Heat Not Burn Tobacco Product-A New Global Trend: Impact of Heat-Not-Burn Tobacco Products on Public Health, a Systematic Review

Use of heated tobacco products by people with chronic diseases: The 2019 JASTIS study

Heated tobacco products (HTPs) have become popular recently. People with chronic disease, such as diabetes, cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD) and cancer, should quit smoking for treatment and recurrence of tobacco-related diseases. However, they have difficulty in quitting smoking, and they may start HTPs use to quit smoking. The purpose of this study is to examine the use of HTPs in people with chronic disease. We used data from an internet study, the Japan Society and New Tobacco Internet Survey (JASTIS). We analyzed 9,008 respondents aged 15-73 years in 2019 using logistic regression. Current use of tobacco products was defined as use within the previous 30 days. Prevalence of current HTP use including dual use and dual use with cigarettes was 9.0% and 6.1% respectively in total. By disease: hypertension 10.2% and 7.4%, diabetes 15.9% and 12.3%, CVD 19.2% and 15.7%, COPD 40.5% and 33.3%, and cancer 17.5% and 11.9%. Diabetes, CVD, COPD, and cancer were positively associated with current use of HTPs (odds ratios (ORs) and 95% confidence intervals (CIs): 1.48 (1.06, 2.07), 2.29 (1.38, 3.80), 3.97(1.73, 9.11), and 3.58(1.99, 6.44), respectively) and dual use of cigarettes and HTPs (ORs and 95% CIs: 2.23 (1.61, 3.09), 3.58 (2.29, 5.60), 7.46 (3.76, 14.80), and 2.57 (1.46, 4.55), respectively) after adjusting for confounders. People with chronic disease were more likely to use HTPs and HTPs together with cigarettes. Further research on the smoking situation of HTPs in patients with chronic diseases is necessary.

Heat-not-burn tobacco (IQOS), oral fibroblasts and keratinocytes: cytotoxicity, morphological analysis, apoptosis and cellular cycle. An in vitro study

OBJECTIVES

The aim of this work is to investigate the biological effects of IQOS smoking on human gingival fibroblasts and human keratinocytes analysing cell viability, morphology, migration, apoptosis and cell cycle.

BACKGROUND

Electronic cigarettes and tobacco heating systems have been marketed to reduce smoking damages caused by combustion.

METHODS

Human gingival fibroblasts and human keratinocytes viability was determined by a colorimetric assay measuring mitochondrial dehydrogenase activity (MTT assay); after an in vitro exposure of 24 h, cell morphology was analysed with scanning electron microscope and cell migration was tested by Scratch assay, a method to mimic the migration of the cells during wound healing in vivo. Apoptosis and cell cycle were analysed with flow cytometry, and the expression of related genes (p53, Bcl2, p16 and p21) was indagated using real-time polymerase chain reaction.

RESULTS

IQOS extracts increased both cell viability (23%-41% with fibroblasts and 30%-79% with keratinocytes) and migration. No morphological alterations were observed. IQOS extracts did not induced an increase in cell death, but rose the number of S- and G2/M-phase cells. IQOS extracts also significantly increased p53 expression by fibroblasts (undiluted and 6.25% dilution, 2- and 3.6-fold higher, respectively) and reduced both Bcl2 (about two- and fivefold, respectively) and p21 expressions (about twofold with both extracts), while on keratinocytes both undiluted and 6.25% dilution extracts increased Bcl2 expression (about four- and threefold higher, respectively) and reduced p53 expression (about two- and fivefold, respectively).

CONCLUSION

IQOS smoke seemed to induce proliferation as highlighted by a viability assay, and migration and cell cycle analysis. The increased cell proliferation induced by IQOS devices must be carefully investigated for its possible clinical effects on oral cell populations.

The association between heated tobacco product use and cigarette cessation outcomes among youth smokers: A prospective cohort study

INTRODUCTION

The U.S. Food and Drug Administration authorized the marketing of heated tobacco products (HTPs) with modified-risk information for adults on July 7, 2020. However, the effects of HTP use on cigarette cessation among youth smokers remain unclear. This study aimed to explore the association of HTP use with cigarette abstinence and cessation outcomes among youth smokers in Hong Kong who were willing to receive telephone counseling for smoking cessation.

