Health outcomes in COPD smokers using heated tobacco products: a 3-year follow-up

Assessing the Italian version of the respiratory symptom experience scale (IT-RSES) in smokers and former smokers: a validation study

BACKGROUND

Smoking causes respiratory symptoms, and research suggests these improve with cessation or switching to less harmful nicotine products. The Respiratory Symptom Experience Scale (RSES) was developed and validated for the purpose of assessing these such symptoms online in an English-speaking American sample. This study aimed to develop and validate an Italian version, the IT-RSES, administered via telephone interview, and, further, to use it to assess symptoms in smokers who had switched to e-cigarettes or to heated tobacco products (HTPs).

METHODS

After translation into Italian, the IT-RSES was administered by phone interview to 750 Italian participants in 5 tobacco use groups (150 each never-smokers, former smokers not using alternative products, HTP users, e-cigarette users, and continuing smokers) who also reported any history of diagnoses with relevant medical conditions. Psychometric analyses examined scale factor structure, reliability, and convergent validity. Analyses controlling for age and for years smoking compared symptoms across tobacco use groups.

RESULTS

Factor analyses confirmed the IT-RSES' unidimensionality (factor one accounting for 74.2% of the variance; all factor loadings > 0.80). Internal-consistency reliability was high ( Cronbach's alpha = 0.91). IT-RSES scores correlated significantly with years of smoking (r = 0.51, p < 0.0001), and were higher in individuals with respiratory conditions (2.02 vs. 1.36, SE = 0.05, significant by THSD). Discriminant validity was demonstrated by higher scores in smokers compared to never-smokers, even among those without respiratory conditions. After adjustment for years of smoking, former smokers, HTP users and e-cigarette users had lower scores than smokers (m = 2.17 vs. 1.49, SE = 0.06, p < 0.05, THSD; 1.63 vs. 2.16, SE = 0.06, THSD) and did not significantly differ from each other.

CONCLUSIONS

The results support the reliability and validity of the IT-RSES, suggesting its utility for assessing respiratory symptoms in smokers, and former smoker who stopped smoking and were using e-cigarettes or HTPs. The scores of former smokers are similar to those not using these products, and lower than smokers', suggests that HTPs and e-cigarettes do not add materially to respiratory symptoms when smokers stop smoking.

Evaluation of Morphology and Biochemical Parameters of Young Adults Using Heated Tobacco Products in Poland: A Case-Control Study

Background/Objectives: Little is currently known of the impact of heated tobacco on health. The aim of this study is to evaluate the impact of heated tobacco use on selected health assessment parameters among people aged 18-30 to determine the effect on health status. Methods: A case-control study was conducted from April 2022 to February 2025. A total of 195 young, healthy adult residents of Lodz, Poland, took part. The participants were divided into three groups: IQOS (I-Quit-Ordinary-Smoking) smokers who had never smoked or who had quit smoking six months previously (n = 65); daily smokers who had smoked at least five cigarettes per day for at least one year and had not used any other smoking substitutes for at least one year (n = 65); and people who have never smoked or used tobacco products (n = 65). Blood samples from 37 IQOS users (57%), 28 traditional cigarette smokers (43%), and 45 non-smokers (69%) were submitted for laboratory analysis. The tested parameters were determined in the diagnostic laboratory of the Bonifratów Hospital in Lodz. Results: No significant differences (p > 0.05) were found between the groups with regard to blood count (white blood cell count (WBC), red blood cell count (RBC), lymphocytes, monocyte number (MONO), hemoglobin concentration (HGB)), biochemical biomarkers (C-reactive protein (CRP), fibrinogen, apolipoprotein A1 (apo A1), apolipoprotein B (apo B), glucose), or lipid profile (total cholesterol, triglycerides (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL)). The cigarette smokers demonstrated significantly higher uric acid levels compared to the IQOS users and non-smokers: 5.22 vs. 4.77 vs. 4.40 mg/dL (p < 0.01). The IQOS users demonstrated significantly higher platelet count levels compared to cigarette smokers and non-smokers: 290.27 vs. 267.14 vs. 256.33 × 103/ μL (p < 0.05). Among the IQOS users (n = 37), the level of glucose (ρ = -0.47; p = 0.01), WBC (ρ = -0.36; p = 0.03), lymphocytes (ρ = -0.38; p = 0.02), and uric acid (ρ = -0.34; p = 0.04) was negatively correlated with the daily number of heated tobacco sticks. The HDL level was positively correlated (ρ = 0.39; p = 0.02) with the daily number of heated tobacco sticks. Conclusions: Further cohort studies assessing the health status of young users of heated nicotine products and prospective analyses are necessary.

Comparative Evaluation of Cigarette Smoke and a Heated Tobacco Product on Corneal Oxidative Stress in an Air/Liquid Interface Model

Purpose

Tobacco smoke harbors toxic combustion by-products contributing to inflammatory diseases. Cigarette smoke's impact on ocular diseases has been poorly characterized, despite conjunctival mucosa's sensitivity to these toxicants. Of note, cigarette smoke triggers redness, tearing, and discomfort, accounting as a risk factor for glaucoma, macular degeneration, cataracts, and other eye conditions. Low quit rates of cessation highlight the need for alternatives. Heated tobacco products (HTPs), may represent a less toxic alternative for those smokers. This study evaluates cigarette smoke and HTPs effects on cornea under standard and clinically relevant conditions.

Methods

Corneal tissues collected from donors and in vitro model in two different cell lines of corneal epithelium were exposed to cigarette (1R6F) smoke and HTPs vapor. Air exposure was included as a control. Tissue pathological evaluation was carried out by hematoxylin and eosin staining. Reactive oxygen species (ROS) were measured, and quantitative PCR assessed inflammatory and antioxidant genes expression. Proteome analysis was used to evaluate differentially expressed proteins related to the oxidative stress. Scratch assay measured smoke and HTPs impact on cells.

Results

Hematoxylin & eosin staining highlighted that cigarette smoke impairs corneal tissue integrity, leading to ROS accumulation and inflammation, as proved by qPCR analysis. Proteomic analysis showed that corneal tissue's proteins were differently oxidized by the different experimental conditions. HTP targeted structural intracellular proteins, whereas 1R6F affects different members of collagen family. Finally, cigarette smoke, but not HTPs, impairs epithelial cells wound closure.

Conclusions

Smoking increases oxidative stress, leading to significant corneal damage and inflammation. HTPs may offer a less toxic alternative.

