18B.7 Effects of heated tobacco product use on smoking

Last updated: May 2024
Suggested citation: Greenhalgh, EM. 18B.7 Effects of heated tobacco product use on smoking. In Greenhalgh EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2024. Available from:  https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/indepth-18b-non-combustible-cigarettes/18b-7-effects-of-heated-tobacco-product-use-on-smoking 

18B.7.1 Effects on smoking behaviours among young people

There is insufficient information regarding how the design and promotion of heated tobacco products may influence young people’s uptake and use of heated and other tobacco/nicotine products. Philip Morris International’s (PMI) application to the US Food and Drug Administration (FDA) to authorise sale of the IQOS in the US included no data or information regarding how IQOS impacts youth. 1, 2 However, data from that application as well as an independent study 2 suggested that the introduction of IQOS would result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.

Recent research has supported these predictions, with a study of Korean adolescents who smoke showing that that more frequent and heavier heated tobacco product use were associated with daily and heavier smoking. There was no association between heated tobacco product use and attempts to quit smoking. 3 Another Korean study similarly found lower odds of cigarette abstinence among adolescent dual users. 4 Regarding concerns that the products could act as a ‘gateway’ to smoking, longitudinal research in Japan found an association between heated tobacco product use among never smokers and subsequent uptake of conventional smoking. 5 Ongoing monitoring is required to establish the risks of heated tobacco product use among young people, including uptake by non-tobacco users, and dual/poly use of other tobacco and nicotine products. 6  

18B.7.2 Effects on smoking behaviours among adults

Results from a Phillip Morris US-based study indicated low rates of smokers completely switching from cigarettes to IQOS. 1 Studies from other countries also show that few people who smoke opt to completely replace cigarettes with heated tobacco products, 1, 7, 8 and many dual users do not cite quitting smoking as a reason for using heated tobacco. 9, 10 These results suggest that people who smoke may be more likely to use IQOS in addition to cigarettes and not as a substitute, increasing their use of tobacco products overall.  

A Cochrane review of studies up to January 2021 found no studies that examined heated tobacco products as a cessation aid, and noted that most studies examining the safety of the products were funded by the tobacco industry. 11 One study evaluating the rates of use of heated tobacco products and users' smoking patterns in Korea found that of the current users of these devices (2.13% of the population) almost all (96.25%) were dual users of cigarettes. 7 Those who used both conventional cigarettes and heated tobacco products did not intend to quit cigarette smoking. Further, while the use of heated tobacco products may reduce cigarette withdrawal symptoms in smokers, 12, 13 one study found that heated tobacco use was perceived as less satisfying than smoking the participants’ own brand of cigarettes, potentially increasing the likelihood of supplementation. 12

Research in Korea, 14-16 the US 17 and Japan 18 has found no differences between dual users and cigarette-only users in quitting plans and behaviours, while another Korean study found that heated tobacco use was associated with lower odds of cigarette abstinence. 19 Daily heated tobacco product users in a representative Korean survey were less likely to report cessation behaviours than intermittent users, 20 and in a survey of people who smoke in Korea, a significant proportion of dual users reported lower intentions to quit smoking. 21 Dual users of cigarettes and heated tobacco frequently report ‘stealth use’ of heated tobacco products where use is prohibited, potentially reducing the likelihood of quitting smoking. 22-24 Research in the UK found that heated tobacco product users maintain strong addiction and ‘smoker identities’, further suggesting a limited role as a cessation aid. 25 Experimental research has found that observing heated tobacco product use increases cravings for cigarettes among people who smoke. 26, 27