METHODS

This prospective cohort study included youth smokers aged ≤25 years who were enrolled in the Hong Kong Youth Quitline service. From December 1, 2016, to September 30, 2019, this study identified as HTP users 106 youth cigarette smokers who reported using HTPs on at least 1 of the past 30 days at enrollment, and identified as non-HTP users 473 smokers who reported smoking at least one conventional cigarette in the past 30 days and never using HTPs. The participants received follow-ups at 1 week and 1-, 3-, and 6-months postenrollment. The primary outcome was self-reported 7-day point prevalence of cigarette abstinence (PPA) at the 6-month follow-up. Secondary outcomes included reduction in cigarette smoking (excluding quitters), the number of cessation attempts, and the level of readiness to quit.

RESULTS

The self-reported 7-day PPA was statistically significantly lower among HTP users than among non-HTP users after 6 months (19.0% vs. 34.2%; p = 0.009), with an adjusted relative risk of 0.47 (95% confidence interval: 0.24-0.91; p = 0.03). The study identified no significant differences in secondary outcomes between the two groups.

CONCLUSIONS

Youth HTP users were less likely to abstain from tobacco use than their non-HTP-using counterparts. These results suggest that HTPs should not be promoted as smoking cessation or reduction aids among the youth population.

Adolescent Use of and Susceptibility to Heated Tobacco Products

BACKGROUND AND OBJECTIVES

A leading brand of heated tobacco products (HTPs), IQOS, was authorized to be sold in the United States in 2019. Researchers have examined the awareness and use of HTPs among US adults. In this study, we examined high school students' awareness, use, and susceptibility pertaining to HTPs.

METHODS

A large, cross-sectional population survey of randomly sampled 10th- and 12th-graders in California (N = 150 516) was conducted online during school hours from September 2019 to March 2020.

RESULTS

Overall, 8.9% (95% confidence interval [CI], 8.7%-9.1%) of California high school students had heard of HTPs. Approximately 0.67% (95% CI, 0.61%-0.73%) had ever tried HTPs, and 0.20% (95% CI, 0.17%-0.23%) were current users (ie, ∼30% of ever users continued to use HTPs at the time of survey). Among those who never tried HTPs, 18.3% (95% CI, 17.9%-18.8%) were susceptible to future use. The susceptibility to HTP use was greater among users of cigarettes or e-cigarettes than among nonusers.

CONCLUSIONS

The awareness of HTPs among adolescents was remarkable given the low availability of products at the time of survey. Only a small percentage of adolescents experimented with HTPs. However, almost a third of those who had experimented with HTPs continued to use them. This high ratio and the fact that almost 1 out of 5 never users were susceptible to future HTP use should put the public health community on high alert as more HTP products are coming into the market, with promotion of these products likely to increase.

Comprehensive Air Quality Assessment of the Tobacco Heating System 2.2 under Simulated Indoor Environments

Despite the growing popularity of heated tobacco products, there are few comprehensive studies on their environmental aerosols. Therefore, the impact of the Tobacco Heating System 2.2 (THS 2.2) on indoor air quality was evaluated on the basis of a comprehensive list of 31 airborne constituents along with targeted screening of the gas–vapor and particulate phases of the environmental aerosol. The assessments were conducted at three ventilation rates. Indoor use of THS 2.2 increased the levels of nicotine, acetaldehyde, glycerin, and (if mentholated products were used) menthol relative to background levels, with a corresponding increase in total volatile organic compounds (TVOC) values. Moreover, a temporary increase in ultrafine particles was observed when two or more tobacco sticks were used simultaneously or with a short time lapse between usages, but the concentrations returned to close to background levels almost immediately. This is because THS 2.2 generates an aerosol of liquid droplets, which evaporate quickly. Nicotine, acetaldehyde, glycerin, and TVOC levels were measured in the low μg/m3 range and were below the existing guideline limits. A comparison of airborne constituent levels during indoor THS 2.2 use with emissions from combustion products and common everyday activities revealed a substantially lower impact of THS 2.2 on the indoor environment.

Assessment of IQOS Marketing Strategies at Points-of-Sale in Israel at a Time of Regulatory Transition

INTRODUCTION

IQOS, a tobacco heating system, and accompanying tobacco sticks (HEETS) entered the Israeli market in 2016, prior to rapid regulatory change. This study assessed IQOS marketing strategies and regulatory compliance at IQOS/HEETS point-of-sale (POS) in Israel in December 17, 2019-January 7, 2020, after the ban on advertisement went into effect in March 8, 2019.

