Heat-not-burn tobacco products: an emerging threat to cardiovascular health

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.

Vaping cessation interventions: a systematic review and meta-analysis

OBJECTIVE

Electronic nicotine delivery systems (ENDS), such as e-cigarettes, have surged in popularity. While long-term risks remain unclear, known dangers include nicotine addiction, E-cigarette or Vaping Use-Associated Lung Injury and potential extrapulmonary effects on the heart, immune system and neurodevelopment. Addressing ENDS addiction may require strategies akin to smoking cessation. However, evidence is lacking; there are no currently approved vaping-cessation aids. The objective of this review is to summarise the available literature addressing interventions for vaping cessation.

DATA SOURCES AND STUDY SELECTION

A librarian-assisted search was conducted in MEDLINE, Embase and Scopus, as well as preprints in Europe PMC, Open Science Framework, and the grey literature searches until January 2024. Six included studies used self-report methods to determine the abstinence rate, while one study used cotinine-level-verified self-reported abstinence. We included randomised controlled trials (RCTs) that examine 'rates of vaping cessation' outcomes. An intention-to-treat approach was used for data extraction, and random-effects meta-analyses models were applied.

DATA SYNTHESIS

Seven RCTs were included, which studied pharmacological therapy, digital interventions and/or educational content. The primary meta-analyses demonstrated a statistically significant increase in the odds of achieving 7-day point prevalence abstinence (PPA) (OR 1.52, 95% CI 1.15 to 2.01, number of participants=3244, moderate-certainty) and continuous abstinence (OR 2.71, 95% CI 1.31 to 5.61, number of participants=164, low-certainty) following intervention. A non-significant increase in odds was noted at 30-day PPA (OR 1.32, 95% CI 0.72 to 2.42, number of participants=1994, very low certainty).

CONCLUSIONS

Vaping cessation interventions increase 7-day PPA rates at 1-12 months follow-up and this was consistent across prespecified subgroup analyses of the intervention type, outcome and duration of follow-up. More high-quality studies with reproducible findings are needed to enhance the certainty of the evidence and guide clinical interventions.

PROSPERO REGISTRATION NUMBER

CRD42022383670.

E-cigarette exposure increases caries risk and modifies dental surface in an in vitro model

OBJECTIVE

Electronic cigarettes have become increasingly popular and can deliver nicotine at levels comparable to traditional tobacco cigarettes. However, the potential adverse effects of these alternative smoking devices on dental health remain uncertain. This study investigates changes in the cariogenic potential of tooth surfaces and analyzes alterations in the chemical composition of aerosols generated from sweet-flavored e-liquids used in electronic cigarettes.

DESIGN

Smoking was simulated using an electronic-cigarette testing machine. Eighty specimens of enamel, dentin and root dentin were divided in two groups according smoking: pre-smoke and post-smoke. The response variables were Microhardness (n=10), SEM (n=5) and FTIR (n=5). E-liquid was analyzed pre-smoke and post-smoke by HPLC-UV/Vis. Data were analyzed by one-way ANOVA and Tukey's tests, with a significance level of 5 %. SEM, FTIR and HPLC-UV/Vis data were qualitatively analyzed.

RESULTS

Enamel exhibited higher microhardness values before and after smoking, with all substrates showing significant microhardness reduction after smoking. All dentin specimens presented standard dentinal tubules, and post-smoke enamel prisms appeared disorganized with various orientations. The specimens' chemical constituents remained stable. Dentin and root dentin post-smoke, carbonate band intensity decreased. There was a thermal degradation of e-liquid products and the formation of new compounds post-vaporization.

CONCLUSIONS

E-cigarette smoking reduces the microhardness of enamel, dentin, and root dentin, alters enamel morphology, induces chemical interactions between e-liquid and tooth tissues, and may increase the risk of cariogenic potential.

Heat-not-burn technology affects plasma testosterone levels and markers of inflammation, oxidative stress in the testes of rats

Introduction

Heating tobacco products (HTPs) are advanced electronic cigarette models. Classified by the FDA as a modified-risk tobacco product and can be used as part of efforts to quit smoking. Using heat-not-burn (HnB) technology, these devices heat tobacco avoiding complete combustion. Although the levels of toxicants in the mainstream are significantly lower than those observed in tobacco smoke, some recent studies have raised concerns about potential health risks associated with their use, particularly regarding their effects on male gonadal function, which remain largely unexplored.

Methods

Adult male Sprague-Dawley rats were exposed, whole body, 5 days/week for 4 weeks to HnB mainstream.

Results

The expression of the cell cycle regulators Bax/Bcl-2 ratio is not affected, along with no changes in p-38. On the other hand, an increase in oxidative stress markers, including those associated with DNA damage, was observed in exposed animals, along with the induction of NF-kB dependent pro-inflammatory mediators: TNF-α, IL-1β, IL-6 and COX-2. Furthermore, inactivation of key androgenic enzymes, such as 3β-hydroxysteroid dehydrogenase and 17β-hydroxysteroid dehydrogenase, together with decreased testosterone synthesis suggest a potential impairment of male gonadal function.

Discussion

The results indicate that animals exposed to HnB smoke show higher levels of oxidative stress markers, including those associated with DNA damage, as well as higher levels of pro-inflammatory cytokines. The impairment of some androgenic key enzymes and those related to the activity of seminiferous epithelium, together with the decrease in testosterone levels, suggest an impairment of gonadal function through the alteration of some cellular pathways typically associated with tobacco consumption.

[Impact of new nicotine delivery devices on smoking trends consumption and health]

The use of electronic cigarettes and heated tobacco products is increasing among adolescents and young adults. Tobacco companies offer these devices to enhance the smoking experience by magnifying its attractive and minimizing the negatives associated with the consumption of conventional cigarettes. The objective of this review is to update the available knowledge on the impact of these devices, both from an individual perspective, in terms of their effects on health, and from a public health perspective due to direct exposure and the effects derived from the second and third hand emissions. Studies show that their aerosols contain a wide variety of toxic chemical components, responsible for adverse effects on organs and systems. There is still little evidence on long-term effects and they likely will not be fully understood for years or decades. The systematic review demonstrates that it is important for health professionals continue to investigate this matter and provide updated information on the adverse effects of these new tobacco products with a view to promoting the health of the population.

Impacts of revised smoke-free regulations under the 2020 Japan Health Promotion Act on cigarette smoking and heated tobacco product use in indoor public places and homes: findings from 2018 to 2021 International Tobacco Control (ITC) Japan Surveys

BACKGROUND

In April 2020, Japan's revised Health Promotion Act (HPA) banned cigarette smoking and heated tobacco products (HTP) use in indoor public places but exempted small establishments and permitted smoking-designated/HTP-designated rooms. This pre-post study evaluated the effectiveness of the HPA.

METHODS

Data were from waves 1 to 4 (2018-2021) of the International Tobacco Control Japan Surveys among a national cohort of adults who smoke cigarettes, use HTPs and do not use any tobacco products. The sample sizes in the respective surveys were 4615, 4222, 4387 and 4254. Multivariable logistic regression models employing generalised estimating equations estimated the prevalence of observed and self-reported indoor smoking/HTP use in key public venues (restaurants/cafés, bars/pubs and workplaces), smoke-free places, and homes, and smoke-free/HTP aerosol-free home policies (model 1). The models were additionally adjusted for waves 1-4 to estimate the impacts of the HPA (model 2).