Tobacco Use, Risk Perceptions, and Characteristics of Adults Who Used a Heated Tobacco Product (IQOS) in the United States: Cross-Sectional Survey Study

BACKGROUND

The Tobacco Heating System (THS; commercialized as IQOS) is a smoke-free heated tobacco product introduced in the United States in 2019 and authorized by the US Food and Drug Administration as a modified risk tobacco product (MRTP) in 2020. THS consists of a holder and specially designed tobacco sticks that are heated instead of burned to produce a nicotine-containing aerosol. THS was available in Atlanta, Georgia; Richmond, Virginia; Charlotte, North Carolina; the Northern Virginia region; and South Carolina before its market removal in November 2021.

OBJECTIVE

This study aims to describe selected sociodemographic characteristics and self-reported health history of adults who used IQOS (AUIs), their tobacco use patterns (eg, tobacco use history, exclusive and dual-use, and switching from cigarette smoking), their risk perceptions of the product, and their understanding of MRTP messages.

METHODS

The IQOS Cross-Sectional Postmarket Adult Consumer Study was a study of AUIs aged 21 years or older who were recruited from a consumer database via direct postal mail and emails. Participants completed the online survey between September and November 2021.

RESULTS

The survey was completed by 645 current and 43 former AUIs who had used at least 100 tobacco sticks (considered established THS use) before the assessment. Of the 688 participants, 424 (61.6%) were male, 502 (73.0%) were non-Hispanic White, and the mean age was 45 years. The vast majority (680/688, 98.8%) of AUIs had ever smoked combusted cigarettes before first trying THS and 628 (91.3%) had smoked cigarettes in the 30 days before first using THS. At the time of assessment, 161 (23.4%) reported using e-cigarettes (vs 229, 33.3%, before THS use), 92 (13.4%) reported smoking cigars (vs 114, 16.6%, before THS use), and 338 (49.1%) were still smoking after an average of 1 year of THS use. Among those currently using THS who were still smoking (n=298), 249 (83.6%) smoked fewer cigarettes compared with before first trying THS; 362 of 688 (52.6%) AUIs reported having no physical health conditions evaluated in this study and almost three-quarters reported having no mental health conditions. Among all AUIs, over 563 (81.8%) had never used a cessation treatment or had not used it in the past 12 months, and 555 (80.7%) AUIs demonstrated a correct understanding of the MRTP message and AUIs perceived THS as having a lower risk than cigarettes (43.8 vs 64.4 on a 100-point composite score scale).

CONCLUSIONS

This study provides evidence that THS can help adult smokers in the United States completely switch away from cigarettes or reduce smoking.

Delphi consensus methodology to gauge expert perspectives on smoking prevention, cessation and harm reduction in Italy

The role of smoke-free alternatives to cigarettes for tobacco harm reduction remains controversial. This study was conducted to understand the perspectives of a panel of Italian experts on this topic. Using Delphi consensus methodology, expert opinions on the use of smoke-free alternatives, tobacco harm reduction and anti-smoking legislation were gathered and analyzed. In July 2022, a Scientific Committee, including five members, proposed 38 statements spanning three areas: (1) harm from tobacco smoking and strategies for harm reduction; (2) smoke-free alternatives to cigarettes; and (3) anti-smoking legislation. Between August and November 2022, the Expert Panel, including members of the Scientific Committee and 15 other key opinion leaders, voted on the statements in two rounds. Consensus was achieved on 24 of 38 statements. The results emphasized the persistent national health threat posed by tobacco smoking in Italy, with a smoking prevalence of 20-24% between 2007 and 2022. Emphasizing harm reduction as a pivotal public healthcare strategy, the Expert Panel agreed on 10 statements related to smoke-free alternatives, but underlined the need for further research despite promising initial findings. The Expert Panel also reached consensus on six statements regarding anti-smoking legislation, stressing the importance of crafting and upholding rigorous anti-smoking laws that are consistent with World Health Organization guidelines. This pioneering Delphi consensus statement illuminates the complicated debate regarding the role of smoke-free alternatives for tobacco harm reduction in Italy. The findings highlight the evolving nature and advocate the need for ongoing discussions and further research on this important issue.

Evaluating the Risks of Heated Tobacco Products: Toxicological Effects on Two Selected Respiratory Bacteria and Human Lung Cells

Heated tobacco products (THPs) are increasingly promoted as potential harm reduction tools, offering an alternative to traditional cigarettes. Despite these claims, understanding of their toxicological impact on respiratory health and associated microbial communities is limited. Comprehensive investigations are needed to elucidate the biological mechanisms and potential health implications associated with their use.

METHODS

This study evaluated the toxicological effects of aerosols produced by THPs (IQOS 3 Duo with Heets "Sienna Selection") in comparison to conventional cigarette smoke (1R6F). Antibacterial activity was evaluated using Streptococcus pneumoniae and Klebsiella pneumoniae as representative species of the respiratory microbiota through agar diffusion assays and MIC/MBC determinations. Cytotoxicity was assessed in human lung fibroblast cells (MRC5) through the neutral red uptake (NRU) assay, whereas mutagenicity was investigated using the Ames test.

RESULTS

THP aerosols demonstrated the ability to inhibit the growth of both S. pneumoniae and K. pneumoniae, exerting bacteriostatic effects at lower concentrations and bactericidal effects at higher concentrations. While these antibacterial effects might initially seem beneficial against pathogens such as K. pneumoniae, they raise concerns about the potential disruption of the respiratory microbial balance, particularly in relation to S. pneumoniae. Despite these microbiological effects, THP aerosols demonstrated minimal cytotoxicity on human lung fibroblasts and lacked detectable mutagenic activity, contrasting with the significant cytotoxicity and mutagenicity caused by cigarette smoke.

CONCLUSIONS

THPs present a reduced short-term toxicological profile compared with conventional cigarettes; however, their effects on respiratory microorganisms deserve attention. The observed inhibition of commensal bacteria highlights the need to explore potential changes in the microbial ecosystem that could affect respiratory health. These findings highlight the need for additional studies to evaluate the long-term effect of THP use on respiratory microbiota and the stability of the overall microbial ecosystem.

Assessing healthcare cost changes associated with transitioning away from cigarette smoking using healthcare claims data: an exploratory study among adult male patients with COPD

BACKGROUND

The assessment of potential health effects of switching from cigarette smoking to non-combustible tobacco products has important implications for public health and regulatory decisions. Robust epidemiological evidence requires long-term follow-up of a large number of individuals. Real-world evidence derived from health records has the potential to help fill the gap in the interim. To our knowledge, this is the first study using individual-level healthcare claims data to assess the potential impact of transitioning from cigarette smoking to smokeless tobacco on short-term direct healthcare costs.

