USE AND AWARENESS OF HEATED TOBACCO PRODUCTS IN EUROPE

A reduced exposure heated tobacco product was introduced then abruptly taken off United States shelves: results from a tobacco harm reduction natural experiment

BACKGROUND

A heated tobacco product (HTP) authorized for purchase in the United States by the Food and Drug Administration as a reduced harm product was removed from the market after about 2 years of sales. Adults who used the HTP were surveyed to determine the impact of the introduction and removal of the HTP on past and current tobacco behaviors.

METHODS

Adults who were using the HTP before its United States market removal (n = 502) completed a cross-sectional online survey to determine their tobacco use behaviors at three timepoints: prior to HTP initiation, just before HTP market removal, and at the time of the survey which was administered approximately 10 months post-removal. Descriptive statistics summarized outcome variables and paired bivariate testing was used to compare percent change between timepoints. Multivariable logistic regression and general linear models estimated associations of tobacco use behaviors and cigarette consumption.

RESULTS

Overall, significantly fewer adults consumed cigarettes while using HTP than before they tried the product (63.0% vs. 89.9%, p value < 0.0001) and the number of cigarettes consumed per week (CPW) decreased (106.3-39.0, p value < 0.0001). After HTP removal, the percent of adults who consumed cigarettes increased non-significantly (63.0-67.5%, p value = 0.0544) while CPW increased significantly (39.0-76.6 CPW, p value < 0.0001). At the time of the survey, over 25% of the sample continued to use the HTP and 7.2% reported use of no tobacco products. Electronic nicotine delivery system use had increased significantly from the prior period (27.4% increase, p value < 0.0001).

CONCLUSION

This study demonstrates reduction or elimination of combustible cigarette smoking while adults were using HTPs and some increased smoking after market removal, albeit at lower levels. If unable to find satisfying alternatives, adults who smoke and transition to reduced harm products may return to smoking or purchase products illicitly if their preferred products are removed from the regulated market.

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.

Comparative evaluation of ten blood biomarkers of inflammation in regular heated tobacco users and non-smoking healthy males-a pilot study

Heated tobacco products (HTPs) are novel tobacco products that are alternatives to cigarettes. The study aimed to investigate the effect of HTPs on blood biomarkers of inflammation as well as to provide a comparative evaluation between daily heated tobacco users and healthy men who do not use nicotine products. This case-control study was carried out among 92 healthy males in Poland (Lodz-Province) aged 20-56 years: 44 daily heated tobacco users (daily use in the past 90 days) and 48 controls who do not use nicotine products. The history of use of the nicotine-containing products was self-reported and verified using a saliva cotinine test. A 20 ml blood sample was collected and the levels of ten blood biomarkers were analyzed. Among all heated tobacco users (n = 44), only the levels of interleukin 8 (IL-8) were significantly higher when compared to controls: 6.86 vs. 3.95 (p = 0.01). Among exclusive heated tobacco users (n = 33), the levels of IL-8 were also significantly higher when compared to controls: 7.76 vs. 3.95 (p = 0.01). IL-8 level was positively correlated (r = 0.37; p = 0.01) with the daily number of heated tobacco sticks. Out of 10 different biomarkers of inflammation, only IL-8 levels were significantly elevated in heated tobacco use compared to controls.

Impact of electronic cigarette and heated tobacco product on conventional smoking: an Italian prospective cohort study conducted during the COVID-19 pandemic

OBJECTIVE

Debate continues about whether electronic cigarettes (e-cigarettes) and heated tobacco products (HTP) reduce or increase the probability of smoking, with many studies compromised by stated or unstated conflicts of interest. We undertook a longitudinal study in Italy.

METHODS

3185 Italian participants aged 18-74 years provided baseline (April-May) and follow-up (November-December) responses in 2020, reporting smoking status and use of e-cigarettes and HTP. We tracked transitions over that period and reported risk ratios (RR) and corresponding 95% CIs for changes in smoking in relation to baseline use of e-cigarettes and HTPs.