RESULTS

The implementation of the HPA significantly reduced observed indoor smoking in bars/pubs (model 1: 82.2% (pre) to 55.5% (post), model 2: p=0.04) but not in restaurants/cafés (model 1: 53.0%-24.9%, model 2: p=0.15) or workplaces (model 1: 35.3%-30.1%, model 2: p=0.62). Observed indoor HTP use was also common postimplementation (restaurants/cafés: 19.6%, bars/pubs: 53.9%, workplaces: 36.4%). The implementation of the HPA was associated with a significant increase in observed HTP use in smoke-free places (model 1: 26.3%-33.3%, model 2: p=0.001) and a suggestive increase in homes without HTP aerosol-free policies among adults who smoke (model 1: 64.0%-77.0%, model 2: p=0.09).

CONCLUSIONS

The implementation of the HPA was limited in its effectiveness. Comprehensive regulations with no exemptions are needed in Japan.

Impact of electronic cigarettes (e-cigs) and heat-not-burn/heated tobacco products (HnB/HTP) on asthma and chronic obstructive pulmonary disease: a viewpoint of the Italian Society of Internal Medicine

The association of cigarette smoking with several severe and very severe diseases (oncological, cardiovascular, respiratory) which have dramatic epidemiological, medical, and financial impact, is a well-known public threat. Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent diseases in Italy, posing significant public health challenges. Tobacco smoking, a primary risk factor for COPD and a common asthma trigger, remains a critical preventable public health issue. While universally acknowledged that quitting smoking drastically reduces the risk of smoking-related health issues, a significant portion of smokers and patients find quitting challenging or undesirable, hence a need for new ways to deal with it. A worth considering alternative might be the switch to electronic cigarettes (e-cig), and heat-not-burn/heated tobacco products (HnB/HTP). Emerging evidence suggests potential benefits in asthma and COPD management when transitioning from traditional smoking to e-cigs or HnB devices. However, the effectiveness of these products in facilitating smoking cessation is still debated, alongside concerns about their role in promoting smoking initiation among non-smokers. Internists are among the physicians who most frequently assist patients with smoking-related diseases, and in this perspective they cannot avoid paying attention to the progressive diffusion of smoking products alternative to the traditional cigarette, and to the controversies with respect to their use. In this context, the Italian Society of Internal Medicine, also recognizing a growing need for clarity for healthcare providers, has undertaken a comprehensive analysis of existing literature to offer an informed perspective on the health impact of e-cigs and HnB/HTP on asthma and COPD.

The Impact of Heat-Not-Burn, E-Cigarettes, and Cigarettes on Small Airway Function

Introduction

E-cigarettes and heated tobacco products (HTPs) are gaining worldwide significance. The tobacco industry is promoting these products as healthier alternatives to conventional cigarettes.

Methods

In this four-arm crossover study, we examined the acute effects of cigarette smoking, vaping IQOS, or vaping e-cigarettes (with or without nicotine) on hemodynamics, arterial stiffness, and small airways. Twenty subjects (10 male, 10 female), all occasional smokers, completed each study arm. There was at least a 48 h washout period before each test day. Arterial stiffness and peripheral and central hemodynamics were assessed using Mobil-O-Graph™ (I.E.M., Germany), whereas tremoFlo® c-100 (Thoracic Medical Systems Inc) was used to evaluate the effects on the small airways and resistance.

Results

Cigarettes, IQOS, e-cigarettes containing nicotine, and nicotine-free e-cigarettes had similar effects on peripheral and central hemodynamics as well as on arterial stiffness. We observed a significant increase in all parameters. However, only nicotine-containing products lead to increased bronchial obstruction, higher reactance, and a higher tidal volume.

Conclusion

Therefore, we concluded that cigarettes, IQOS, and e-cigarettes have similar effects on hemodynamics. No differences were observed between the nicotine-containing and nicotine-free e-cigarettes. All nicotine-containing products also influence small airways. These findings suggest that e-cigarettes and HTPs are not healthier alternatives than conventional cigarettes.

Smokers' perception of the comparative health risks of cigarettes, e-cigarettes and heated tobacco products: a survey among the German population

BACKGROUND

Tobacco cigarettes, e-cigarettes and heated tobacco products can pose different health risks (harm continuum). As current tobacco smokers could benefit from switching to less harmful products, we aimed to assess current smokers' perceived comparative health risks of these three products and to explore associations between risk perceptions and specific user characteristics.

METHODS

We analysed data from 11 waves (2019-2021; N = 5657 current tobacco smokers) of a representative, cross-sectional household survey conducted in Germany. Associations were assessed with multivariable logistic regression models.

RESULTS

55.2% of smokers (95%CI = 53.8-56.5%) ranked cigarettes as the most harmful product. 36.1% of smokers (95%CI = 34.8-37.3%) perceived e-cigarettes and 33.8% (95%CI = 32.5-35.0%) heated tobacco products as more harmful than cigarettes. Misperceptions that e-cigarettes or heated tobacco products are more harmful to health than cigarettes increased over the 3-year study period and were more common among those with lower educational attainment.

CONCLUSIONS

Only half of current tobacco smokers in Germany perceive the comparative health risks of cigarettes adequately and such misperceptions have increased recently. As current smokers could benefit most from switching to less harmful products, educational campaigns are needed to inform this group about the health risks of tobacco smoking and the comparative health risks of the various nicotine and tobacco products along the harm continuum.

Comparison of smoking traditional, heat not burn and electronic cigarettes on salivary cytokine, chemokine and growth factor profile in healthy young adults-pilot study

Objective: Smoking is the cause of numerous oral pathologies. The aim of the study was to evaluate the effect of smoking traditional cigarettes, e-cigarettes, and heat-not-burn products on the content of salivary cytokines, chemokines, and growth factors in healthy young adults. Design: Three groups of twenty-five smokers each as well as a control group matched in terms of age, gender, and oral status were enrolled in the study. In unstimulated saliva collected from study groups and participants from the control group, the concentrations of cytokines, chemokines, and growth factors were assessed by Bio-Plex® Multiplex System. Results: We demonstrated that smoking traditional cigarettes is responsible for increasing the level of IFN-γ compared to non-smokers and new smoking devices users in unstimulated saliva in the initial period of addiction. Furthermore, e-cigarettes and heat-not-burn products appear to have a similar mechanism of affecting the immune response system of unstimulated saliva, leading to inhibition of the local inflammatory response in the oral cavity. Conclusion: Smoking traditional cigarettes as well as e-cigarettes and heat-not-burn products is responsible for changes of the local immune response in saliva. Further research is necessary to fill the gap in knowledge on the effect of new smoking devices on the oral cavity immune system.

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes

BACKGROUND

Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears.

METHODS

This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity.

RESULTS

Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group.

