A New Front in the Tobacco Wars

Decades of research have conclusively documented the evils and devastating health effects associated with conventional cigarettes (CC), cigars, e-cigarettes (EC) and chewing tobacco. Many lawsuits have successfully been filed against tobacco companies, both by individuals and governments. Despite this, the tobacco companies refuse to give up, and have opened a new front in their war to promote smoking. Vaping is the new wonder weapon.

As cigarette sales declined, vaping – the inhaling of vapor from electronic cigarettes – was introduced and promoted as being both less dangerous than CC, and as an aid to help smokers quit CC. While this was the promise that EC held out, the tobacco companies did not stop there.

A number of unsubstantiated claims are used. Vaping is promoted as:1-3

  • a weight loss method

  • an appetite suppressant

  • a form of aromatherapy

  • a nutritional supplement

  • a way to speed up one’s metabolism

  • a vitamin delivery method

As the TV ads of the 1990s used to say, “But wait, there’s more”. Vaping, according to the tobacco companies, also provides:

  • health benefits

  • improvements to the immune system

  • better sleep

  • increased energy

The tobacco companies have been very successful in their EC campaigns, targeting youth who welcomed something “new” and “cool” and not associated with old-fashioned conventional cigarettes. The “Monitoring the Future Survey”, which tracks national substance use by adolescents in the USA, determined that vaping by this age-group increased from 11% in 2017 to 21% in 2018.4 The CDC's 2018 National Youth Tobacco Survey5,6 found that EC use increased by

  • 80 % among high school students (16.1% versus 8.2% in 2017)

  • 50 % among middle school students (from 3.5 % to 6.1 % in 2018)

Research by Lee and colleagues noted that many EC contain the biological contaminants endotoxin and glucan (found in the cell walls of most fungi), both known to cause acute and chronic respiratory problems.7

IQOS and HNB – new incarnations of tobacco

Recognizing potential health concerns, and also realizing that new government regulations will curtail their activities further, tobacco companies have refocused their attention on a different approach to tobacco. Now they offer IQOS and HNB – I-Quit-Ordinary-Smoking in which a heat-not-burn method is used to create vapor. A new technological advance allows sticks of tobacco to be gently heated to produce a nicotine-laced vapor without combustion, ash or smoke. Since the tobacco is not burnt, there are lower levels of harmful chemicals produced.

IQOS-HNB products are a sort of hybrid between EC and CC since actual tobacco, not liquid, is heated. Promoted as part of a ‘smoke-free future’, they come in two forms – an ballpoint pen-shaped device that combines holder and charger, and which can be used many times before the built-in battery needs recharging; and one that has three separate components – tobacco sticks (the so-called “Heets” or “HeatSticks”), an IQOS holder and a charger. The heater is activated by a button, and the user can then draw on the heated tobacco. When fully consumed, the heated tobacco stick has to be removed and disposed of safely.8

Variations on a theme

Continuing the HNB approach, the tobacco companies are currently introducing TEEPS8, the latest “un-cigarette”. They claim that this new product, which looks like a CC, has a pressed carbon heat source which when ignited transfers the heat to the tobacco plug allowing the tobacco to heat, not burn. The images used in TEEPS marketing replace the letters “EE” with what appears to be a mild and innocuous CC, further suggesting the look, feel and ritual associated with smoking CC.

The marketing of IQOS

Outside the USA, IQOS is marketed as a fun lifestyle product, using imagery and themes that are intended to attract children and youth. The tobacco companies sponsor youth events including beach parties and fashion shows, and use social media to attract youth.

EC usage among youth in the U.S. almost doubled in 2018 compared with 2017. That means about 1.3 million teenagers could well become nicotine-addicted users.

While the FDA has allowed limited sales of IQOS, it has restricted marketing that targets children and youth. It has also disallowed an application by the tobacco companies to market IQOS as a “modified risk tobacco product”.

The manufacturer claims that IQOS would reduce the risk of tobacco-related diseases. Because the tobacco is heated, not burned, they claim that the new HNB devices produce 95% lower levels of toxic compounds compared to conventional cigarettes (CC). This is not strictly correct: independent researchers have shown that some levels of toxic and carcinogenic compounds are lower than CC, while others are higher.9 Analysis of these claims found that “IQOS may have unexpected organ toxicity that has not been associated with cigarettes”.10,11 IQOS users showed significantly higher toxicity then EC users. While IQOS users are exposed to lower levels of some toxins they are also exposed to higher levels of other toxins – 22 substances were >200% higher and seven were more than 1000 % higher than the values on the FDA’s list of harmful and potentially harmful constituents.12 Cancer-inducing tobacco-specific nitrosamines were also detected with IQOS.13

Davis et al14 evaluated the manufacturer’s claims that IQOS heats but does not burn tobacco. They noted that thermochemical decomposition takes place resulting in charring of the tobacco and increasing the melting of the polymer-film filter even when the manufacturer’s cleaning instructions are followed. Charring increased when the device was not cleaned between HeatSticks. Further, formaldehyde was released at 90OC – a temperature considerably lower than the 350OC maximum temperature attained during normal usage. The particular form of formaldehyde released (cyanohydrin) is extremely toxic even at very low concentrations.