RESULTS

Never cigarette smokers who used e-cigarettes at baseline were much more likely to start smoking (compared with never users, RR 8.78; 95% CI: 5.65 to 13.65) and current HTP users (RR 5.80; 95% CI: 3.65 to 9.20). Among ex-smokers, relapse (17.2%) at follow-up was more likely among e-cigarette (RR 4.25; 95% CI: 2.40 to 7.52) and HTP users (RR 3.32; 95% CI: 2.05 to 5.37). Among current smokers at baseline, those who had continued smoking at follow-up were 85.4% overall. These were more frequently current novel product users (compared with non-users, RR 1.10; 95% CI: 1.02 to 1.19 for e-cigarette users; RR 1.17; 95% CI: 1.10 to 1.23 for HTP users).

CONCLUSIONS

Both e-cigarette and HTP use predict starting smoking and relapse, and appear to reduce smoking cessation. Due to the limited sample size within specific strata, the association with quitting smoking should be confirmed by larger prospective studies. These findings do not support the use of e-cigarettes and HTPs in tobacco control as a consumer product, at least in Italy.

Awareness, Attitudes, and Concerns Regarding Heated Tobacco Products Among Physicians in Japan

BACKGROUND

New tobacco products, particularly heated tobacco products (HTPs), have been introduced across several international markets as alternatives to combustible products, such as cigarettes. However, there are limited studies on physicians' perceptions of HTPs. This study analyzes the awareness of HTPs among physicians and assesses their concerns and attitudes toward patients using HTPs.

METHODS

A self-administered questionnaire was sent to a sample of 7,500 member physicians (6,000 male and 1,500 female) from the Japan Medical Association (JMA). The smoking status of physicians was categorized as never smokers, ever HTP smokers, current HTP smokers, and ever and current smokers of other products. Physicians' awareness and attitudes toward patients using HTPs were analyzed using descriptive statistics. The correlation between the outcomes was examined using logistic regression models, whereas physicians' concerns about HTPs were analyzed using descriptive statistics.

RESULTS

Data were obtained from 5,492 physicians (21.9% women; aged 60.4; standard deviation, 12.1 years) with a response rate of 74.6%. Overall, 76.7% of the physicians had awareness of HTP, and about half of whom asked patients about using HTPs. Physicians who took longer to discuss cessation were more likely to discourage patient use. Smoking status was associated with discouraging HTP use in patients. Physicians who had experience with HTP use were primarily concerned about the products' long-term safety and less about product regulation.

CONCLUSION

Japanese physicians do not have sufficient information and knowledge about HTPs. Therefore, evidence-based guidelines are required to support physicians in advising patients against HTP use.

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.

Romanian young adult perceptions on using heated tobacco products following exposure to direct marketing methods

Heated tobacco products have a rapid uptake, especially among young people, mostly where advertising is unregulated, as is the case in Romania. This qualitative study explores the influence of direct marketing methods of heated tobacco products on young people, their perception and behaviour towards smoking. We have carried out 19 interviews with smokers of heated tobacco products (HTPs) or/and combustible cigarettes (CCs) or non-smokers (NS), aged 18-26. Using the thematic analysis, we have identified three overarching themes: (1) people, places, and subjects of marketing, (2) engagement with risk narratives and (3) social body, family bonds, and autonomous self. Even if most of the participants have been exposed to a mix of marketing methods, they did not acknowledge the influence that marketing has on their decision to experience smoking. Young adults' decision to use heated tobacco products seems to be influenced by a cluster of reasons: overcoming the legislation gap which prohibits indoor use of combustible cigarettes but not heated tobacco products; the attractivity of the product (novelty, inviting appearance, technological appeal and price) and presumed less damaging effects on health.

IQOS Use and Interest by Sociodemographic and Tobacco Behavior Characteristics among Adults in the US and Israel

Heated tobacco products (HTPs) have expanded globally. IQOS, a global HTP leader, was launched in Israel in 2016 and the US in 2019. To inform tobacco control efforts, it is critical to understand who is likely to use HTPs in different countries with distinct regulatory and marketing contexts. Thus, we conducted a cross-sectional survey among adult (ages 18-45) online panelists in the US (n = 1128) and Israel (n = 1094), oversampling tobacco users, in the fall of 2021, and used multivariable regression to identify correlates of (1) ever using IQOS; (2) past-month vs. former among ever users; and (3) interest in trying IQOS among never users. Among US adults, correlates of ever use included being Asian (aOR = 3.30) or Hispanic (aOR = 2.83) vs. White, and past-month use of cigarettes (aOR = 3.32), e-cigarettes (aOR = 2.67), and other tobacco (aOR = 3.34); in Israel, correlates included being younger (aOR = 0.97), male (aOR = 1.64), and cigarette (aOR = 4.01), e-cigarette (aOR = 1.92) and other tobacco use (aOR = 1.63). Among never users, correlates of greater interest included cigarette and e-cigarette use in the US (β = 0.57, β = 0.90) and Israel (β = 0.88, β = 0.92). IQOS use prevalence was low (US: 3.0%; Israel: 16.2%) but represented in vulnerable subpopulations (younger adults, racial/ethnic minorities).