CONCLUSIONS

Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Impact of More Intense Smoking Parameters and Flavor Variety on Toxicant Levels in Emissions of a Heated Tobacco Product

INTRODUCTION

IQOS HEETS are promoted as reduced-risk alternatives to cigarettes. Although some studies have investigated the chemical composition of HEETS emissions, little is known on whether toxicant levels in such emissions are affected by different puffing parameters and flavor varieties. This has important implications when assessing actual human exposure, since IQOS users develop a specific and personalized puffing behavior and may use different HEETS variants.

METHODS

This study measured the levels of nicotine, total particulate matter, carbonyl compounds, and tobacco-specific nitrosamines (TSNAs) in the emissions of nine differently flavored HEETS and two cigarettes (1R6F and Marlboro Red, MR). Emissions from Yellow HEETS, 1R6F, and MR were collected using the World Health Organization Intense smoking regime and four more intense smoking regimes.

RESULTS

Yellow HEETS aerosol contained lower levels of toxicants compared to 1R6F and MR smoke. More intense smoking regimes increased carbonyl release in cigarette smoke, whereas only higher puff frequency led to lower levels of toxicants in Yellow HEETS aerosol. Some HEETS varieties exhibited higher levels of formaldehyde and TSNAs in their aerosols compared to Yellow HEETS.

CONCLUSIONS

Puff frequency was identified as the only smoking parameter that significantly lowered the release of almost all toxicants in Yellow HEETS, whereas a combination of higher puff volume and puff duration led to increased levels of some carbonyls. Differences in toxicant levels between various commercially available HEETS have important implications when assessing their health impact, as their consumption might induce different toxicant exposure and health effects.

IMPLICATIONS

HEETS release about half as much nicotine and substantially lower levels of toxicants compared to cigarettes. Literature data showed that puffing intensity is increased in cigarette smokers switching to HEETS, maybe in reaction to these lower nicotine levels. Our results show a differential impact of increased puff frequency, puff duration, and puff volume in the release of toxicants from HEETS. Thus, industry-independent studies on puff topography are critical to make choices for the most relevant puffing regime for heated tobacco product regulation. Regulators should consider evaluating the health impact of multiple HEETS varieties, as the tobacco filler composition significantly affects the release of certain toxicants.

Particle emissions from heated tobacco products

INTRODUCTION

This study determines the particle emissions from five heated tobacco products (HTPs).

METHODS

An aethalometer is used for the determination of black carbon (BC) and an aerosol monitor for total particulate matter (PM) concentration and also PM fractions (1, 2.5, 4, and 10 μm) in the mainstream emissions of 5 HTPs: IQOS, LIL, PULZE, ILUMA, and GLO. Fifteen different flavors were used, five sticks per flavor, which were smoked using a peristaltic pump under both ISO and Canadian smoking regimes. The method repeatability was determined using 15 sticks of one flavor for each brand for each smoking regime.

RESULTS

All HTPs emit particles, and more than 99.7% of the particles emitted are smaller than 1 μm. Both BC and PM emissions show quite low repeatability. Particle emissions increase in relation to the heating temperature and the intensity smoking regime, and are depending on the flavor used. BC corresponds to a small percentage of total PM.

CONCLUSIONS

Although HTPs are promoted as products of reduced risk compared to conventional cigarettes, high particle concentrations are detected in their emissions, depending on the smoking regime, the flavor used, and the operation parameters. PM emissions vary significantly between different brands under the ISO smoking regime, probably due to the heating temperature. In contrast, PM emissions under the Canadian smoking regime do not vary significantly between different brands. This could probably be attributed to the fact that increased puff frequency does not allow the device to cool down between puffs, resulting in an increase in PM emissions for all the brands, but not dependent on the maximum heating temperature of the device. BC emissions only consist of a very small fraction of PM and do not vary significantly between different brands under both smoking regimes.

Impact of heat-not-burn cigarette passive smoking on children's oxidative stress, endothelial and platelet function

Growing global use of heat-not-burn cigarettes (HNBC) prompts investigation. Prior studies assessed HNBC's effects on cardiovascular health, revealing heightened oxidative stress, platelet activation, and endothelial dysfunction. However, limited understanding exists regarding passive smoking's impact on children exposed to HNBC. This study aims to assess levels of oxidative stress, endothelial and platelet function among children exposed to passive smoke from HNBC, traditional tobacco (TT) cigarettes and unexposed subjects. Seventy-eight children (2-18 years) were divided into three groups: HNBC passive smokers (n = 26), TT cigarette exposed (n = 26), and control (CNT) group (n = 26, unexposed). Oxidative stress was evaluated by serum NADPH oxidase-2 (NOX2) activity, assessed by soluble Nox2-derived peptide (sNOX2-dp), isoprostanes, hydrogen peroxide (H2O2) production, hydrogen break-down activity (HBA) and NO bioavailability. Endothelial function was assessed by brachial flow-mediated dilation (FMD). Platelet function was evaluated by soluble CD40 ligand (sCD40L), soluble P-selectin (sP-selectin) and thrombus formation by T-TAS analysis. Passive smoking-exposed children (both HNBC and TT) exhibited significantly increased serum sNOX2-dp, isoprostanes, H2O2, sCD40L sP-selectin and thrombus formation versus controls. Conversely, exposed children displayed reduced brachial FMD and serum NO bioavailability. No significant differences were found between children exposed to passive smoking of HNBC vs TT. Multivariable regression linked sNOX2 (standardized coefficient β: 0.284; SE: 0.040; p = 0.01) and H2O2 (standardized coefficient β: 0.243; SE: 0.0; p = 0.02) as independent predictors of FMD, and isoprostanes (standardized coefficient β:0.388; SE: 0.022; p < 0.001) and serum cotinine (standardized coefficient β:0.270; SE: 0.048; p = 0.01) with sNOX2-dp levels. Exposure to HNBC smoke heightened oxidative stress, endothelial dysfunction, platelet activation, and thrombus formation in children. Findings suggest avenues for interventions to curb childhood passive smoking exposure.

Association of the blood levels of specific volatile organic compounds with nonfatal cardio-cerebrovascular events in US adults

BACKGROUND

Cardio-cerebrovascular diseases constitute a major global public health burden. Volatile organic compounds (VOCs) exposure has become progressively severe, endangering human health and becoming one of the main concerns in environmental pollution. The associations of VOCs exposure with nonfatal cardio-cerebrovascular events have not been identified in observational study with a large sample size, so we aim to examine the association in US adult population.

METHODS

Adults aged > 18 years with complete data regarding selected blood levels of VOCs (including benzene, ethylbenzene, o-xylene, and m-/p-xylene) and nonfatal cardio-cerebrovascular events were included in the analysis (n = 3,968, National Health and Nutrition Examination Survey, NHANES, 2013-2018 survey cycle). Participants were classified into low- and high-exposure based on whether above selected VOCs low limit detect concentration or median value. Weighted multivariate logistic analyses and subgroup analyses were used to detect the association between selected VOCs exposure and nonfatal cardio-cerebrovascular events in US adults.