METHODS

We conducted a retrospective cohort study of adult male patients with COPD who smoked cigarettes at baseline using the MarketScan® Databases. We compared changes in direct healthcare costs between the 12-month periods before (baseline) and after the index date (follow-up) across three cohorts: continued smoking (CS), quit all tobacco (QT), or switched to smokeless tobacco (SW), using a non-linear difference-in-differences model with average marginal effects.

RESULTS

A total of 23,427 COPD patients were included (CS: 11,167; QT: 12,013; SW: 247). At baseline, the QT cohort had the highest total average healthcare costs ($43,771), followed by SW ($38,419), and CS ($27,149). The unadjusted difference-in-differences model revealed no statistically significant differences in total healthcare cost changes when comparing the QT or SW cohorts to the CS cohort (-$1,532 [95% CI: -$3,671, $608] for the QT cohort, and -$452 [95% CI: -$15,415, $14,511] for the SW cohort). After adjusting for Deyo-Charlson Comorbidity Index and COPD exacerbation, assuming patients had two comorbidities and exacerbations, the QT cohort had greater reduction in total healthcare costs compared to the CS cohort (-$2,910 dollars [95% CI: -$4,485, $-1,335]). The same trend was observed for the SW cohort, although the estimate was not statistically significant (-$5,312 [95%CI: -$11,067, $442], p = 0.08).

CONCLUSIONS

This study demonstrated the feasibility of using administrative claims to conduct real-world evidence studies on the harm-reduction potential of non-combustible tobacco products and found evidence suggesting reductions in direct healthcare costs after quitting tobacco or switching to smokeless tobacco among patients with COPD. Based on the learnings and limitations identified during the study, we propose concrete recommendations to improve future observational studies by integrating additional real-world healthcare data from multiple data sources.

Statistical analyses plan for "MAGnItude of cigarette substitutioN after initiation oF e-cigarettes and its ImpaCt on biomArkers of exposure and potenTial harm in dual users": MAGNIFICAT trial

Background

The substitution of combustible cigarettes (CC) with non-combustible nicotine alternatives, such as e-cigarettes (EC), significantly lowers exposure to harmful chemicals. However, many individuals who use ECs continue smoking CCs, becoming dual users and remaining at increased risk of toxin exposure. This study will examine how the reduction in cigarettes smoked per day (CPD) after switching to ECs correlates with changes in biomarkers of exposure (BoE) and potential harm (BoPH) to evaluate the extent of harm in dual users.

Methods

The study is a prospective, non-randomised, observational, longitudinal cohort study in which 250 CC smokers will be invited to use EC as part of a smoking reduction/cessation strategy. Participants will be grouped in five dual use categories based on the change from baseline in CPD at 1, 3 and 6 months, based on self-reported use in the preceding 30 days. The primary outcome of interest is the mean absolute urinary 2-cyanoethyl mercapturic acid (2CyEMA), a well-validated BoE, also assessed at 1, 3 and 6 months. Other BoE will be assessed, together with exploration of the association between varying intensities of dual use and BoPH. The association between the dual use category and levels of BoE will be evaluated using analysis of variance (ANOVA), in order to understand which BoE are best suited to identifying different levels of dual use. Exploratory assessment of the value of BoPH will similarly be evaluated, to assess whether their predictive power extends from the binary smoker/non-smoker categorization to a more nuanced dual use categorization. The specific details of the own-brand CC will be available once smokers' enrollment in the study is complete. The EC used in the study will be the KIWI 2 Pen refillable pod system, with participants given the option to choose from three different flavored e-liquids: LEAF, MIDWAY, and GLACIAL, all containing 0.9 % nicotine. For specialized equipment used for biomarker analysis please refer our previous publication: https://pubmed.ncbi.nlm.nih.gov/38584934/.

Conclusion

EC are increasingly adopted as a harm reduction strategy in CC smokers who wish to quit smoking, the outlined Statistical Analysis Plan (SAP) provides a robust approach to understand the impact of EC on CC use and to quantify the impact of dual use on clinical outcomes using BoPH. For statistical calculations we will use R software.

The effects of electronic cigarette use patterns on health-related symptom burden and quality of life: analysis of US prospective longitudinal cohort study data

Objective

This study aimed to examine the association between e-cigarette (EC) use patterns and health-related symptoms (fatigue, pain, and emotional problems) as well as general quality of life (QoL).

Methods

Data were analyzed from 7,225 adults across Waves 1-6 of the US Population Assessment of Tobacco and Health (PATH) study. Current combustible cigarette (CC) or EC use patterns included dual CC/EC use, exclusive EC use, non-current use of CC or EC, and exclusive CC smoking. Multivariate linear mixed-effects models were used to investigate longitudinal associations between EC use patterns, and symptom burdens/QoL scores.

Results

Those who were not currently smoking or vaping reported the lowest fatigue, pain, and emotional problems, and the best QoL, among the four groups (all p < 0.001). Compared to exclusive CC smoking, exclusive EC use was associated with a significant decrease of 0.065 units in average fatigue (95% confidence interval [CI]: -0.121, -0.009), of 0.206 units in average pain (95% CI: -0.355, -0.058), and of 0.103 units in average QoL scores (95% CI: -0.155, -0.051), with emotional problems similar over time.

Conclusion

Exclusive EC users had less health-related symptoms and better QoL than those who were exclusive CC smokers. This should be taken into account when assessing the harm reduction potential of ECs.

Impact of switching from cigarette smoking to tobacco heating system use on biomarkers of potential harm in a randomized trial

BACKGROUND

Smoking cessation reduces the risk of developing smoking-related diseases. Although smoking prevalence has declined, many continue smoking cigarettes. Switching completely to smoke-free alternatives like the Tobacco Heating System (THS) 2.2-a heated tobacco product for which there is evidence demonstrating significantly reduced formation and exposure to harmful chemicals compared to cigarettes-has the potential to reduce the harm caused by continuing to smoke cigarettes.

METHODS

We conducted a 6-month clinical study (NCT02396381) with a 6-month extension (NCT02649556), initially randomizing 984 adult smokers to continue smoking or switch to THS (non-mentholated), of which 672 continued into the extension study. Endpoints were evaluated at baseline and at 3, 6, and 12 months. We longitudinally assessed biomarkers of potential harm (BoPHs) known to be reversible upon smoking cessation as indicators of pathways involved in the pathogenesis of cardiovascular or respiratory diseases and carcinogenicity. The need to cough and safety profile were also assessed. Impact on eight key BoPHs was used as a proxy to evaluate harm reduction potential.