METHODS

Research staff audited 80 randomly-selected IQOS/HEETS POS in 4 cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data was linked to neighbourhood characteristics, including socioeconomic status (SES), ethnicity, and proximity (under 300 meters) to schools.

RESULTS

Almost half of the stores (48.7%) were convenience stores. HEETS were visible to the customers in 46.1% of POS, 35% carried at least four HEETS colours, 20.0% had IQOS/HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was 8.7 USD (range: 7.5-11.3 USD), 27% more than the least expensive cigarette pack, and 39% less than the most expensive cigarette. HEETS promotions were uncommon. Compliance with the newly-introduced advertisement ban was fairly high for HEETS (94.8%). Only one POS was located in a low-SES area; 68.7% were in close proximity to a school.

CONCLUSION

The relatively limited IQOS/HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher SES populations, as indicated by pricing and POS neighbourhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research.

IMPLICATIONS

Globally, the point-of-sale is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the point-of-sale provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS/HEETS marketing at point-of-sale suggests that primary marketing strategies may shift to online or other forms/channels as regulatory contexts become more progressive/restrictive. Ongoing surveillance of IQOS via online marketing and point-of-sales, specifically with regard to product placement and proximity to schools, is needed.

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.

A newly developed aerosol exposure apparatus for heated tobacco products for in vivo experiments can deliver both particles and gas phase with high recovery and depicts the time-dependent variation in nicotine metabolites in mouse urine

INTRODUCTION

There is no standardized aerosol exposure apparatus to deliver heated tobacco products (HTPs) for in vivo experiments. Therefore, we developed a novel HTPs aerosol exposure apparatus for mice and demonstrated that nicotine and other chemicals in HTPs aerosol generated by the apparatus can be delivered to mice which replicate human smoke.

METHODS

The amounts of nicotine, tar, and carbon monoxide (CO) in IQOS (Marlboro Regular HeatSticks™) aerosol generated by two types of apparatuses were determined. C57BL/6N mice were exposed to IQOS aerosol, followed by determination of the urinary nicotine metabolites. Further, the skin surface temperature of mice was monitored to confirm the vasoconstriction action of nicotine.

RESULTS

The amounts of chemicals in IQOS aerosol by the novel air push-in inhalation apparatus for HTPs (APIA) was equivalent to that of the analytical vaping machine (LM4E) [1.60 ± 0.08 (APIA) vs 1.46 ± 0.07 mg/stick (LM4E) in nicotine and 0.55 ± 0.04 (APIA) vs 0.45 ± 0.01 mg/stick (LM4E) in CO]. After mice were exposed to IQOS aerosol by APIA, the urinary nicotine metabolites levels were determined; peak values in cotinine and 3-hydroxycotinine were 6.82 μg/mg creatinine at 1 h after exposure and 32.9 μg/mg creatinine at 2 h after exposure, respectively. The skin surface temperature decreased and was lower (33.5°C ± 0.5°C) at 30 min than before exposure (37.6°C ± 0.8°C).

CONCLUSIONS

The new apparatus for HTPs aerosol exposure to mice showed good performances in terms of both chemical analysis of collected aerosol and fluctuations in the urinary nicotine metabolites.

Alternative tobacco products use and its impact on urologic health - will the lesser evil still be evil? A commentary and review of literature

INTRODUCTION

Alternative tobacco products, including electronic cigarettes (e-cigarettes) and non-combustible tobacco products or heat-not-burn (HNB) products, are substitutes to conventional combustible cigarettes with the potential to impact urologic health, similar to traditional smoking. Most urologists, however, have limited knowledge of these products and are unfamiliar with their potential health implications. We conducted a review to assess the impact of e-cigarettes and HNB products on urologic health.

MATERIAL AND METHODS

A bibliographic search covering the period up to April, 2021 was conducted using MEDLINE®/PubMed® and Google Scholar. Articles were reviewed and categorized based on the potential impact on erectile dysfunction, semen quality, lower urinary tract symptoms, genitourinary malignancies, and smoking cessation. Data were extracted, analyzed and summarized.