RESULTS

Weighted multivariate logistic analyses showed that the high-VOCs exposure group had an increased risk of nonfatal cardio-cerebrovascular events compared with the low-VOCs exposure group; the adjusted odds ratios (OR) and 95% confidence intervals (CI) of nonfatal cardio-cerebrovascular events for the high-VOCs exposure group were 1.41 (0.91, 2.19), 1.37 (0.96, 1.95), 1.32 (0.96, 1.82), and 1.17 (0.82, 1.67) for benzene, ethylbenzene, o-xylene, and m-/p-xylene, respectively, which was not significant assuming statistical significance at a 0.05 significance level (95% CI) for a two-tailed test. Lastly, we found high-VOCs exposure was associated with increased incidence of nonfatal cardio-cerebrovascular events in both daily smokers an non-daily smokers (p-interaction > 0.01), but the association was not statistically significant in non-daily smokers.

CONCLUSIONS

This study found that VOCs (benzene, ethylbenzene, o-xylene, and m-/p-xylene) exposure was associated with increased incidence of nonfatal cardio-cerebrovascular events in US adults, and the results need to be confirmed by larger cohort studies.

International and national frameworks, guidelines, recommendations, and strategies for maternal tobacco prevention and cessation: A scoping review protocol

Tobacco use during and around pregnancy can significantly increase the risk of stillbirth, congenital disabilities, premature birth, and low-weight birth. To establish maternal tobacco prevention and cessation frameworks for primary care and dental providers and to facilitate cross-national learning, this scoping review aims: 1) to analyze the body of literature on maternal tobacco prevention and cessation frameworks, guidelines, recommendations, and strategies at the international and national level; 2) to identify common core elements; and 3) to identify gaps in the literature, and propose future initiatives and policy development directions. A systematic database search based on the JBI methodology and corresponding PRISMA-ScR guidelines will be conducted from January 2015 to August 2023. Searches in different databases will be combined with an expert survey among the members of the World Federation of Public Health Associations (WFPHA) - Oral Health, Tobacco Control, and the Women, Adolescent, and Children's Working Groups to evaluate the search outcomes and add maternal tobacco prevention and cessation frameworks, guidelines, recommendations, or strategies. Using a systematic review tool to support the screening, two independent reviewers will screen the titles and abstracts of all articles, in order to include the relevant ones for full-text screening, and an independent third author will resolve conflicts, if there is any discrepancy between the two independent reviewers' search. After a full-text review, data extraction will be conducted for analysis. Descriptive analyses include the publication year, country, legal quality, and target group addressed. A narrative synthesis will describe the scope and content of the frameworks, guidelines, recommendations, and strategies. The scoping review will serve as a stepping-stone to creating a WFPHA policy resolution on tobacco prevention and cessation framework for women of childbearing age led by the WFPHA Oral Health, Tobacco Control and the Women, Adolescent, and Children's Working Group members. This WFPHA policy resolution 'Maternal Tobacco Cessation and Prevention Recommendations for Primary Care Providers and Dental Providers' will be forwarded to the WFPHA General Council and the General Assembly for approval and will be disseminated to the WFPHA public health association members. Ultimately, this recommendation will be used by each national public health association to consider integrating it into their maternal health strategy.

Evaluation of the Effects of e-Cigarette Aerosol Extracts and Tobacco Cigarette Smoke Extracts on RAW264.7 Cells

With the advancement of society, electronic cigarettes (e-cigarettes) have gained popularity among a growing number of individuals. While numerous toxicological studies have suggested that e-cigarettes are a safer alternative to traditional cigarettes, there is also a body of literature presenting contrasting findings. This in vitro study aimed to compare the effects of e-cigarettes and tobacco cigarettes (t-cigarettes) on RAW264.7 cells by using four e-cigarette aerosol extracts (ECA) and cigarette smoking extracts (CS) containing different nicotine concentrations. The results revealed that low concentration of nicotine in CS as well as in ECA with grape, watermelon, and cola flavors could promote cell viability. Conversely, high nicotine concentration in CS and ECA with four flavors decreased cell viability. Furthermore, our study demonstrated that CS significantly reduced the phagocytic capability of RAW264.7 cells and increased the levels of inflammatory cytokines (IL-6, TNF-α, and IL-1β) and reactive oxygen species (ROS) compared to ECA. Overall, our findings indicate all four e-cigarettes induced less cytotoxicity to RAW264.7 cells and might be safer than t-cigarettes.

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.

Regulation of endothelial function by cigarette smoke and next-generation tobacco and nicotine products

Cigarette smoking is the most important avoidable cardiovascular risk factor. It causes endothelial dysfunction and atherosclerosis and increases the risk of its severe clinical complications like coronary artery disease, myocardial infarction, stroke, and peripheral artery disease. Several next-generation tobacco and nicotine products have been developed to decrease some of the deleterious effects of regular tobacco smoking. This review article summarizes recent findings about the impact of cigarette smoking and next-generation tobacco and nicotine products on endothelial dysfunction. Both cigarette smoking and next-generation tobacco products lead to impaired endothelial function. Molecular mechanisms of endothelial dysfunction like oxidative stress, reduced nitric oxide availability, inflammation, increased monocyte adhesion, and cytotoxic effects of cigarette smoke and next-generation tobacco and nicotine products are highlighted. The potential impact of short- and long-term exposure to next-generation tobacco and nicotine products on the development of endothelial dysfunction and its clinical implications for cardiovascular diseases are discussed.

The Usefulness of a Smartphone App-Based Smoking Cessation Program for Conventional Cigarette Users, Heated Tobacco Product Users, and Dual Users: Retrospective Study

BACKGROUND

Heated tobacco products (HTPs) are widespread in Japan, and smoking cessation of such products has become an important issue owing to the spread of harmful effects from HTPs. The efficacy of online digital therapy has been reported in smoking cessation treatment; however, we have limited evidence of online smoking cessation programs for HTP users.

OBJECTIVE

In this study, we evaluate the usefulness of the Ascure program for HTP users (defined as exclusive HTP use or dual use of HTP and cigarettes) compared with exclusive cigarette users.

METHODS

This was a retrospective study. We recruited adult smokers participating in the Ascure online smoking cessation program in Japan from June 2019 to February 2021. The Ascure smartphone app provided four elements: (1) educational video tutorials to enhance the understanding of nicotine dependence, (2) a personalized to-do list for behavior change, (3) a digital diary for record keeping, and (4) interactive chat sessions for relief from cravings or withdrawal symptoms. The primary outcome was the continuous abstinence rate (CAR) at weeks 21 to 24, biochemically validated using salivary cotinine testing. We considered those who dropped out of the program as smoking cessation failures. We analyzed the primary outcome using inverse probability weighting against tobacco product type estimated by multinomial propensity scores. We also assessed CAR at weeks 9 to 12 and program adherence.