RESULTS

At 12 months, comparison of BoPH levels between the predominant THS use and cigarette smoking groups showed a positive effect in favor of switching, partially or in full, to THS.

CONCLUSION

These results provide additional evidence of the harm reduction potential of THS for smokers who would otherwise continue smoking, but they need to be verified in long-term confirmatory studies.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT0264955. Date of registration: January 7, 2016 https://clinicaltrials.gov/ct2/show/NCT02649556.

A scoping review of the toxicity and health impact of IQOS

This work aims to summarize the current evidence on the toxicity and health impact of IQOS, taking into consideration the data source. On 1 June 2022, we searched PubMed, Web of Science, and Scopus databases using the terms: 'heated tobacco product', 'heat-not-burn', 'IQOS', and 'tobacco heating system'. The search was time-restricted to update a previous search conducted on 8 November 2021, on IQOS data from 2010-2021. The data source [independent, Philip Morris International (PMI), or other manufacturers] was retrieved from relevant sections of each publication. Publications were categorized into two general categories: 1) Toxicity assessments included in vitro, in vivo, and systems toxicology studies; and 2) The impact on human health included clinical studies assessing biomarkers of exposure and biomarkers of health effects. Generally, independent studies used classical in vitro and in vivo approaches, but PMI studies combined these with modeling of gene expression (i.e. systems toxicology). Toxicity assessment and health impact studies covered pulmonary, cardiovascular, and other systemic toxicity. PMI studies overall showed reduced toxicity and health risks of IQOS compared to cigarettes, but independent data did not always conform with this conclusion. This review highlights some discrepancies in IQOS risk assessment regarding methods, depth, and breadth of data collection, as well as conclusions based on the data source.

The Product Science of Electrically Heated Tobacco Products: An Updated Narrative Review of the Scientific Literature

Heated tobacco products represent a novel category of tobacco products in which a tobacco consumable is heated to a temperature that releases nicotine from the tobacco leaf but not to a temperature sufficient to cause combustion. Heated tobacco products may therefore have the potential to be a less harmful alternative for adult smokers who would otherwise continue to smoke cigarettes, as their use should result in exposure to substantially fewer and lower levels of toxicants. This update represents a two-year extension to our previous narrative review, which covered peer-reviewed journal articles published up to August 31, 2021. The scientific evidence published between 2021 and 2023 continues to indicate that aerosols produced from heated tobacco products contain fewer and substantially lower levels of harmful and potentially harmful constituents and that these observed reductions consistently translate to reduced biological effects in both in vitro and in vivo toxicological studies. Biomarker and clinical data from studies in which product use is controlled within a clinical setting continue to suggest changes in levels of biomarkers of exposure, biomarkers of potential harm, and clinical endpoints indicating the potential for reduced harm with switching to exclusive use of heated tobacco products in adult smokers. Overall, the available peer-reviewed scientific evidence continues to indicate that heated tobacco products offer promise as a potentially less harmful alternative to cigarettes, and as such, the conclusions of our original narrative review remain valid.

Protocol for the "magnitude of cigarette substitution after initiation of e-cigarettes and its impact on biomarkers of exposure and potential harm in dual users" (MAGNIFICAT) study

Introduction

Many smokers who use e-cigarettes (ECs) to quit continue smoking alongside vaping. The impact on health among individuals who simultaneously smoke conventional cigarettes (CCs) and use ECs remains unclear. The varying patterns of dual use present differing levels of overall toxin exposure and relative risks concerning smoking-related diseases. Understanding these complexities is vital to assessing the implications for human health.

Objective

Herein we describe a protocol designed to analyze the impact of different level of substituting CCs with ECs on exposure to toxicants. We'll use biomarkers to measure this exposure and assess harm reduction in dual users through clinical endpoints, harm-related biomarkers, and behavioral correlations. We expect to observe progressive changes with varying patterns of dual use.

Methods and analyses

For this purpose, we planned to recruit a group of 250 smokers who will be asked to reduce their CC consumption by adopting ECs (intervention group). A separate group of 50 smokers will continue to smoke CC (reference group). Study groups will be followed up for 6 months during which biospecimens will be collected for biomarker analyses, and clinical endpoints will be assessed. The trial is structured to characterize subjects' usage patterns over time using robust biomarkers of exposure and a standardized mobile phone application to facilitate the precise categorization of dual users along the risk continuum based on their usage behaviors. Subject recruitment will start in February 2024 and enrolment is expected to be completed by August 2024. Results will be reported early in 2025. Study findings may provide valuable insights into health benefits or risks associated with varying patterns of dual use.

Ethics and dissemination

The study protocol and informed consent forms will be approved by the local Ethical Review Boards. Study results will be disseminated through articles published in reputable, peer-reviewed, open access, scientific journals, presentations at conferences, and the University website.

The potential health effects associated with electronic-cigarette

A good old gateway theory that electronic-cigarettes (e-cigarettes) are widely recognized as safer tobacco substitutes. In actuality, demographics also show that vaping cannibalizes smoking, the best explanation of the data is the "common liability". However, the utilization of e-cigarette products remains a controversial topic at present. Currently, there has been a widespread and substantial growth in e-cigarette use worldwide owing to their endless new flavors and customizable characteristics. Furthermore, e-cigarette has grown widespread among smokers as well as non-smokers, including adolescents and young adults. And some studies have shown that e-cigarette users are at greater risk to start using combustible cigarettes while e-cigarettes use was also observed the potential benefits to people who want to quit smoking or not. Although it is true that e-cigarettes generally contain fewer toxic substances than combustible cigarettes, this does not mean that the chemical composition in e-cigarettes aerosols poses absolutely no risks. While concerns about toxic substances in e-cigarettes and their widespread use in the population are reasonable, it is also crucial to consider that e-cigarettes have been associated with the potential for promoting smoking cessation and the clinically relevant improvements in users with smoking-related pathologies. Meanwhile, there is still short of understanding of the health impacts associated with e-cigarette use. Therefore, in this review, we discussed the health impacts of e-cigarette exposure on oral, nasal, pulmonary, cardiovascular systems and brain. We aspire for this review to change people's previous perceptions of e-cigarettes and provide them with a more balanced perspective. Additionally, we suggest appropriate adjustments on regulation and policy for e-cigarette to gain greater public health benefits.

Polyphyllin B inhibited STAT3/NCOA4 pathway and restored gut microbiota to ameliorate lung tissue injury in cigarette smoke-induced mice

OBJECTIVE

Smoking was a major risk factor for chronic obstructive pulmonary disease (COPD). This study plan to explore the mechanism of Polyphyllin B in lung injury induced by cigarette smoke (CSE) in COPD.

