xlsx [accessed 2025 Aug 1].\u003c/li\u003e\n\u003cli\u003eThe World Bank. World Development Indicators. Washington, DC: World Bank; 2025 . https://databank.worldbank.org/source/world-development-indicators [accessed 2025 Aug 1].\u003c/li\u003e\n\u003cli\u003eThe World Bank. World Bank country and lending groups. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups [accessed 2025 Aug 1].\u003c/li\u003e\n\u003cli\u003eBlecher EH, van Walbeek CP. An international analysis of cigarette affordability. Tob Control. 2004;13(4):339-46. https://doi.org/10.1136/tc.2003.006726. \u003c/li\u003e\n\u003cli\u003eTriossi MN, Cloos TA. Disrupting the Tobacco Industry: How Tobacco Companies Seek to Stay in Business \u0026ndash; A Case Study on the Strategic Transformation of Philip Morris International [master\u0026rsquo;s thesis]. Copenhagen: Copenhagen Business School; 2022. 99 p. https://research-api.cbs.dk/ws/portalfiles/portal/76442875/1390284_Thesis_Philip_Morris.pdf [accessed 2025 Aug 4].\u003c/li\u003e\n\u003cli\u003eEdwards R, Hoek J, Karreman N, Gilmore A. Evaluating tobacco industry \u0026lsquo;transformation\u0026rsquo;: a proposed rubric and analysis. Tob Control. 2022;31(3):365-371. https://doi.org/10.1136/tobaccocontrol-2021-056687.\u003c/li\u003e\n\u003cli\u003eMehegan J, Gallagher A, Elmitwalli S, Edwards R, Gilmore A. Analysis of Philip Morris International\u0026rsquo;s \u0026lsquo;aspirational\u0026rsquo; target for its 2025 cigarette shipments. Tob Control. 2024;33(e1):e11\u0026ndash;e18. https://doi.org/10.1136/tc-2023-058511.\u003c/li\u003e\n\u003cli\u003eLevy DT, Thirlway F, Sweanor D, Liber A, Sanchez-Romero LM, Meza R, Douglas CE, Cummings KM. Do tobacco companies have an incentive to promote \u0026ldquo;harm reduction\u0026rdquo; products?: The role of competition. Nicotine Tob Res. 2023;25(12):1810\u0026ndash;21. https://doi.org/10.1093/ntr/ntad014. \u003c/li\u003e\n\u003cli\u003eHendlin YH, Han EL, Ling PM. Pharmaceuticalisation as the tobacco industry\u0026rsquo;s endgame. BMJ Glob Health. 2024;9:e013866. https://doi.org/10.1136/bmjgh-2023-013866. \u003c/li\u003e\n\u003cli\u003eMathers A, Hawkins B, Lee K. Transnational tobacco companies and new nicotine delivery systems. Am J Public Health. 2019;109(2):227\u0026ndash;235. https://doi.org/10.2105/AJPH.2018.304813. \u003c/li\u003e\n\u003cli\u003eBasu K, Pitsuwan F, Zhang P. The economics of profit-cap policy: Big Pharma, Big Tech, and the duopoly rule. J Econ Behav Organ. 2023;215:120-33. https://doi.org/10.1016/j.jebo.2023.08.027. \u003c/li\u003e\n\u003cli\u003eLee KS, Kassab YW, Taha NA, Zainal ZA. A systematic review of pharmaceutical price mark-up practice and its implementation. Explor Res Clin Soc Pharm. 2021;2:100020. https://doi.org/10.1016/j.rcsop.2021.100020. \u003c/li\u003e\n\u003cli\u003eGuenette JD. Price controls: good intentions, bad outcomes. Policy Research Working Paper No. 9212. Washington, DC: World Bank; 2020. http://hdl.handle.net/10986/33606.\u003c/li\u003e\n\u003cli\u003ePlatform for Collaboration on Tax (IMF, OECD, UN, World Bank). Tax Incentives Principles. Washington, DC: IMF; 2025. https://www.tax-platform.org/sites/pct/files/publications/Tax-Incentives-Principles.pdf [accessed 2025 Aug 4]. \u003c/li\u003e\n\u003cli\u003eOECD. Countering harmful tax practices more effectively, taking into account transparency and substance (BEPS Action 5 \u0026mdash; Final Report). Paris: OECD Publishing; 2015. https://doi.org/10.1787/9789264241190-en [accessed 2025 Aug 4]. \u003c/li\u003e\n\u003cli\u003eBresnahan TF, Reiss PC. Entry and competition in concentrated markets. J Polit Econ. 1991;99(5):977-1009. https://doi.org/10.1086/261786. \u003c/li\u003e\n\u003cli\u003eYoung D, Borland R, Hammond D, Cummings KM, Devlin E, Yong HH, O\u0026apos;Connor RJ, ITC Collaboration. Prevalence and attributes of roll-your-own smokers in the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006;15(Suppl 3):iii76-82. https://doi.org/10.1136/tc.2005.013268. \u003c/li\u003e\n\u003cli\u003eGallus S, Lugo A, Ghislandi S, La Vecchia C, Gilmore AB. Roll-your-own cigarettes in Europe: use, weight and implications for fiscal policies. Eur J Cancer Prev. 2014;23(3):186-92. https://doi.org/10.1097/CEJ.0000000000000010. \u003c/li\u003e\n\u003cli\u003eRothwell L, Britton J, Bogdanovica I. The relation between cigarette price and hand-rolling tobacco consumption in the UK: an ecological study. BMJ Open. 2015;5(6):e007697. https://doi.org/10.1136/bmjopen-2015-007697.