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

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.

“It’s Like Jogging Next to the Highway”: A Qualitative Analysis of the Motivations and Experiences of Single-, Dual-, and Ex-Users of IQOS in The Netherlands

The popularity of heated tobacco products (HTPs) is of concern, as most users are dual users exposed to emissions of both HTPs and conventional cigarettes. Furthermore, HTPs may appeal to young people and non-smokers. This study aims to build intelligence on user experiences in order to inform policy development. We conducted five semi-structured focus group interviews with single-, dual-, and ex-users of the HTP IQOS. The discussions focused on initiation and use, experiences and perception, and knowledge and information needs. We performed a thematic analysis of the transcripts. All users smoked cigarettes and/or roll your own (RYO) tobacco before using HTP. We found that almost all users started using IQOS after being introduced to it by others. Single users successfully quit smoking cigarettes using the IQOS, liked the taste, and experienced physical benefits. Dual users experienced more satisfaction from smoking cigarettes and used the IQOS for specific occasions, such as social situations or in places with smoking bans. All IQOS users described themselves as smokers and considered using the IQOS as an alternative way of smoking. Regulators may consider providing reliable and easily accessible information and regulating points of sale, promotional activities, and product properties such as flavors and devices in order to reduce product attractiveness and discourage use.

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'.

European Tobacco Products Directive (TPD): current impact and future steps

Efforts to reduce the toll of tobacco-related morbidity and mortality in the European Union are spearheaded by the Tobacco Products Directive (TPD), a legal act implemented during 2016-2021, with the overall aim to reduce tobacco consumption by 2% in Europe. Within this time frame, several core tobacco control measures were implemented, the impact of which is outlined within this manuscript. Key successful legislative actions implemented in this time frame led to greater availability of information and further regulation of additives, the banning of mentholated cigarettes, enhanced pictorial package warnings and a regulatory framework for e-cigarettes. While repeated cross-sectional data indicated a 12.5% relative reduction in smoking prevalence after implementation of the TPD, the differential regulation of cigarettes and roll-your-own tobacco compared with other products, such as cigarillos, e-cigarettes and heated tobacco products, may have also led to product displacement. Moreover, as the TPD could not keep up with the ever-changing nicotine product landscape, further adaptations may be needed.

Evolution of tobacco products: recent history and future directions

Declines in cigarette smoking prevalence in many countries and the consolidation of the tobacco industry have prompted the introduction of other forms of nicotine delivery. These include electronic nicotine delivery systems (ENDS), heated tobacco products (HTPs) and oral nicotine products (ONPs). Evolving over time, some of these products now deliver nicotine at levels comparable to cigarettes and may serve as effective substitutes for smokers. However, certain products, especially ENDS like JUUL, have also appealed to youth and non-smokers, prompting concerns about expanding nicotine use (and potentially nicotine addiction). The tobacco industry could shift away from primarily promoting cigarettes to promoting ENDS, HTPs and/or ONPs, though at this time it continues to heavily promote cigarettes in low and middle-income countries. Differing regulatory regimes may place upward and downward pressures on both cigarettes and these newer products in terms of population use, and may ultimately drive the extent to which cigarettes are or are not displaced by ENDS, HTPs and/or ONPs in the coming decade.

Heated tobacco products for smoking cessation and reducing smoking prevalence

BACKGROUND

Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence.

OBJECTIVES

To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence.  SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers.  RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible.

MAIN RESULTS

We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes.  There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence.

AUTHORS' CONCLUSIONS

No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from  all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed.  The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.