METHODS

Network pharmacology and molecular docking were applied to analyze the potential binding targets for Polyphyllin B and COPD. Commercial unfiltered CSE and LPS were used to construct BEAS-2B cell injury in vitro and COPD mouse models in vivo, respectively, which were treated with Polyphyllin B or fecal microbiota transplantation (FMT). CCK8, LDH and calcein-AM were used to detect the cell proliferation, LDH level and labile iron pool. Lung histopathology, Fe3+ deposition and mitochondrial morphology were observed by hematoxylin-eosin, Prussian blue staining and transmission electron microscope, respectively. ELISA was used to measure inflammation and oxidative stress levels in cells and lung tissues. Immunohistochemistry and immunofluorescence were applied to analyze the 4-HNE, LC3 and Ferritin expression. RT-qPCR was used to detect the expression of FcRn, pIgR, STAT3 and NCOA4. Western blot was used to detect the expression of Ferritin, p-STAT3/STAT3, NCOA4, GPX4, TLR2, TLR4 and P65 proteins. 16S rRNA gene sequencing was applied to detect the gut microbiota.

RESULTS

Polyphyllin B had a good binding affinity with STAT3 protein, which as a target gene in COPD. Polyphyllin B inhibited CS-induced oxidative stress, inflammation, mitochondrial damage, and ferritinophagy in COPD mice. 16S rRNA sequencing and FMT confirmed that Akkermansia and Escherichia_Shigella might be the potential microbiota for Polyphyllin B and FMT to improve CSE and LPS-induced COPD, which were exhausted by the antibiotics in C + L and C + L + P mice. CSE and LPS induced the decrease of cell viability and the ferritin and LC3 expression, and the increase of NCOA4 and p-STAT3 expression in BEAS-2B cells, which were inhibited by Polyphyllin B. Polyphyllin B promoted ferritin and LC3II/I expression, and inhibited p-STAT3 and NCOA4 expression in CSE + LPS-induced BEAS-2B cells.

CONCLUSION

Polyphyllin B improved gut microbiota disorder and inhibited STAT3/NCOA4 pathway to ameliorate lung tissue injury in CSE and LPS-induced mice.

Examining acute psychopharmacological effects of nicotine vaping versus heated tobacco products in a randomised crossover study of product naïve adult smokers

Nicotine vaping products (NVPs) and heated tobacco products (HTPs) are designed to replicate the sensory and behavioural aspects of smoking cigarettes while avoiding combustion. The success of these products as harm reduction tools will partially depend on their ability to satisfy smokers and alleviate nicotine-related withdrawal symptoms. This study aims to compare short-term effects of NVPs (Juul and Aspire PockeX) versus HTPs (IQOS) on smoking-related withdrawal relief, product satisfaction, intention to switch to NVP/HTP, perceptions and attitudes in UK adult cigarette smokers naïve to these products. In a randomized cross-over study, 45 participants visited the lab twice, at each visit trying one of the two products (NVP/HTP) and completing a questionnaire. Responses were normalized on a 0-100% scale and mean differences (MD) between NVP and HTP scores computed, with positive and negative MD values indicating greater endorsement for NVP and HTP, respectively. Cigarette cravings were reduced similarly (~ 20.0%) by both products (MD = 4.5%, 95%Confidence Interval (CI) - 4.8, 13.8). Direct positive effects (MD = - 3.5%, 95%CI - 7.2, 0.2) and adverse side effects (MD = 1.8%, 95%CI - 0.3, 3.8) were comparable after each product use, though marginally favouring HTPs. HTPs were perceived as more satisfying overall (MD = - 13.2%, 95%CI - 20.3 - 6.1) than NVPs but both were perceived as similarly addictive (MD = 3.6%, 95%CI - 4.6, 11.8), relative to cigarettes. Intention to switch to either product was comparable (MD = 4.0%, 95%CI - 5.7, 13.8). Comparison of acute use of NVP versus HTP in a sample of UK smokers naïve to these products suggests that HTPs are perceived as more satisfying than NVPs, though still less satisfying than cigarettes.Registration: The analysis plan was pre-registered, and it is available at https://osf.io/6ymdu.

Relationship between heated tobacco product use and allergic rhinitis in Korean adults

INTRODUCTION

Combustible cigarette (CC) smoking is a risk factor for chronic obstructive pulmonary disease (COPD) and asthma, and some studies reported that tobacco smoking might affect the development or symptom control of allergic rhinitis, sinusitis, and atopic dermatitis. However, evidence on the health risks of heated tobacco products (HTPs) is lacking. We investigated the prevalence of respiratory and allergic diseases according to tobacco use types in Korean adults.

METHODS

We used data from 18230 adults in the Korea National Health and Nutrition Examination Survey. Multiple logistic regression analyses were performed to assess the prevalence of respiratory and allergic diseases according to tobacco use types (current exclusive CC use, current exclusive HTPs use, and dual use of CC and HTPs).

RESULTS

The prevalence of exclusive CC users, exclusive HTPs users, dual users of CC and HTPs was 15% (n=2740), 1% (n=182), and 2.4% (n=435), respectively. The prevalence of COPD was higher among past tobacco users (AOR=2.37; 95% CI: 1.02-5.51) versus no tobacco use group. The prevalence of asthma was higher among past tobacco users or exclusive CC users (AOR=1.73; 95% CI: 1.26-2.38, and AOR=1.57; 95% CI: 1.08-2.26) versus non-users of tobacco. The prevalence of allergic rhinitis was higher among past tobacco users versus non-users of tobacco (AOR=1.33; 95% CI: 1.13-1.57), and the prevalence of allergic rhinitis was higher among exclusive HTPs users versus non-users of tobacco or exclusive CC users (AOR=1.60; 95% CI: 1.06-2.42, and AOR=1.74; 95% CI: 1.14-2.66). The adjusted odds of sinusitis and atopic dermatitis were not significantly different between tobacco use types.

CONCLUSIONS

Exclusive use of HTPs was associated with allergic rhinitis in Korean adults. Further longitudinal studies are needed to clarify the health risk of HTPs.