RESULTS

We analyzed data from 2952 participants, including 52% (1524/3478) in the cigarette group, 35% (1038/3478) in the HTP group, and 13% (390/3478) in the dual-use group, who had a mean age of 43.4 (SD 10.8) years and included 17% (513/2952) women. CAR at weeks 21 to 24 showed that exclusive HTP users were more likely to stop tobacco use than exclusive cigarette smokers (CAR 52.6% for cigarette users vs CAR 64.8% for HTP users; odds ratio [OR] 1.17, 95% CI 1.12-1.22; P<.001). There was no significant difference between the exclusive cigarette users and the dual users (CAR 52.6% for cigarette users vs CAR 48.7% for dual users; OR 0.99, 95% CI 0.93-1.05; P=.77). CAR at weeks 9 to 12 was 56.7% (95% CI 54.2%-59.2%) for the exclusive cigarette users, 68.3% (95% CI 65.5%-71.1%) for the exclusive HTP users, and 58.2% (95% CI 53.3%-63.1%) for the dual users. The program adherence rate at week 24 was 70.7% overall (68.4% for cigarette users, 75% for HTP users, and 67.9% for dual users).

CONCLUSIONS

Exclusive HTP users had higher CARs and adherence compared with exclusive cigarette users, indicating a higher affinity for the Ascure online smoking cessation program. This program might be a useful smoking cessation option for HTP users, as well as for cigarette smokers.

Characterizing Heated Tobacco Products Marketing on Instagram: Observational Study

BACKGROUND

Heated tobacco products (HTPs), including I Quit Ordinary Smoking (IQOS), are new tobacco products that use an electronic device to heat compressed tobacco leaves to generate an aerosol for consumers to inhale. Marketing of HTPs is prevalent on Instagram, a popular social media platform.

OBJECTIVE

This study aims to characterize posts related to HTPs on Instagram and their associations with user engagement.

METHODS

Through the Instagram application programming interface, 979 Instagram posts were collected using keywords related to HTPs, such as "IQOS" and "heat-not-burn." Among them, 596 posts were related to IQOS and other HTP marketing. The codebook was developed from a randomly selected 200 posts on the post content by hand coding, which was applied to the remaining 396 Instagram posts. Summary statistics were calculated, and statistical hypothesis testing was conducted to understand the popularity of Instagram posts on HTPs. Negative binomial regression models were applied to identify Instagram post characteristics associated with user engagement (eg, count).

RESULTS

Among Instagram posts related to HTP marketing (N=596), "product display" was dominant (n=550, 92.28%), followed by "brand promotion" (n=41, 6.88%), and "others" (n=5, 0.84%). Among posts within "product display," "device only" was the most popular (n=338, 61.45%), followed by "heatstick only" (n=80, 14.55%), "accessory" (n=66, 12%), "device and heatstick" (n=56, 10.18%), and "capsule" (n=10, 1.82%). A univariate negative binomial regression model with pairwise comparisons across "product display" types showed that the number of likes for posts with HTP heatsticks was significantly lower compared to posts with HTP devices, accessories, and device-heatstick sets. Multivariate negative binomial regression models showed that HTP-related Instagram posts with a model or lifestyle elements (;=.60, 95% CI 0.36-0.84) or without obvious product advertising information (=.69, 95% CI 0.49-0.89) received more likes.

CONCLUSIONS

It is shown that posts with product displays were dominant among HTP-related posts on Instagram. Posts with model or lifestyle elements are associated with high user engagement, which might be one of the web-based marketing strategies of HTPs.

Cardiotoxicity of Electronic Cigarettes and Heat-Not-Burn Tobacco Products-A Problem for the Modern Pediatric Cardiologist

Electronic nicotine delivery systems (ENDS) have become increasingly popular among adolescents, either as an alternative to conventional cigarettes (CCs) or as a newly acquired recreational habit. Although considered by most users as a safer option for nicotine intake, these devices pose significant health risks, resulting in multisystem damage. Heat-not-burn products, which, unlike ENDS, contain tobacco, are also alternatives to CCs that consumers use based on the idea that their safety profile is superior to that of cigarettes. Recent studies in the USA and EU show that adolescents are particularly prone to using these devices. Pediatric cardiologists, as well as other healthcare professionals, should be aware of the complications that may arise from acute and chronic consumption of these substances, considering the cardiovascular damage they elicit. This article summarized the known data about the impact of ENDS on the cardiovascular system, with emphasis on the pathophysiological and molecular changes that herald the onset of systemic lesions alongside the clinical cardiovascular manifestations in this scenario.

Increased vulnerability to atrial and ventricular arrhythmias caused by different types of inhaled tobacco or marijuana products

BACKGROUND

The emergence of a plethora of new tobacco products marketed as being less harmful than smoking, such as electronic cigarettes and heated tobacco products, and the increased popularity of recreational marijuana have raised concerns about the potential cardiovascular risk associated with their use.

OBJECTIVE

The purpose of this study was to investigate whether the use of novel tobacco products or marijuana can cause the development of proarrhythmic substrate and eventually lead to arrhythmias.

METHODS

Rats were exposed to smoke from tobacco, marijuana, or cannabinoid-depleted marijuana, to aerosol from electronic cigarettes or heated tobacco products, or to clean air once per day for 8 weeks, following by assays for blood pressure, cardiac function, ex vivo electrophysiology, and histochemistry.

RESULTS

The rats exposed to tobacco or marijuana products exhibited progressively increased systolic blood pressure, decreased cardiac systolic function with chamber dilation, and reduced overall heart rate variability, relative to the clean air negative control group. Atrial fibrillation and ventricular tachycardia testing by ex vivo optical mapping revealed a significantly higher susceptibility to each, with a shortened effective refractory period and prolonged calcium transient duration. Histological analysis indicated that in all exposure conditions except for air, exposure to smoke or aerosol from tobacco or marijuana products caused severe fibrosis with decreased microvessel density and higher level of sympathetic nerve innervation.

CONCLUSION

These pathophysiological results indicate that tobacco and marijuana products can induce arrhythmogenic substrates involved in cardiac electrical, structural, and neural remodeling, facilitating the development of arrhythmias.

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.

Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020

INTRODUCTION

Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults.

AIMS AND METHODS

Using 2020 cross-sectional data from 2,470 young adults (ages 18-34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively.

RESULTS

19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (β = 0.26, 95%CI = 0.21, 0.30; β = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (β = -0.06, 95%CI = -0.10, -0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users.

CONCLUSIONS

Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims.

IMPLICATIONS

Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.

Nicotine and novel tobacco products drive adverse cardiac remodeling and dysfunction in preclinical studies

Background

The heart undergoes structural and functional changes in response to injury and hemodynamic stress known as cardiac remodeling. Cardiac remodeling often decompensates causing dysfunction and heart failure (HF). Cardiac remodeling and dysfunction are significantly associated with cigarette smoking. Although cigarette smoking has declined, the roles of nicotine and novel tobacco products (including electronic cigarettes and heat-not-burn tobacco) in cardiac remodeling are unclear. In this perspective, we present evidence demonstrating maladaptive cardiac remodeling in nicotine-exposed mice undergoing hemodynamic stress with angiotensin (Ang)-II infusion and review preclinical literature linking nicotine and novel tobacco products with cardiac remodeling and dysfunction.

Methods

Adult, male C57BL/6J mice were exposed to room air or chronic, inhaled nicotine for 8 weeks. A subset of mice was infused with Ang-II via subcutaneous osmotic mini-pumps during the final 4 weeks of exposure. Left ventricular structure and function were assessed with echocardiography.

