Last updated: April 2019
Suggested citation: Greenhalgh, EM. 18C. Heated tobacco (‘heat-not-burn’) products. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2019. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18c-non-combustible-cigarettes/18c-4-potential-risks-benefits-to-public-health
The introduction and growing popularity of heated tobacco products presents challenges to the public health and tobacco control communities similar to those stemming from the growth of e-cigarette use.1 As with e-cigarettes, the recency of heated tobacco products means that their long-term health effects are largely unknown. There is insufficient evidence regarding heated tobacco products' usefulness as a smoking cessation aid vs. their likelihood to be used concurrently with cigarettes, or their potential to attract young never smokers or serve as a ‘gateway’ to combustible cigarettes.2 A small number of independent studies have found that a relatively small percentage of conventional cigarette smokers and e-cigarette users also supplement that use with heated products (see 18C.2). Further, one independent study found that while the use of heated tobacco products reduced the severity of abstinence symptoms in cigarette smokers, it was perceived as less satisfying than smoking the participants’ own brand of cigarettes, potentially increasing the likelihood of supplementation. Also, given that the products deliver nicotine, they have the potential for creating and/or maintaining nicotine dependence in the user.3
The involvement of the tobacco industry in research and regulations concerning ‘reduced-risk’ or cessation products is of concern to public health experts. Claims by the tobacco industry that its goal is for smokers to switch to ‘safer’ products have been met with scepticism. For example, Philip Morris International (PMI) claims that it wants to ‘quit smoking’ and that ‘the greatest contribution PMI can make to society is to replace cigarettes with less harmful alternatives’.4 Despite these claims, PMI has taken no active moves to cease selling cigarettes and continues to fight effective tobacco control measures.5 The company’s plan to market the IQOS Heatstick under the Marlboro name could strengthen the Marlboro brand, including the appeal of its other tobacco products.
Also, despite the lack of robust evidence, heated tobacco products have been advertised as reduced-risk tobacco products in their Japanese test market, and such marketing messages will likely spread to other markets even where such messaging is banned.1 In 2016, PMI submitted an application to the FDA seeking authorisation to market IQOS with reduced risk and reduced exposure claims. Its own studies submitted alongside the application showed that adult consumers misperceive reduced exposure claims as reduced risk claims, despite the data in the application not supporting reduced risk claims. Such claims are prohibited by the FDA.6
There is also insufficient information regarding how the design and promotion of heated tobacco products may influence young people’s uptake and use. PMI's own data, as well as independent studies, suggest that the introduction of IQOS will 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. Researchers examined PMI’s US FDA application to determine whether the company had provided sufficient data to address the following three health risks: (1) tobacco users’ initiation with IQOS, (2) youth misperception of the modified risk claims being made concerning IQOS, and (3) youth perception of reduced health risks associated with IQOS. Researchers found that PMI’s studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS, and will not perceive these products as risk-free. Furthermore, PMI plans to introduce its IQOS heatsticks in menthol: a flavour which has been shown to attract young users.7
Research independent of the industry is needed to evaluate potential risks to public health and individual consumers.8 A study by PMI modelled the potential population health impact of introducing a reduced-risk tobacco product (RRP) into Japan and concluded that the introduction would substantially reduce tobacco-related deaths.9 However, another group of researchers examining the PMI studies used in the company’s application to the FDA found that the model suffered from methodological flaws which bring into question their reduced risk claims.10 Researchers assessed the PMI model against FDA guidelines for modified risk tobacco product (MRTP) applications along with more general criteria for evaluating reduced-risk tobacco products. The following two key components of the model were evaluated:
- the assumptions implicit in the PMI model about outcomes (including relative harm of the IQOS vs cigarettes, the tobacco-related diseases considered, whether dual or polyuse of the new product was modelled, and what other tobacco products were included) and;
- the data used by PMI to estimate and validate model parameters (transition rates between non-smoking, cigarette-only smoking, dual use of cigarettes and MRTP, and MRTP-only use; and starting tobacco use prevalence).
The study found that the PMI model limits examination of the impact of cigarette and MRTP use on mortality to only four tobacco-attributable diseases and excludes morbidity, underestimates mortality, excludes tobacco products other than cigarettes, does not include FDA-recommended impacts on non-users, and underestimates the impact on other population groups.
Given their rapid growth in some markets, some have suggested that the tobacco control community could pre-empt the rising popularity of these products—and the associated risks to public health—by extending existing tobacco control strategies to encompass heated tobacco products, including the research and dissemination of messages regarding potential health risks, restricting advertising and promotion, and extending smokefree areas to protect bystanders from heated tobacco emissions.11 Banning characterising flavours and including the products in minimum age of purchase laws may also help prevent vulnerable young people from taking up the products.8
1. Caputi T, Leas E, Dredze M, Cohen J, and Ayers J. They're heating up: Internet search query trends reveal significant public interest in heat-not-burn tobacco products. PLoS ONE, 2017; 12(10):e0185735. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29020019
2. World Health Organization. Heated tobacco products (HTPs) information sheet. 2017. Available from: http://www.who.int/tobacco/publications/prod_regulation/heated-tobacco-products/en/
3. Lopez AA, Hiler M, Maloney S, Eissenberg T, and Breland AB. Expanding clinical laboratory tobacco product evaluation methods to loose-leaf tobacco vaporizers. Drug and Alcohol Dependence, 2016; 169:33–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27768968
4. Philip Morris International. Sustainability report. 2017. Available from: https://www.pmi.com/resources/docs/default-source/pmi-sustainability/pmi_sustainability_report_2016.pdf?sfvrsn=143382b5_2
5. Hawkes N. Big Tobacco's New Year's resolution to quit smoking. British Medical Journal, 2018; 360:k79. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29305417
6. Popova L, Lempert LK, and Glantz SA. Light and mild redux: Heated tobacco products' reduced exposure claims are likely to be misunderstood as reduced risk claims. Tobacco Control, 2018; 27(Suppl 1):s87–s95. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30209208
7. 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?utm_source=Truth+Initiative+Mailing+List&utm_campaign=d3d9155e49-Newsletter_090_2018_03_01&utm_medium=email&utm_term=0_c91fd8a5c5-d3d9155e49-86454907
8. Jenssen BP, Walley SC, and McGrath-Morrow SA. Heat-not-burn tobacco products: Tobacco industry claims no substitute for science. Pediatrics, 2018; 141(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29233936
9. Lee PN, Djurdjevic S, Weitkunat R, and Baker G. Estimating the population health impact of introducing a reduced-risk tobacco product into Japan. The effect of differing assumptions, and some comparisons with the US. Regulatory Toxicology and Pharmacology, 2018; 100:92–104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30367904
10. Max WB, Sung HY, Lightwood J, Wang Y, and Yao T. Modelling the impact of a new tobacco product: Review of Philip Morris international's population health impact model as applied to the IQOS heated tobacco product. Tobacco Control, 2018; 27(Suppl 1):s82–s6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30275170
11. Caputi TL, Leas E, Dredze M, Cohen JE, and Ayers JW. They're heating up: Internet search query trends reveal significant public interest in heat-not-burn tobacco products. PLoS ONE, 2017; 12(10):e0185735. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29020019