Immunology in COPD and the use of combustible cigarettes and heated tobacco products

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic respiratory diseases, characterised by high morbidity and mortality. COPD is characterised by a progressive decline of lung function caused by chronic inflammatory reactions in the lung tissue due to continual exposure to harmful molecules by inhalation. As prevention plays a very important role in COPD, quitting smoking is the most important factor in reducing the decline in lung function. Unfortunately, many people are unable to break their nicotine addiction. This paper summarises current knowledge about combustible cigarettes (CSs) and alternative tobacco products such as heated tobacco products (HTPs) in COPD. The paper focuses on the immunological aspects of COPD and the influence of tobacco products on lung tissue immunology. There are differences in research results between HTPs and CSs in favour of HTPs. More long-term studies are needed to look at the effects of HTPs, especially in COPD. However, there is no doubt that it would be best for patients to give up their nicotine addiction completely.

Association of cigarette smoking with increased use of heated tobacco products in middle-aged and older adults with self-reported chronic obstructive pulmonary disease, asthma, and asthma-COPD overlap in Japan, 2022: the JASTIS study

BACKGROUND

Smoking cessation is the most important intervention in chronic obstructive pulmonary disease (COPD), asthma, and asthma-COPD overlap (ACO); however, high rates of current cigarette smoking are observed in adults with these respiratory diseases. Meanwhile, rapidly increasing use of heated tobacco products (HTPs) is observed in Japan; however, the status of HTPs use has not been fully understood in adults with COPD, asthma, and ACO. This study aimed to reveal the association between COPD, asthma, and ACO and HTPs use in adults.

METHODS

Data on Japanese individuals ≥ 40 years old obtained from the Japan Society and New Tobacco Internet Survey were analyzed. The prevalence of HTPs use in adults with COPD, asthma, and ACO, among individuals categorized into three groups according to cigarette smoking (never, former, and current), was calculated and the relationship between each disease and HTPs use were evaluated. The clinical diagnosis of these diseases was based on the self-reported diagnosis, as obtained from questionnaires.

RESULTS

A total of 19,308 individuals were included. The proportions of never, past, and current cigarettes smokers were 10,900 (56.5%), 4,903 (25.4%), and 3,505 (18.2%), respectively, and that of HTPs use was 1,813 (9.4%). In current cigarettes smokers, the adjusted odds ratios (ORs) of HTPs use was 2.88 (95% CI [confidence interval], 1.86-4.47), 1.23 (95% CI, 0.99-1.52), and 5.81 (95% CI, 3.12-10.82) in adults with COPD, asthma, and ACO compared to those without these respiratory diseases, respectively. Meanwhile, in past cigarettes smokers, the adjusted ORs of HTPs use was 0.51 (95% CI, 0.24-1.08), 0.69 (95% CI, 0.53-0.88), and 0.25 (95% CI, 0.06-1.07) in adults with COPD, asthma, and ACO, respectively.

CONCLUSIONS

HTPs use is more prevalent among current cigarettes smokers with COPD, asthma, and ACO compared to those without these respiratory diseases. Complete cessation of smoking both cigarettes and HTPs is the only way to achieve complete smoking cessation, therefore, adults with COPD, asthma, and ACO need to make greater efforts to quit smoking.

Heated Tobacco Products: Insights into Composition and Toxicity

Heated tobacco products (HTPs) are novel products that allow users to inhale nicotine by heating (350 °C) reconstituted tobacco rather than combustion (900 °C) as in conventional cigarettes. HTP sticks containing reconstituted tobacco come in various flavours such as menthol, citrus, etc., like electronic cigarette liquids. Thus, the composition of HTP aerosol will also vary according to the flavouring agents added. Overall, the content of toxic chemicals in HTP aerosol appears to be lower than in cigarette smoke. However, the concentrations of more than twenty harmful and potentially harmful constituents have been reported to be higher in HTP aerosol than in cigarette smoke. Further, several toxic compounds not detected in cigarette smoke are also reported in HTP aerosol. Thus, the risks of HTP use remain unknown. Most of the available data on the composition and health effects of mainstream HTP aerosol exposure are generated by the tobacco industry. Few independent studies have reported short-term pathophysiological effects of HTP use. Currently available HTP toxicity data are mainly on the pulmonary and cardiovascular systems. Moreover, there are no long-term toxicity data and, therefore, the claims of the tobacco industry regarding HTPs as a safer alternative to traditional combustible cigarettes are unsubstantiated. Furthermore, HTP aerosol contains the highly addictive substance nicotine, which is harmful to the adolescent brain, developing foetuses, pregnant women, and also adults. Hence, comprehensive studies addressing the safety profiling related to long-term HTP use are warranted. With this background, the following review summarizes the current state of knowledge on HTP toxicity on four broad lines: composition of mainstream HTP aerosol compared to traditional combustible cigarette smoke, biomarkers of HTP exposure, health effects of HTP exposure, and the harm reduction aspect.

Comparison of the Smoking Cessation of Heated Tobacco Product Users and Conventional Cigarette Smokers in Korea

BACKGROUND

Since the introduction of heated tobacco products (HTPs) in Korea in 2017, their annual sales have increased. Several studies have investigated the perceptions of HTPs and smoking cessation behaviors. For the first time, In 2019, questions focused on HTP use were introduced in the Korea National Health and Nutrition Examination Survey (KNHNES). This study aimed to compare smoking cessation behaviors between HTP users and conventional cigarette smokers using KNHANES data.

METHODS

Data of 947 current adult smokers from the 8th KNHNES (2019) were analyzed. Current smokers were divided into conventional cigarette (CC)-only, HTP-only, and dual-use groups. The general characteristics of the three groups were investigated. Differences in current intention to quit smoking and past attempts to quit smoking among the three groups were analyzed using multivariate logistic regression analysis by IBM SPSS ver. 25.0.

RESULTS

HTP-only users demonstrated fewer future smoking cessation plans (adjusted odds ratio [AOR], 0.398; 95% confidence interval [CI], 0.195-0.813; P=0.012) and fewer smoking cessation attempts in the past year (AOR, 0.533; 95% CI, 0.298-0.954; P=0.034) than CC-only smokers. However, there was no significant difference between dual-use (CC+HTP) and CC-only smokers.

CONCLUSION

While dual-use and CC-only smokers showed similar smoking cessation behaviors, HTP-only users had fewer previous attempts to quit smoking and were less likely to be currently ready to quit smoking. These findings can be explained by a decrease in the need to quit smoking due to the convenience of HTP and the perception that HTPs are less harmful than CC.

Comparing the Effectiveness, Tolerability, and Acceptability of Heated Tobacco Products and Refillable Electronic Cigarettes for Cigarette Substitution (CEASEFIRE): Randomized Controlled Trial

BACKGROUND

People who smoke and who face challenges trying to quit or wish to continue to smoke may benefit by switching from traditional cigarettes to noncombustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and electronic cigarettes (ECs). HTPs and ECs are being increasingly used to quit smoking, but there are limited data about their effectiveness.