Results

Chronic, inhaled nicotine abrogated Ang-II-induced thickening of the left ventricular posterior wall, leading to reduced relative wall thickness. Ang-II infusion was associated with increased left ventricular mass index in both air- and nicotine-exposed mice.

Conclusions

These changes suggest a phenotypic shift from concentric hypertrophy to eccentric hypertrophy in nicotine-exposed, hemodynamically-stressed mice which could drive HF pathogenesis. These findings join a growing body of animal studies demonstrating cardiac remodeling and dysfunction following nicotine and electronic cigarette exposure. Further exploration is necessary; however, clinicians and researchers should not overlook these emerging products as potential risk factors in the pathogenesis of cardiac remodeling and associated diseases including HF.

Sex-Related Differences in Oxidative, Platelet, and Vascular Function in Chronic Users of Heat-not-Burn vs. Traditional Combustion Cigarettes

Smoking is still a major cardiovascular risk factor, despite many public awareness campaigns and dedicated interventions. Recently, modified risk products (MRP), e.g., heat-not-burn cigarettes (HNBCs), have been introduced as surrogates of traditional combustion cigarettes (TCCs). Although these products are promoted as healthier than TCCs, few studies have been conducted to assess it. This work is a sex-focused sub-study of a prospective observational study in which apparently healthy chronic TCC smokers were age-matched with regular HNBC users. Blood samples were collected for biochemical assays and blood pressure and flow-mediated dilation (FMD) were measured. Out of 60 subjects, 33 (55%) were women, and 27 (45%) men, with 11 (33%) vs. 9 (33%) non-smokers, respectively, 10 (30%) vs. 10 (37%) TCC smokers, and 12 (36%) vs. 8 (30%) HNBC smokers (p = 0.946). Bivariate and multivariable analyses showed no statistically significant between-sex differences in NO, H2O2, sCD40L, sNox2-dp, sP-selectin, platelet aggregation, cotinine or FMD, overall, in non-smokers, in TCC smokers, or in HNBC smokers (all p > 0.05). HNBCs appeared safer than TCCs when focusing on Nox2-dp (p = 0.026) and sP-selectin (p = 0.050) but had similar levels of the other measured markers. In conclusion, HNBCs have similar detrimental effects on women and men’s oxidative stress (H2O2: p = 0.49; sNox2-dp: p = 0.31) and platelet activation (sP-selectin: p = 0.33; platelet aggregation p = 0.87).

Documento de posicionamiento de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) ante las estrategias de reducción del daño del tabaco

In the last decade, the appearance of electronic cigarettes and new tobacco products (heated tobacco or smokeless tobacco) has generated a growing interest in harm reduction methods that are defined as mechanisms that seek to reduce the harmful consequences of tobacco without give up the pleasant effects of it by replacing it with these new electronic devices. However, these products are addictive and not safe as they contain nicotine. Harm reduction is a false solution as it represents a commercial strategy of the tobacco industry to increase its sales, making it difficult to control smoking, since it keeps smokers from consuming tobacco and prevents them from making serious attempts to quit. In addition, these products are a gateway to adolescents in tobacco.

Smoking cessation behaviors and reasons for use of electronic cigarettes and heated tobacco products among Romanian adults

We report cessation behaviors, reasons for use of electronic cigarettes (EC) and heated tobacco products (HTP) and association of their use with quit attempts and smoking intensity using Romania Global Adult Tobacco Survey 2018. Weighted estimates of EC and HTP by cigarette smoking (CS) status were assessed. Quit attempts, intention to quit, reasons for lack of intention to quit among current CS, and reasons for current use of EC and HTP were estimated. The association of 'ever use' of EC and HTP with cigarette smoking intensity and quit attempts was explored using binary logistic regression. Of the total 4571 surveyed, 1243 (27.3%) were current CS, 300 (24.4%) made quit attempts in the past 12 months. Only 38 (12.5%) and 26 (8.6%) had used EC and HTP as an aid to quit. Among current CS, 512 (41.2%) had no intention to quit. Reasons for this were, 'enjoy smoking' (86.1%), 'reduce stress' (65.9%), and 'staying alert' (46.3%). Awareness and use of EC and HTP were significantly higher among current CS. 'Dual use' of EC and HTP with CS was manifolds higher than stand-alone use. Reasons for current use of EC and HTP were 'enjoyment', and 'use in places where smoking was prohibited'.

Evaluating tobacco industry 'transformation': a proposed rubric and analysis

Some tobacco companies claim they are 'transforming' by adopting harm reduction goals or even seeking to achieve a 'smokefree' world. What characterises transformation and whether companies can or are transforming is unclear. Nevertheless, such claims are gaining traction. We critically investigated tobacco industry transformation by exploring the definition and criteria for evaluating transformation, and assessed whether transformation is occurring and feasible.Companies' transformation claims centre on increasing sales of new tobacco and nicotine products like e-cigarettes ('new products') with little attention to reducing sales of more hazardous smoked and oral products ('conventional products').We define a transforming tobacco company as one demonstrating substantial, rapid and verifiable progress towards eliminating the production and sale of conventional tobacco products within 5 years in all markets where it operates.We found no evidence any tobacco company is meeting the three essential criteria of rapidly progressing towards eliminating conventional products, ceasing to obstruct effective tobacco control measures and taking action to minimise smoking uptake and disparities. While some companies are developing new product portfolios, their actions are more consistent with profit maximisation than eliminating conventional product use. This approach is best described as 'pseudo-transformation', designed to delay implementation of effective tobacco control policies. In addition, our analysis suggests replacing conventional products with new nicotine products is unlikely to be a viable long-term business model.Public health practitioners should not rely on tobacco industry claims but should lead the transformation debate, establish credible definitions and criteria, and monitor and assess whether transformation is occurring.

Understanding the long-term policy influence strategies of the tobacco industry: two contemporary case studies

OBJECTIVE

This paper explores transnational tobacco companies' (TTCs) long-term policy influence strategies using two case studies, harm reduction and illicit tobacco, to identify lessons for the tobacco control movement and wider efforts to address the commercial determinants of health.

METHODS

Evidence from a broad combination of sources including leaked documents and findings from over two decades of TTC monitoring were reviewed for each case study and categorised using the Policy Dystopia Model, focusing on the primary discursive strategy and key instrumental (action-based) strategies used.

RESULTS

In both case studies, TTCs seek to advance their interests by engaging primarily in reputation management, coalition management and information management strategies over the long-term to propagate their over-riding discursive strategy-'we've changed, we are part of the solution'-despite clear evidence from both case studies that this is not the case. These strategies are globally coordinated and attempt primarily to reshape norms towards TTC involvement in tobacco control policy and delivery. Findings also suggest that industry denormalisation and the advent of Article 5.3 have led to the TTCs growing use of increasingly complex and opaque 'webs of influence'.

CONCLUSIONS

The tobacco control community must develop its own proactive long-term strategies which should include industry denormalisation, new ways to fund research that reduce industry control, and improved transparency measures for research and policy. These findings, including TTC adaptations to Article 5.3, also indicate the need for more structural solutions, addressing corporate power and the underlying political and economic system. These lessons can be applied to other unhealthy commodity industries.