Research in Japan—where IQOS has been aggressively marketed as a reduced harm product—found that introduction of the IQOS was associated with a decline in cigarette sales. 28, 29 Similar results were found in Korea, with increased sales of heated tobacco products occurring alongside decreased sales of cigarettes. 30 However, researchers have noted that declines in cigarette sales driven by dual use (i.e., reduced consumption of cigarettes alongside heated tobacco use) are far less clinically meaningful than declines driven by complete cessation or reduced uptake of all tobacco products. 28 An examination of sales data in Poland found that unlike Japan, there was no evidence that sales of heated tobacco products may have replaced cigarettes, with total sales of tobacco products increasing following the introduction of heated tobacco products. 31 A study in the UK found that while smokers reduced daily cigarette consumption following uptake of heated tobacco products, most had become dual users, and some had increased tobacco consumption overall. 32 A US study similarly found reduced cigarettes per day but not complete switching among smokers using IQOS. 33 As described in Section 3.36, cutting down on cigarettes does not lead to meaningful reductions in a person’s risk of early death. Further, among those who dual use, there does not appear to be differences in biomarkers of toxin exposure compared with those who exclusively smoke. 34

Two studies in Japan, one prospective and one retrospective, found that among participants of a smoking cessation program, dual users of cigarettes and heated tobacco products were less likely to achieve abstinence than exclusive smokers. 35, 36 Similar results were found in a study of young people enrolled in a smoking cessation program in Hong Kong, with heated tobacco product users less likely to quit smoking than non-users. 37 A clinical trial in Hong Kong found that heated tobacco product use was not associated with quitting success, while use of established cessation aids was. 38 Longitudinal research in Japan concluded that heated tobacco product use did not help cigarette smokers quit or prevent former smokers from relapsing overall, and in fact reduced the likelihood of quitting and increased the likelihood of relapse among certain subgroups. 39 Another longitudinal study similarly found increased risk of relapse among long-term ex-smokers who use heated tobacco products. 5 These findings highlight the importance of people who smoke being encouraged to use evidence-based cessation aids. 39  

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References

1. No authors listed. 4 big concerns about selling IQOS heat-not-burn cigarettes in the US. Truth Initiative,  2018. Available from: https://truthinitiative.org/news/4-big-concerns-about-selling-iqos-heat-not-burn-cigarettes-us

2. Glantz S. PMI’s MRTP Application for IQOS Does Not Consider IQOS’s Appeal to Youth or Adolescents. UCSF Center for Tobacco Control, Research and Education,  2017. Available from: https://tobacco.ucsf.edu/pmi%E2%80%99s-mrtp-application-iqos-does-not-consider-iqos%E2%80%99s-appeal-youth-or-adolescents

3. Lee H and Lee BG. Associations between the Frequency and Quantity of Heated Tobacco Product Use and Smoking Characteristics among Korean Smoking Adolescents. J Korean Acad Nurs, 2023; 53(2):155-66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37164344

4. Kang SY, Lee S, and Cho HJ. Prevalence and predictors of heated tobacco product use and its relationship with attempts to quit cigarette smoking among Korean adolescents. Tobacco Control, 2021; 30(2):192-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32108085

5. Matsuyama Y and Tabuchi T. Heated tobacco product use and combustible cigarette smoking relapse/initiation among former/never smokers in Japan: the JASTIS 2019 study with 1-year follow-up. Tobacco Control, 2022; 31(4):520-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33408121

6. WHO Study Group on Tobacco Product Regulation. Report on the scientific basis of tobacco product regulation: Eighth report of a WHO study group., WHO Technical Report Series, No. 1029.Geneva, Switzerland: WHO, 2021. Available from: https://www.who.int/publications/i/item/9789240022720

7. Hwang JH, Ryu DH, and Park SW. Heated tobacco products: Cigarette complements, not substitutes. Drug and Alcohol Dependence, 2019; 204:107576. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31586808

8. Harada S, Sata M, Matsumoto M, Iida M, Takeuchi A, et al. Changes in Smoking Habits and Behaviors Following the Introduction and Spread of Heated Tobacco Products in Japan and Its Effect on FEV(1) Decline: A Longitudinal Cohort Study. J Epidemiol, 2022; 32(4):180-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34657910