[Tobacco heated products: a new challenge in tobacco control]

As cigarette sales decline, the tobacco industry has turned to the sale of heated tobacco products (HTP), which are on the rise. We are concerned with reports erroneously indicating that heated tobacco is associated with a lower risk of cancer and other diseases than conventional cigarettes, citing as a source the Food and Drug Administration (FDA) of the United States. The FDA has indeed authorized the sale of an HTP, but denies that this approval is an endorsement of the product or that it is safe. Philip Morris asked the FDA to approve this product as a "modified risk" tobacco product. However, the Agency denied that the risk to users' health was less than conventional cigarettes, despite emitting less amount of some toxicants. Spain and the European Union should end the regulatory privileges that HTPs have until now. We identified at least five aspects to improve: 1) compliance with the prohibition of HTPs use where smoking is prohibited; 2) control of the prohibition of advertising, promotion, and sponsorship of HTPs; 3) that HTPs carry the same type of labeling as cigarettes; 4) limit that HTPs have characteristic aromas; and 5) treat HTPs fiscally at the same level as cigarettes.

Awareness, use and perceptions of cigarillos, heated tobacco products and nicotine pouches: A survey among Dutch adolescents and adults

OBJECTIVES

Many tobacco and related products (TRPs) are less strictly regulated and marketed as less harmful than cigarettes. Little is known about their awareness, use, user profile, use behavior, reasons for use and risk perception, especially for the newest products. In an exploratory survey study among Dutch adolescents and adults, we have investigated three examples of non-cigarette TRPs available on the worldwide market.

METHODS

In a two-step web-based design, data on cigarillos, heated tobacco products (HTPs) and nicotine pouches were collected. In the first step (N = 5805), a representative sample (≥13 years) was studied to quantify their awareness, ever and current use in the Dutch population. In the second step (N = 526), in-depth data regarding use behavior, reasons for use and risk perception were collected among users and non-users.

RESULTS

Awareness (<50%) and use (<15% ever use and <2% current use) is relatively low for all three products, but overall higher among men, (e-)cigarette users and respondents with higher education and social economic status. Most participants became aware of the products through people they knew. Reasons for use were mainly curiosity, pleasant taste, flavour variety, and lower harmfulness. All products were perceived as (slightly) less harmful and addictive than cigarettes.

CONCLUSIONS

This study is one of the first to investigate awareness and use of cigarillos, HTPs and nicotine pouches. To prevent increased use, we recommend regulators to extend flavour and smoking bans to these products. In addition, public information may discourage use by increasing awareness of health risks.

Electronic cigarette use in 12 European countries. Results from the TackSHS survey

BACKGROUND

Limited data on electronic cigarette prevalence, patterns and settings of use are available from several European countries.

METHODS

Within the TackSHS project, a face-to-face survey was conducted in 2017-2018 in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain). Overall, 11,876 participants, representative of the population aged ≥15 years in each country, provided information on electronic cigarette.

RESULTS

2.4% (95% confidence interval, CI: 2.2-2.7) of the subjects (2.5% among men and 2.4% among women; 0.4% among never, 4.4% among current- and 6.5% among ex-smokers) reported current use of electronic cigarette, ranging from 0.6% in Spain to 7.2% in England. Of the 272 electronic cigarette users, 52.6% were dual users (i.e., users of both electronic and conventional cigarettes) and 58.8% used liquids with nicotine. In all, 65.1% reported using electronic cigarette in at least one indoor setting where smoking is forbidden, in particular in workplaces (34.9%), and bars and restaurants (41.5%). Multivariable logistic regression analysis showed that electronic cigarette use was lower among older individuals (p for trend <0.001) and higher among individuals with high level of education (p for trend 0.040). Participants from countries with higher tobacco cigarette prices more frequently reported electronic cigarette use (odds ratio 3.62; 95% CI: 1.80-7.30).

CONCLUSIONS

Considering the whole adult population of these 12 European countries, more than 8.3 million people use electronic cigarettes. The majority of users also smoked conventional cigarettes, used electronic cigarettes with nicotine and consumed electronic cigarettes in smoke-free indoor areas.

Prevalence and reasons for use of Heated Tobacco Products (HTP) in Europe: an analysis of Eurobarometer data in 28 countries

BACKGROUND

Heated Tobacco Products (HTP) are a relatively new class of tobacco products, with limited data on usage patterns. We assessed the prevalence and reasons for use among persons aged ≥15 years in 27 European Union member states and the United Kingdom·.