\u003c/li\u003e\n\u003cli\u003eBrown AK, Nagelhout GE, van den Putte B, Willemsen MC, Mons U, Guignard R, Thompson ME. Trends and socioeconomic differences in roll-your-own tobacco use: findings from the ITC Europe Surveys. Tob Control. 2015;24(Suppl 3):iii11-9. https://doi.org/10.1136/tobaccocontrol-2014-051986.\u003c/li\u003e\n\u003cli\u003eMzhavanadze G. Illicit cigarette market in Georgia: potential impacts on smoking prevalence and tax revenues. Public Health. 2023;223:223-9. https://doi.org/10.1016/j.puhe.2023.08.010.\u003c/li\u003e\n\u003cli\u003eFuchs A, Gonzalez Icaza MF, Paz DP. Distributional effects of tobacco taxation: a comparative analysis. World Bank Policy Research Working Paper No. 8805. Washington, DC: World Bank; 2019 Apr 8. https://ssrn.com/abstract=3368579/.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7460827/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7460827/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince their introduction in 2014, heated tobacco products (HTPs) have entered a growing number of national markets. Despite this expansion, few studies have systematically compared their affordability with that of cigarettes or examined differences in access across income groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study assesses the affordability of HTPs relative to combustible cigarettes across 55 countries of varying income levels, with a focus on disparities by socioeconomic status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing publicly available data from the World Health Organization, World Bank, and industry sources, we compared retail prices, affordability (measured as the share of GDP per capita required to purchase 100 packs), and tax burden (the share of all taxes in the retail price) across 55 countries. Income distribution data were incorporated to assess affordability across different economic strata.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHTPs were absent from low-income countries. HTP sticks were more expensive than the most-sold cigarette brand in 26 countries and costlier than the cheapest cigarette brand in 48 countries. In all 9 lower-middle-income countries and 11/16 upper-middle-income countries, HTPs were more expensive than the most-sold brand; in 24/30 high-income countries they were cheaper. In lower-middle-income countries, HTPs were on average 1.5 times less affordable than the most-sold brand and 2.3 times less affordable than the cheapest cigarettes; in high-income countries they were 1.2 times more affordable than the most-sold brand. For the lowest-income quintile across countries, purchasing 100 packs of HTPs required 9.2% of annual income compared with 8.0% for cigarettes; for the highest-income quintile the figures were 1.5% and 1.3%, respectively. Including device costs increased annual HTP use costs by 9.2–35.3%.\u003c/p\u003e\n\u003cp\u003eHTPs faced lower tax burden than cigarettes in 52 of 55 countries (mean gap: 24.3 percentage points), but this advantage was not reflected in retail prices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOutside high-income countries, higher relative prices for HTPs remain a major barrier to their use as substitutes for cigarettes. Although average HTP tax shares were lower in most countries, observed retail prices did not consistently reflect this difference. Policies that promote pass-through to consumers, alongside higher cigarette excise taxes and measures to improve market competition, may increase the financial incentive to switch away from combustibles where such strategies are pursued.\u003c/p\u003e","manuscriptTitle":"Relative affordability of heated tobacco products and cigarettes: a cross- country comparative analysis of 55 countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-07 06:19:51","doi":"10.21203/rs.3.rs-7460827/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"273760946807782743728525216381196279014","date":"2026-04-16T15:12:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-23T04:28:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-26T12:12:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-26T12:10:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-08-26T08:40:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4cffbcff-c807-4dbc-905a-3d3bbe83dd8b","owner":[],"postedDate":"October 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-07T06:19:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-07 06:19:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7460827","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7460827","identity":"rs-7460827","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}