9. Seo HG, Xu SS, Li G, Gravely S, Quah ACK, et al. Reasons for Initiation and Regular Use of Heated Tobacco Products among Current and Former Smokers in South Korea: Findings from the 2020 ITC Korea Survey. International Journal of Environmental Research and Public Health, 2023; 20(6). Available from: https://www.ncbi.nlm.nih.gov/pubmed/36981869

10. Xu SS, Meng G, Yan M, Gravely S, Quah ACK, et al. Reasons for Regularly Using Heated Tobacco Products among Adult Current and Former Smokers in Japan: Finding from 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 2020; 17(21). Available from: https://www.ncbi.nlm.nih.gov/pubmed/33142757

11. Tattan-Birch H, Hartmann-Boyce J, Kock L, Simonavicius E, Brose L, et al. Heated tobacco products for smoking cessation and reducing smoking prevalence. Cochrane Database of Systematic Reviews, 2022; 1(1):CD013790. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34988969

12. Kale D, Tattan-Birch H, Brown J, Cox S, Dawkins L, et al. Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naive adult smokers. Scientific Reports, 2023; 13(1):22676. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38114686

13. Queloz S and Etter JF. A survey of users of the IQOS tobacco vaporizer: perceived dependence and perceived effects on cigarette withdrawal symptoms. Journal of Addictive Diseases, 2021; 39(2):208-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33336625

14. Won D, Jung W, and Shin D. Comparison of the Smoking Cessation of Heated Tobacco Product Users and Conventional Cigarette Smokers in Korea. Korean J Fam Med, 2023; 44(3):151-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/37225440

15. Ryu DH, Park SW, and Hwang JH. Association between Intention to Quit Cigarette Smoking and Use of Heated Tobacco Products: Application of Smoking Intensity Perspective on Heated Tobacco Product Users. International Journal of Environmental Research and Public Health, 2020; 17(22). Available from: https://www.ncbi.nlm.nih.gov/pubmed/33207771

16. Kim SH and Cho HJ. Prevalence and correlates of current use of heated tobacco products among a nationally representative sample of Korean adults: Results from a cross-sectional study. Tobacco Induced Diseases, 2020; 18:66. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32818029

17. Dunbar MS, Seelam R, Tucker JS, Rodriguez A, Shih RA, et al. Correlates of Awareness and Use of Heated Tobacco Products in a Sample of US Young Adults in 2018-2019. Nicotine & Tobacco Research, 2020; 22(12):2178-87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32047910

18. Sutanto E, Miller C, Smith DM, Borland R, Hyland A, et al. Concurrent Daily and Non-Daily Use of Heated Tobacco Products with Combustible Cigarettes: Findings from the 2018 ITC Japan Survey. International Journal of Environmental Research and Public Health, 2020; 17(6). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32235702

19. Kim J, Lee S, Kimm H, Lee JA, Lee CM, et al. Heated tobacco product use and its relationship to quitting combustible cigarettes in Korean adults. PLoS One, 2021; 16(5):e0251243. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33961641

20. Yu H and Lee CM. Comparison of Tobacco Use and Cessation Behavior between Conventional Cigarette and Heated Tobacco Product Users: Based on the Analyses of the Eighth Korea National Health and Nutrition Examination Survey 2019. Korean J Fam Med, 2022; 43(5):296-304. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36168901

21. Park J, Kim HJ, Shin SH, Park E, Oh JK, et al. Perceptions of Heated Tobacco Products (HTPs) and Intention to Quit Among Adult Tobacco Users in Korea. J Epidemiol, 2022; 32(8):357-62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33551386

22. Lee JA, Lee C, and Cho HJ. Use of heated tobacco products where their use is prohibited. Tobacco Control, 2023; 32(2):146-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34257152

23. Kiyohara K and Tabuchi T. Use of heated tobacco products in smoke-free locations in Japan: the JASTIS 2019 study. Tobacco Control, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33199542

24. Laverty AA, Vardavas CI, and 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. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34557853