METHODS

The 2020 Eurobarometer (93·2) survey was analysed (n=28,300, aged ≥15). Multi-level regression analyses assessed socio-demographic differences in use while separate analyses investigated reasons for starting to use HTP. Results are presented as adjusted Odds Ratios (aOR) and weighted percentages with 95% Confidence Intervals (95%CI).

FINDINGS

Overall, 6·5% (95% CI 6·1;7·0) of participants had ever used a HTP. 1·3% (1·1%;1·5%) of participants were current users of HTP, and 0·7% (0·6% to 0·9%) daily users. Current and former tobacco smokers were more likely than never tobacco smokers to use HTP (aOR 36·3 (22·9;57·5), and 7·3 (4·3;12·3) respectively. Youth aged 15-24 years of age were substantially more likely to report use, e.g. aOR for ever use=7·77 (6·56;9·21) compared to those aged ≥55 years. 51·3% of ever HTP users reported at least weekly concurrent use of combustible tobacco. Among those who reported ever use of HTP, but not e-cigarettes, the most popular reason for use was the perception that HTP are less harmful than smoking tobacco (39·5%), followed by use by friends (28·4%) and stopping or reducing smoking (28·2%).

INTERPRETATION

Considerable numbers of people in the EU have ever used HTP, although current and daily use remains low. Current use is more common among younger people, and current and former smokers.

FUNDING

None.

Exposure to Heated Tobacco Products and Adverse Health Effects, a Systematic Review

Heated tobacco products (HTP) are a form of nicotine delivery intended to be an alternative to traditional cigarettes. HTP tobacco products are sold to consumers as a less harmful alternative to traditional cigarettes, both for users and bystanders. The actual impact of HTP on the health of users and its overall impact on public health is still not fully known. A systematic search of the literature was carried out to identify relevant studies published in English from 2015 to February 2021. The following databases were used: PubMed, Scopus, Elsevier and ClinicalKey. 25 studies (independent and sponsored by the tobacco industry) were considered. The analysis of exposure biomarkers and cardiovascular and respiratory biomarkers showed differences between smokers and people using heated tobacco products. Improvements in clinically relevant risk markers, especially cholesterol, sICAM-1, 8-epi-PGF2α, 11-DTX-B2, HDL and FEV1, were observed compared to persistent cigarette smokers. On the other hand, exposure to IQOS has been reported to alter mitochondrial function, which may further exaggerate airway inflammation, airway remodeling and lung cancer. These products have the potential to increase oxidative stress and increase respiratory tract infections by increasing microbial adherence to the respiratory tract. Our review suggests that HTP products may be products with a reduced risk of chronic diseases, including respiratory and cardiovascular diseases and cancer compared to traditional smoking, although in the case of non-smokers so far, they may pose a risk of their occurrence. Research seems to be necessary to assess the frequency of HTP use and its potential negative health effects.

The Role of Novel (Tobacco) Products on Tobacco Control in Italy

In Italy, electronic cigarettes have spread since 2010 and heated tobacco products (HTP) since 2016. We investigated their public health consequences on conventional cigarette smoking, taking advantage of a series of cross-sectional studies annually conducted between 2001 and 2019 in Italy. Every year, the sample, including around 3000 individuals, was representative of the general Italian population aged ≥15 years. In Italy, smoking prevalence steadily declined from 29.1% in 2001 to 20.6% in 2013, then increased to 22.0% in 2019. In 2017-2019, current electronic cigarette users were 2.1% and in 2019 current HTP users were 1.1%. Among 498 ever electronic cigarette users, 23.2% started or re-started smoking and 15.7% quit smoking after electronic cigarette use; of 49 ever HTP users, 19.1% started or re-started smoking combusted cigarettes and 14.6% quit smoking after HTP use. The availability of novel products in Italy resulted in a halt of the decreasing trend in smoking prevalence. For the first time, we observed an increase of Italians inhaling nicotine, concurrently with the spread of novel (tobacco) products. More importantly, the use of novel products appears to increase-rather than decrease-the likelihood of smoking conventional cigarettes. Considering this evidence, we see no argument to justify the huge fiscal and regulatory benefits these products continue to have, at least in Italy.