OBJECTIVE

We conducted the first randomized controlled trial comparing quit rates between HTPs and ECs among people who smoke and do not intend to quit.

METHODS

We conducted a 12-week randomized noninferiority switching trial to compare effectiveness, tolerability, and product satisfaction between HTPs (IQOS 2.4 Plus) and refillable ECs (JustFog Q16) among people who do not intend to quit. The cessation intervention included motivational counseling. The primary endpoint of the study was the carbon monoxide-confirmed continuous abstinence rate from week 4 to week 12 (CAR weeks 4-12). The secondary endpoints included the continuous self-reported ≥50% reduction in cigarette consumption rate (continuous reduction rate) from week 4 to week 12 (CRR weeks 4-12) and 7-day point prevalence of smoking abstinence.

RESULTS

A total of 211 participants completed the study. High quit rates (CAR weeks 4-12) of 39.1% (43/110) and 30.8% (33/107) were observed for IQOS-HTP and JustFog-EC, respectively. The between-group difference for the CAR weeks 4-12 was not significant (P=.20). The CRR weeks 4-12 values for IQOS-HTP and JustFog-EC were 46.4% (51/110) and 39.3% (42/107), respectively, and the between-group difference was not significant (P=.24). At week 12, the 7-day point prevalence of smoking abstinence values for IQOS-HTP and JustFog-EC were 54.5% (60/110) and 41.1% (44/107), respectively. The most frequent adverse events were cough and reduced physical fitness. Both study products elicited a moderately pleasant user experience, and the between-group difference was not significant. A clinically relevant improvement in exercise tolerance was observed after switching to the combustion-free products under investigation. Risk perception for conventional cigarettes was consistently higher than that for the combustion-free study products under investigation.

CONCLUSIONS

Switching to HTPs elicited a marked reduction in cigarette consumption among people who smoke and do not intend to quit, which was comparable to refillable ECs. User experience and risk perception were similar between the HTPs and ECs under investigation. HTPs may be a useful addition to the arsenal of reduced-risk alternatives for tobacco cigarettes and may contribute to smoking cessation. However, longer follow-up studies are required to confirm significant and prolonged abstinence from smoking and to determine whether our results can be generalized outside smoking cessation services offering high levels of support.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03569748; https://clinicaltrials.gov/ct2/show/NCT03569748.

Heated Tobacco Products and Chronic Obstructive Pulmonary Disease: A Narrative Review of Peer-Reviewed Publications

An estimated 65 million people worldwide have moderate or severe chronic obstructive pulmonary disease (COPD), an umbrella term used to describe a group of progressive lung diseases that obstruct airflow such as emphysema and chronic bronchitis. Smoking contributes to an estimated 90% of COPD cases, as the harmful chemicals produced during tobacco combustion damage the lungs and airways. Although smoking cessation is the only intervention shown to improve COPD prognosis in smokers, many patients who try to quit continue to smoke. The continued use of conventional cigarettes exacerbates COPD symptoms, and globally more than 3 million people die from the disease every year. The last two decades have seen the introduction of combustion-free nicotine delivery alternatives that produce significantly lower levels of the harmful components in cigarette smoke, and researchers have begun to assess the impact of switching from cigarettes to these products. Several studies have examined how patients with COPD use e-cigarettes as assistance for quitting, but few have examined how heated tobacco products (HTP) may reduce risk. This narrative review summarises results from pre-clinical, clinical, and real-world evidence studies showing possible harm reduction benefits for patients with COPD who switch to HTPs rather than continuing to smoke cigarettes. Epidemiological studies, real-world data analyses, and randomised clinical trials must be conducted to determine whether switching from cigarettes to HTPs can improve health outcomes in patients with COPD who would otherwise continue to smoke combustible cigarettes.

Current Evidence on Tobacco Harm Reduction in Pneumology: Interviews with Two Key Opinion Leaders

The negative impact of smoking on the lung is well documented. Cigarette smoke is the cause of 90% of cases of chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema. COPD is a progressive and debilitating condition with morbidity and mortality rates similar to myocardial infarction (MI) and stroke. Despite the widely recognised risks, millions of people continue to smoke, in some cases even after receiving a diagnosis of COPD and despite knowing that the habit will accelerate disease progression. While there is no doubt that smoking cessation is the most important health intervention for all cigarette smokers, it can be challenging. Nicotine addiction, social norms and culture, and the length of time it can take smokers to feel the adverse consequences of the habit all contribute to the high cessation failure rate. However, increasing clinical and epidemiological evidence indicates that for those who are unwilling or cannot stop smoking, harm reduction strategies can help reduce exposure to the harmful chemicals and carcinogens released during tobacco combustion. Electronic devices heat processed tobacco without combusting it to deliver an aerosol containing fewer toxic products or harmful and potentially harmful constituents (HPHC) than cigarette smoke. Clinical evidence to support their use is growing. In Japan, for example, a decrease in hospitalisations due to COPD exacerbation after the introduction of such heat-not-burn (HNB), or tobacco heating systems (THS), has been reported. In this article, Wolfgang Popp, Döbling Doctor’s Center, Privatklinik Döbling, Vienna, Austria, and Klara Szondy, Semmelweis University, Budapest, Hungary, discuss the impact of cigarette smoke on the lung, and how to support smoking cessation in those willing and able to quit smoking. They also explain when strategies that reduce the harmful effects of smoking may be useful, and outline the latest evidence supporting the use of HNB systems.

Health impact of e-cigarettes and heated tobacco products in chronic obstructive pulmonary disease: current and emerging evidence

INTRODUCTION

Quitting is the only proven method to attenuate the progression of chronic obstructive pulmonary disease (COPD). However, most COPD smokers do not seem to respond to smoking cessation interventions and may benefit by lessening the negative health effects of long-term cigarette smoke exposure by switching to non-combustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and e-cigarettes (ECs).

AREAS COVERED

Compared with conventional cigarettes, HTPs and ECs offer substantial reduction in exposure to toxic chemicals and have the potential to reduce harm from cigarette smoke when used as tobacco cigarette substitutes. In this review, we examine the available clinical studies and population surveys on the respiratory health effects of ECs and HTPs in COPD patients.

EXPERT OPINION

The current research on the impact of ECs and HTPs on COPD patients' health is limited, and more high-quality studies are needed to draw definitive conclusions. However, this review provides a comprehensive overview of the available literature for health professionals looking to advise COPD patients on the use of these products. While ECs and HTPs may offer some benefits in reducing harm from cigarette smoke, their long-term effects on COPD patients' health are still unclear.