25. Kale D, Brown J, Dawkins L, Goniewicz ML, Leppin C, et al. Comparing identity, attitudes, and indicators of effectiveness in people who smoke, vape or use heated tobacco products: A cross-sectional study. Addictive Behaviors, 2024; 151:107933. Available from: https://www.ncbi.nlm.nih.gov/pubmed/38142579

26. Brett EI, Lee Z, Leavens ELS, Fridberg DJ, and King AC. Cue Reactivity Effects of Heated Tobacco Product Use in Current, Former, and Never Smokers in the United States. Nicotine & Tobacco Research, 2023; 25(5):1014-21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36205373

27. Brett EI, Miloslavich K, Vena A, Didier N, and King AC. Effects of Visual Exposure to IQOS Use on Smoking Urge and Behavior. Tobacco Regulatory Science, 2021; 7(1):31-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34327281

28. Stoklosa M, Cahn Z, Liber A, Nargis N, and Drope J. Effect of IQOS introduction on cigarette sales: evidence of decline and replacement. Tobacco Control, 2020; 29(4):381-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31209129

29. Cummings KM, Nahhas GJ, and Sweanor DT. What Is Accounting for the Rapid Decline in Cigarette Sales in Japan? International Journal of Environmental Research and Public Health, 2020; 17(10). Available from: https://www.ncbi.nlm.nih.gov/pubmed/32443663

30. Lee CM. The Impact of Heated Tobacco Products on Smoking Cessation, Tobacco Use, and Tobacco Sales in South Korea. Korean J Fam Med, 2020; 41(5):273-81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32961046

31. Liber AC, Cadham C, Cummings M, Levy DT, and Pesko M. Poland is not replicating the HTP experience in Japan: a cautionary note. Tobacco Control, 2023; 32(4):524-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34876532

32. Stone MD, DeAtley T, Pianin S, Strasser AA, and Audrain-McGovern J. Switching from cigarettes to IQOS: A pilot examination of IQOS-associated reward, reinforcement, and abstinence relief. Drug and Alcohol Dependence, 2022; 238:109569. Available from: https://www.ncbi.nlm.nih.gov/pubmed/35841732

33. DeAtley T, Stone MD, Strasser AA, and Audrain-McGovern J. The role of IQOS risk perceptions on cigarette smoking behaviours: results from a prospective pilot study. Tobacco Control, 2024; 33(2):263-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36002165

34. Ludicke F, Ansari SM, Lama N, Blanc N, Bosilkovska M, et al. 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 Epidemiology, Biomarkers & Prevention, 2019; 28(11):1934-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31270101

35. Nomura A, Ikeda T, Fujimoto T, Morita Y, Taniguchi C, et al. Outcomes of a telemedicine smoking cessation programme for heated tobacco product users in Japan: a retrospective cohort study. BMJ Open, 2022; 12(12):e063489. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36600419

36. Kanai M, Kanai O, Tabuchi T, and Mio T. Association of heated tobacco product use with tobacco use cessation in a Japanese workplace: a prospective study. Thorax, 2021; 76(6):615-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34161920

37. Xia W, Li WHC, Luo YH, Liang TN, Ho LLK, et al. The association between heated tobacco product use and cigarette cessation outcomes among youth smokers: A prospective cohort study. Journal of Substance Abuse Treatment, 2022; 132:108599. Available from: https://www.ncbi.nlm.nih.gov/pubmed/34419325

38. Luk TT, Weng X, Wu YS, Chan HL, Lau CY, et al. Association of heated tobacco product use with smoking cessation in Chinese cigarette smokers in Hong Kong: a prospective study. Tobacco Control, 2021; 30(6):653-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32912861

39. Odani S, Tsuno K, Agaku IT, and Tabuchi T. Heated tobacco products do not help smokers quit or prevent relapse: a longitudinal study in Japan. Tobacco Control, 2023. Available from: https://www.ncbi.nlm.nih.gov/pubmed/36849258