Comparison of nicotine products

A study to measure carbonyl emissions from IQOS products found that intense puffing did produce increased levels of formaldehyde. While these levels were three to four times lower than CC, they were higher than EC. A comparison of CC, EC and HNB found that IQOS exposure was as toxic as CC smoke exposure in causing similar cell inflamation.15

Measurements of cytotoxic effects of the three products showed that IQOS were lower than CC but higher than EC.16 Like the other two, IQOS likely increases inflammation, infections, oxidative stress and initiates both airway remodeling and epthelial changes in the airway, affecting as it does both the upper and lower airway.17 IQOS use may also have negative cardiac effects and impair flow-mediated dilation in arteries.18

Passive smoking dangers

The dangers of second-hand smoke have been well documented, and there is concern about the effects of HNB devices on the passive smoker. Researchers19 compared CC, EC and IQOS devices. They noted the difficulty raised by the different substances produced by three different products. To overcome this problem, they measured sub-micron particles (SMP) which were released both during and after use. They noted that

  • SMPs released by CC are four times greater than EC or IQOS devices

  • SMPs of CC are six-times higher than the background and persist in the air for a long time while SMPs from EC and IQOS coalesce rapidly and settle immediately

  • exposure to SMPs from electronic devices occurs only during the smoking period and is negligible when the device is turned off

  • approximately half of the deposited SMPs were small enough to reach the alveoli of passive exposed subjects

  • one hour spent with a CC, EC and IQOS was respectively equal to spending 49, 12 and 10 minutes in a heavy traffic area.

Health care professionals have a duty to warn patients of the dangers they face with tobacco, whether it is CC, EC or IQOS. It is clear and there is no safe way to inhale tobacco without risk of toxicity and disease. Reduced exposure is not reduced harm, and reduced harm does not translate into safety.

Abbreviations: CC conventional cigarettes, EC electronic cigarettes, CDC Centers of Disease Control, HNB heat not burn, IQOS I Quit Ordinary Smoking, SMP sub-micron particles

References

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  2. Mantey DS, Omega-Njemnobi O, Kelder SH. E-cigarette use is associated with intentions to lose weight among high school students. Nicotine Tob Res. 2018 Nov 19. doi: 10.1093/ntr/nty245

  3. Basáñez T, Majmundar A, Cruz TB, Allem JP, Unger JB. E-cigarettes are being marketed as "vitamin delivery" devices. Am J Public Health. 2019;109:194-196. https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2018.304804

  4. Johnston LD, Miech RA, et al. (2019). Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan.

  5. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm

  6. Miech R, Johnston L, et al. Adolescent vaping and nicotine use in 2017-2018 - U.S. national estimates. N Engl J Med 2018; 380:192-193. DOI: 10.1056/NEJMc1814130.

  7. Lee MS, Allen JG and Christiani DC. Endotoxin and (1 3)- -D-glucan contamination in electronic cigarette products sold in the United States. Environ Health Perspec, 2019; 127 (4): 047008 DOI: 10.1289/EHP3469

  8. https://www.pmi.com/smoke-free-products/iqos-our-tobacco-heating-system

  9. Sohal SS, Eapen MS et al. IQOS exposure impairs human airway cell homeostasis: direct comparison with traditional cigarette and e-cigarette. ERJ Open Research, 2019; 5 (1): 00159-2018 DOI: 10.1183/23120541.00159-2018

  10. Chun L, Moazed F et al. Possible hepatotoxicity of IQOS. Tob Control. 2018 Nov;27(Suppl 1):s39-s40. doi: 10.1136/tobaccocontrol-2018-054320.

  11. Glantz SA. Heated tobacco products: the example of IQOS. Tob Control. 2018 Nov;27(Suppl 1):s1-s6. doi: 10.1136/tobaccocontrol-2018-054601.

  12. St Helen G, Iii J, et al. IQOS: examination of Philip Morris International's claim of reduced exposure. Tob Control. 2018 Nov;27(Suppl 1):s30-s36. doi: 10.1136/tobaccocontrol-2018-054321.

  13. Leigh NJ, Palumbo MN et al. Tobacco-specific nitrosamines (TSNA) in heated tobacco product IQOS. Tob Control. 2018 Nov;27(Suppl 1):s37-s38. doi: 10.1136/tobaccocontrol-2018-054318.

  14. Davis B, Williams M, Talbot P. iQOS: evidence of pyrolysis* and release of a toxicant from plastic. Tob Control. 2019 Jan;28(1):34-41. doi: 10.1136/tobaccocontrol-2017-054104

  15. Farsalinos KE, Yannovits N, et al. Carbonyl emissions from a novel heated tobacco product (IQOS): comparison with an e-cigarette and a tobacco cigarette. Addiction 2018; 113: 2099–2106.

  16. Leigh NJ, Tran PL et al. Cytotoxic effects of heated tobacco products (HTP) on human bronchial epithelial cells. Tob Control. 2018 Nov;27(Suppl 1):s26-s29. doi: 10.1136/tobaccocontrol-2018-054317

  17. Sohal SS, Eapen MS et al. IQOS exposure impairs human airway cell homeostasis: direct comparison with traditional cigarette and e-cigarette. ERJ Open Research, 2019; 5 (1): 00159-2018 DOI: 10.1183/23120541.00159-2018

  18. Nabavizadeh P, Liu J et al. Vascular endothelial function is impaired by aerosol from a single IQOS HeatStick to the same extent as by cigarette smoke. Tob Control. 2018 Nov;27(Suppl 1):s13-s19. doi: 10.1136/tobaccocontrol-2018-054325.

  19. Protano C, Manigrasso M et al. Second-hand smoke exposure generated by new electronic devices (IQOS® and e-cigs) and traditional cigarettes: submicron particle behaviour in human respiratory system. Ann Ig. 2016 Mar-Apr;28(2):109-12. doi: 10.7416/ai.2016.2089,