Use of Human Induced Pluripotent Stem Cell-Derived Cardiomyocytes to Predict the Cardiotoxicity Potential of Next Generation Nicotine Products

Combustible cigarette smoking is an established risk factor for cardiovascular disease. By contrast, the cardiotoxicity potential of non-combustible next generation nicotine products (NGPs), which includes heated tobacco products (HTPs) and electronic vaping products (EVPs), and how this compares relative to combustible cigarettes is currently an area of scientific exploration. As such, there is a need for a rapid screening assay to assess this endpoint. The Cardio quickPredict is a metabolomics biomarker-based assay that uses human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CM) to screen for potential structural and functional cardiac toxicants based on the changes of four metabolites, lactic acid, arachidonic acid, thymidine, and 2'-deoxycytidine. The study aims were to investigate the cardiotoxicity potential of NGPs compared to cigarettes, in addition to nicotine. To accomplish this, hiPSC-CM were exposed to smoke or aerosol bubbled PBS samples: reference cigarette (1R6F); three variants of HTP; and three EVP variants. The 1R6F bPBS was the most active, having cardiotoxic potential at 0.3-0.6% bPBS (0.4-0.9 μg/mL nicotine), followed by HTP, which displayed cardiotoxic potential at a 10 times higher concentration, 3.3% bPBS (4.1 μg/mL nicotine). Both 1R6F and HTP bPBS (at 10-fold higher concentration than 1R6F) affected all four predictive metabolites, whereas none of the EVP bPBS samples were active in the assay up to the maximal concentration tested (10% bPBS). Nicotine tested on its own was predicted to have cardiotoxic potential at concentrations greater than 80 μg/mL, which is higher than expected physiological levels associated with combustible cigarette smoking. The application of this rapid screening assay to NGP research and the associated findings adds to the weight-of-evidence indicating that NGPs have a tobacco harm reduction potential when compared to combustible cigarettes. Additionally, this technique was shown to be sensitive and robust for the assessment of different NGPs and may be considered as part of a larger overall scientific framework for NGP assessments.

The effect of emerging tobacco related products and their toxic constituents on thrombosis

Although conventional cigarette smoking is declining, emerging tobacco related products (ETRPs) are currently gaining ground, especially among the youth. These products include electronic cigarettes, waterpipes/hookah, cigars/cigarillo, smokeless tobacco, and heat-not-burn cigarettes. The observed increase in the use of ETRPs is multifactorial and complex but appears to be mainly driven by efforts from the major tobacco companies to reinvent themselves, and present more appealing and allegedly safe(r) tobacco products. However, it is becoming apparent that these products produce substantial amounts of toxic chemicals, many of which have been shown to exert negative health effects, including in the context of the cardiovascular system. Thus, there has been research efforts, albeit limited in general, to characterize the health impact of these products on occlusive/thrombotic cardiovascular diseases (CVD). In this review, we will discuss the potential impact of ETRPs on thrombosis-based CVD. Specifically, we will review how these products and the major chemicals they produce and/or emit can trigger key players in the process of thrombosis, namely inflammation, oxidative stress, platelets, coagulation, and the vascular endothelium, and the relationship between these effects.

Experimental and Kinetic Studies on Tobacco Pyrolysis under a Wide Range of Heating Rates

In the present work, experimental and kinetic studies are conducted to explore and model tobacco pyrolysis characteristics under a wide range of heating conditions. First, thermal decomposition processes of a tobacco sample were investigated using thermogravimetric analysis/difference thermogravimetry (TGA/DTG) experiments under a wide range of heating rates (10-500 K/min), and the TGA/DTG profiles were compared to highlight the effect of heating rate on the pyrolysis characteristics. The results showed that the tobacco sample was sufficiently devolatilized at 1173.15 K (900 °C) and the final volatiles yields were not sensitive to the heating rate. Moreover, it was illustrated that the DTG curve presents a polymerization trend with the increase in heating rate. Then, kinetic parameters, including total component mass fraction, preexponential factor, and activation energy, were derived by deconvolution from TG/DTG profiles for each component with a one-step kinetic framework, and the correlations between kinetic parameters and heating rates were further explored and modeled. The results illustrated that four subpeaks can be found in the deconvolution, indicating the four components (volatile components, hemicellulose, cellulose, and lignin). In addition, the activation energy of each component was found to be insensitive with heating rate (with standard deviation less than 20%). Therefore, an average activation energy was used for each component to avoid the compensation effect and a power correlation between the heating rate and the preexponential factor could be found. A posteriori analysis also confirmed the validity of this correlation.

Novel Solvent-Free Extraction Method for Analyzing Tobacco Heating Product Aerosols: An Analytical and In Vitro Toxicological Five-Way Product Comparison

Harmful and potentially harmful constituents (HPHCs) in tobacco smoke are thought to be responsible for the increased health risks. Tobacco heating products (THPs) heat tobacco instead of burning it to achieve significantly fewer toxicants than conventional cigarettes. To assess the toxicity of THP aerosols, it is often desirable to extract the main constituents using a solvent method. In this study, we developed a high-speed centrifugal method for extracting the total particulate matter (TPM) from THPs to quantitatively compare the toxicity of different THPs and conventional cigarettes. Its TPM extraction efficiency exceeded 85%, and the primary aerosol components and typical HPHCs were comparable to those of the solvent method. The TPMs extracted from five THPs were subjected to 14 in vitro toxicology assessments, and the results were compared with those of a 3R4F reference cigarette. Physical separation can improve biases from solvent selectivity and potential interactions between solvent and aerosol constituents. By eliminating solvent influence, the extraction method could achieve high-dose exposures, enabling the toxicity comparison of different THPs. The relative toxicity of the THPs differed under different dosage units, including the TPM concentration, nicotine equivalent, and puff number.

Lifetime prevention of cardiovascular disease. Part III: young, middle, elderly and senile age

Intensive investigation of cardiovascular disease (CVD) risk factors (RFs), both traditional (smoking, dyslipidemia, diabetes, etc.) and non-traditional, which are a component of the so-called exposome, as well as their non-drug and drug correction provide wide prospects for effective cardiovascular prevention. Prevention becomes the dominant trend in cardiology and in medicine in general. The aim of the article was to describe cardiovascular prevention in young, middle, elderly and senile age. Due to the multifaceted nature of cardiovascular RFs, an integrated biopsychosocial approach, individual and population-based prevention, cumulative risk assessment of all CVDs, intersectoral collaboration and the involvement of decision-makers, are key to the success and effectiveness of prevention measures. It is important to note that, on the one hand, preventive measures should be started as early as possible due to cumulative effect of RFs, on the other hand, most of the preventive interventions for CVD are extremely relevant at all life stages.

Combined Associations of Changes in Noncombustible Nicotine or Tobacco Product and Combustible Cigarette Use Habits With Subsequent Short-Term Cardiovascular Disease Risk Among South Korean Men: A Nationwide Cohort Study

BACKGROUND

The associations of changes in noncombustible nicotine or tobacco product (NNTP) and combustible cigarette (CC) use habits with subsequent cardiovascular disease (CVD) risk are still unclear.