Update on new forms of tobacco use

Smoking remains the leading cause of morbidity and mortality worldwide. Because of its clear influence on cardiovascular and respiratory diseases, it is an important factor in internal medicine consultations. Although the rate of smoking cessation has been increasing in recent years, there is a percentage of patients who continue to smoke because they are unable or unwilling to quit, despite having tried existing pharmacological and non-pharmacological therapies. For this group of patients there are strategies based on interventions aimed at reducing the negative effects of smoking without the need for complete cessation. In this review it is shown that due to the absence of combustion of organic matter in conventional cigarettes, snus, e-cigarettes and heated tobacco products generate significantly lower levels of toxic substances.

Insight into the pulmonary molecular toxicity of heated tobacco products using human bronchial and alveolar mucosa models at air-liquid interface

Heated tobacco products (HTP) are novel nicotine delivery products with limited toxicological data. HTP uses heating instead of combustion to generate aerosol (HTP-smoke). Physiologically relevant human bronchial and alveolar lung mucosa models developed at air-liquid interface were exposed to HTP-smoke to assess broad toxicological response (n = 6-7; ISO puffing regimen; compared to sham; non-parametric statistical analysis; significance: p < 0.05). Elevated levels of total cellular reactive oxygen species, stress responsive nuclear factor kappa-B, and DNA damage markers [8-hydroxy-2'-deoxyguanosine, phosphorylated histone H2AX, cleaved poly-(ADP-Ribose) polymerase] were detected in HTP-smoke exposed bronchial and/or alveolar models. RNA sequencing detected differential regulation of 724 genes in the bronchial- and 121 genes in the alveolar model following HTP-smoke exposure (cut off: p ≤ 0.01; fold change: ≥ 2). Common enriched pathways included estrogen biosynthesis, ferroptosis, superoxide radical degradation, xenobiotics, and α-tocopherol degradation. Secreted levels of interleukin (IL)1ꞵ and IL8 increased in the bronchial model whereas in the alveolar model, interferon-γ and IL4 increased and IL13 decreased following HTP-smoke exposure. Increased lipid peroxidation was detected in HTP-smoke exposed bronchial and alveolar models which was inhibited by ferrostatin-1. The findings form a basis to perform independent risk assessment studies on different flavours of HTP using different puffing topography and corresponding chemical characterization.

Developments in smoking cessation interventions for patients with chronic obstructive pulmonary disease in the past 5 years: a scoping review

INTRODUCTION

Smoking cessation is the most effective strategy for slowing the progression of chronic obstructive pulmonary disease (COPD). However, COPD patients find it difficult to quit smoking with standard cessation interventions.

AREAS COVERED

A scoping review of smoking cessation for COPD patients was conducted by searching the MEDLINE, Embase, and Cochrane Library databases for all studies published between 1 January 2016 and 22 September 2021. Four themes were set up and 47 studies were included eventually. The majority of the included studies (61.7%, 29/47) investigated efficacy and effectiveness, including new strategies for extended treatment and mobile health (mHealth) delivery approach. Studies examining accessibility and utilization (31.9%, 15/47), safety (10.6%, 5/47), and health economics (6.4%, 3/47) were also reviewed. The quality of the included randomized controlled trials was also evaluated.

EXPERT OPINION

Pharmacotherapy combined with behavioral interventions delivered via mHealth may be a promising strategy to help COPD smokers quit. However, the overall quality of the current studies is poor, making it challenging for clinicians to make informed decisions. Future high-quality studies are needed to provide conclusive evidence on the optimal pharmacotherapies and the most cost-effective comprehensive smoking cessation interventions, particularly those integrated into disease management for smokers with COPD.

E-Cigarettes-a review of the evidence-harm versus harm reduction

The World Health Organization estimates there are 1.1 billion cigarette smokers across the globe and that tobacco related deaths number 7 million per year. Electronic nicotine delivery systems (ENDS) are available to contribute options for smoking cessation and include e-cigarettes, e-hookahs, vape pens, mods, and vaping. The growing use of ENDS, or e-cigarettes, in the US and globally across populations is dramatic. Although users may think that e-cigarettes are less harmful than combustible tobacco products, the evidence shows that there are known risks and harms for users. E-cigarettes have varying amounts of toxicants, nicotine, and carcinogens and put the user at risk for lung diseases and COVID-19 similar to smokers. Currently, most governing bodies have not approved e-cigarettes as a smoking cessation tool but do state if a person has failed conventional smoking cessation treatments that e-cigarettes used alone for the short term may help those to quit combustible tobacco and nicotine. A shared decision-making approach should be used when discussing e-cigarettes as a harm reduction tool. More studies and long-term data are needed to assess potential benefits and harms. What is known is that prevention efforts and policy are needed to avoid adolescents and other vulnerable populations from initiating tobacco or e-cigarette use.

Perceived relative harm of heated tobacco products and electronic cigarettes and its association with use in smoke-free places: A cross-sectional analysis of Korean adults

INTRODUCTION

Electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are often considered to be less harmful and safer than combustible cigarettes (CCs). As a result, numerous tobacco product users opt to use e-cigarettes or HTPs as a safer alternative, though the safety of these products is not fully warranted. The present study aimed to assess the various attitudes towards e-cigarettes and/or HTPs among Korean tobacco product users and their associations with the practical use of e-cigarettes and/or HTPs in private or smoke-free public places.

METHODS

A cross-sectional study using self-administered questionnaires was conducted from March 2019 to July 2019 on 2971 adult tobacco product users. Attitude towards e-cigarettes and/or HTPs, as well as the relative harm perceptions, in association with their practical use in private or smoke-free areas, were also analyzed.

RESULTS

Among those surveyed, 46.8% were exclusive users (CC-only smokers 23.5%, e-cigarette-only users 10.7%, HTP-only users 12.7%), and 47.6% were poly-users. Compared with non-e-cigarette or non-HTP users, current e-cigarette or HTP users perceived e-cigarettes or HTPs as less harmful than CCs and they were more acceptable to e-cigarettes or HTPs being used indoors. Their positive attitudes were associated with their more frequent use at home or in their car. Less number of participants supported that the government should regulate e-cigarettes or HTPs in the same way as CCs, their attitude being associated with more frequent use in smoke-free public places.

CONCLUSIONS

E-cigarettes or HTPs users have more positive attitudes toward their tobacco products than non-e-cigarette or non-HTP users. Those with more positive attitudes toward e-cigarettes or HTPs are closely related to their use in smoke-free places.