METHODS

The study population consisted of 5 159 538 adult men who underwent health screening examinations during both the first (2014-2015) and second (2018) health screening periods from the Korean National Health Insurance Service database. All participants were divided into continual CC-only smokers, CC and NNTP users, recent (<5 years) CC quitters without NNTP use, recent CC quitters with NNTP use, long-term (≥5 years) CC quitters without NNTP use, long-term CC quitters with NNTP use, and never smokers. Propensity score matching analysis was conducted to further compare CVD risk among CC quitters according to NNTP use. Starting from the second health screening date, participants were followed up until the date of CVD event, death, or December 31, 2019, whichever came earliest. Multivariable Cox proportional hazards regression was used to determine the adjusted hazard ratios (aHRs) and 95% CIs for CVD risk according to changes in NNTP and CC smoking habits.

RESULTS

Compared with continual CC-only smokers, CC and NNTP users (aHR, 0.83 [95% CI, 0.79-0.88]) and initial CC smokers who quit CCs and switched to NNTP use only (recent CC quitters with NNTP use, aHR, 0.81 [95% CI, 0.78-0.84]) had lower risk for CVD. After propensity score matching, recent CC quitters with NNTP use (aHR, 1.31 [95% CI, 1.01-1.70]) had higher risk for CVD than recent CC quitters without NNTP use. Similarly, compared with long-term CC quitters without NNTP use, long-term CC quitters with NNTP use (aHR, 1.70 [95% CI, 1.07-2.72]) had higher CVD risk.

CONCLUSIONS

Switching to NNTP use among initial CC smokers was associated with lower CVD risk than continued CC smoking. On CC cessation, NNTP use was associated with higher CVD risk than CC quitting without NNTPs. Compared with CC smokers who quit without NNTP use, CC quitters who use NNTPs may be at higher future CVD risk.

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda

BACKGROUND

Disparities in exposure to and density of tobacco advertising are well established; however, it is still unclear how e-cigarette and heated tobacco product (HTP) advertising vary by age, education, sex, gender identity, race/ethnicity, sexual orientation, socioeconomic status (SES), and/or urban/rural area. Through a scoping review, we sought to identify potential disparities in exposure to e-cigarette and HTP advertising and promotion across populations.

METHODS

In January 2020, a systematic literature search was conducted in five databases: PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. The search was updated in October 2020. Articles reporting on exposure to e-cigarette and/or HTP advertising and promotion across age, education, sex, gender identity, race/ethnicity, sexual orientation, SES, and/or urban/rural areas were included for full-text review (n = 25). Of those, 15 were deemed relevant for data extraction.

RESULTS

The majority of the studies were from the U.S. (n = 12) and cross-sectional (n = 14). Studies were published between 2014 and 2020 and focused on determining causal relationships that underlie disparities; only one study assessed HTP advertising and promotion. Exposure to e-cigarette and HTP advertising was assessed at the individual-level (e.g., recall seeing ads on television) and at the neighborhood-level (e.g., ad density at the point-of-sale). Studies addressed differences across age (n = 6), education (n = 2), sex (n = 6), gender identity and sexual orientation (n = 3), race/ethnicity (n = 11), SES (n = 5), and urban/rural (n = 2). The following populations were more likely to be exposed to e-cigarette advertising: youth, those with more than a high school diploma, males, sexual and gender minorities, Whites, and urban residents. At the neighborhood-level, e-cigarette advertisements were more prevalent in non-White neighborhoods.

CONCLUSIONS

Exposure to e-cigarette/HTP advertising varies based on sociodemographic characteristics, although the literature is limited especially regarding HTPs. Higher exposure among youth might increase tobacco-related disparities since it can lead to nicotine/tobacco use. Research should incorporate and apply a health equity lens from its inception to obtain data to inform the elimination of those disparities.

Tobacco, Nicotine and Health

Recent studies have explored improvements in smoking prevention and cessation to reduce smoking prevalence, however, in Europe, only Finland has already set a date to become nicotine free. Studies reporting on central, eastern and southern Europe have mostly focused on combustible cigarettes up to now. In young people, correlations were found between traditional smoking, the "vaping" of e-cigarettes, experimentation with alcohol intoxication, and the use of illicit drugs. Prevention and cessation should include strategies against active and passive exposures to new nicotine products. This is a prerequisite for a successful public health policy and a future end-game against the business interests of the tobacco industry and its allies.

Impact of chronic use of heat-not-burn cigarettes on oxidative stress, endothelial dysfunction and platelet activation: the SUR-VAPES Chronic Study

Tobacco habit still represents the leading preventable cause of morbidity and mortality worldwide. Heat-not-burn cigarettes (HNBCs) are considered as an alternative to traditional combustion cigarettes (TCCs) due to the lack of combustion and the absence of combustion-related specific toxicants. The aim of this observational study was to assess the effect of HNBC on endothelial function, oxidative stress and platelet activation in chronic adult TCC smokers and HNBC users. The results showed that both HNBC and TCC display an adverse phenotype in terms of endothelial function, oxidative stress and platelet activation. Future randomised studies are strongly warranted to confirm these data.

Comparison of IQOS (heated tobacco) and cigarette smoking on cardiac functions by two-dimensional speckle tracking echocardiography

AIMS

IQOS is a novel tobacco product claimed to be safer than conventional cigarette smoking due to the heat-not-burn system. This study aimed to evaluate the acute effects of IQOS smoking on myocardial systolic and diastolic functions and also compare the acute impacts of IQOS with cigarette smoking.

METHODS

In this prospective study, twenty-seven healthy participants who were using IQOS were included. Transthoracic echocardiography was performed three times for each participant; before smoking any tobacco product (group1), after IQOS smoking (group 2), after cigarette smoking (group3). In addition to conventional echocardiographic measurements, left ventricle (LV) and right ventricle (RV) strain analyses were performed by speckle tracking echocardiography.

RESULTS

In comparison with non-smoking status, LV global longitudinal strain (GLS) decreased after IQOS and cigarette smoking (-18.9 ± 2.4% in baseline vs. -17.9 ± 2.4% in IQOS vs. -17.9 ± 2.8% in cigarette smoking; p = 0.003, p = 0.001; respectively). LV global circumferential strain (GCS) reduced after IQOS and cigarette smoking (-19.8 ± 4.4% in baseline vs. -18.3 ± 3.9% in IQOS vs. -17.5 ± 3.9% in cigarette smoking; p = 0.005, p < 0.001; respectively). RV GLS was significantly lower in groups smoking IQOS and cigarette (-23.2 ± 4.6% in baseline vs. -21.4 ± 4.1% in IQOS vs. -19.4 ± 4.1% in cigarette smoking; p < 0.001, p = 0.001; respectively).

CONCLUSION

IQOS (heat-not-burn) tobacco smoking impairs myocardial systolic and diastolic functions in the acute phase like conventional cigarette smoking. The use of IQOS is rising among young adults in recent years, so further studies should be designed to evaluate the chronic effects of IQOS on myocardial function.