RESULTS

Mature data on the long-term impact of e-cigarette and HNB product use on urologic health are lacking. E-cigarette and HNB vapors appear to contain decreased concentrations of chemicals responsible for erectile dysfunction compared to tobacco smoke but may play a role through endothelial damage. Use of e-cigarettes is associated with lower sperm counts. No definitive data has shown a link between e-cigarette or HNB product use and lower urinary tract symptoms. Multiple carcinogens including those specifically linked to bladder cancer have been identified in the urine of e-cigarette and HNB product users. Limited data suggest e-cigarettes may aid in smoking cessation.

CONCLUSIONS

Urologists may benefit from understanding the urologic health concerns surrounding e-cigarettes and HNB product use and patients may benefit from being properly educated.

Categorizing IQOS-Related Twitter Discussions

(1) Background: The heated tobacco product IQOS, by Philip Morris International, is now available in over 55 countries, including the United States. Social media sites such as Twitter are often used to promote or discuss tobacco products, though prior research has not examined how IQOS is presented on Twitter. (2) Methods: This study collected and categorized Twitter conversations involving IQOS. A manual content analysis was performed on N = 3916 English tweets related to IQOS published internationally between 1 January 2020 and 30 June 2020. (3) Results: Most tweets were either online marketing for IQOS (32.3%) or personal testimonials related to IQOS use (34.2%). Personal testimonial tweets made harm reduction claims about IQOS either as an avenue to quit smoking/tobacco use (3.4%), or in comparison to combustible cigarettes (2.0%). Tobacco policy-related tweets were detected (13.9%), split between discussions of United States (4.9%) and international (4.4%) policies. News media tweets (14.2%) were also detected. (4) Conclusions: Our study suggests IQOS may be understood as a less harmful alternative to vaping and combustible cigarettes. Discussions also suggest IQOS is likely to be used to avoid clean air policies or used in areas in which smoking is restricted.

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.

Heated tobacco product awareness, use, and perceptions in a sample of young adults in the U.S

SIGNIFICANCE

The emergence of heated tobacco products (HTPs) in the US marks a critical time for identifying those most likely to use, particularly among young adults.

METHODS

We analyzed Fall 2019 data from a longitudinal study of young adults (ages 18-34; n=2,375, Mage=24.66±4.68) in 6 US cities, 24.1% of whom used cigarettes and 32.7% e-cigarettes. We assessed HTP awareness, use, and sources, as well as perceived risk, social acceptability, and likelihood of future use.

RESULTS

In this sample, 9.7% (n=230) heard of HTPs, 3.5% (n=84) ever used them, and 2.4% (n=56) reported past-year purchases (tobacco shops, 66.1%; traditional retailers, 60.7%; online, 39.3%; IQOS specialty stores, 35.7%). In multivariable analyses, having heard of HTPs correlated with being older, male, and current cigarette and e-cigarette users; among those ever hearing of them, using HTPs correlated with being non-Hispanic and current cigarette and e-cigarette users. Greater likelihood of future use correlated with being older, male, sexual minority, non-Hispanic, and current cigarette and e-cigarette users. Among past-month users (n=78), the average number of days used was 5.48 (SD=5.54). Past-month cigarette and e-cigarette users, respectively, who tried HTPs were more likely to report consistent or more frequent use of their respective product than a year ago (p's<.001). HTPs were perceived as less addictive than cigarettes, smokeless tobacco, and e-cigarettes, and less harmful and more socially acceptable than other tobacco products except e-cigarettes and hookah.

CONCLUSIONS

The relatively positive perceptions of HTPs and access via various channels underscores potential penetration of HTPs among US young adults.

Associations between electronic cigarette use and quitting behaviours among South African adult smokers

BACKGROUND

The South African Medicines Control Council classifies e-cigarettes as Schedule 3 substances and requires them to be dispensed only within pharmacies. e-Cigarettes are however ubiquitous and are marketed as cessation aids. We investigated the relationship between e-cigarette use and smoking cessation among South African adult smokers.

METHODS

Data came from a 2018 web survey of South African adults aged ≥18 years (n=18 208). Cessation-related attitudes and behaviours were assessed. Using multivariable logistic regression, we measured the association between e-cigarette use and cessation behaviours among ever-established combustible tobacco smokers who tried to quit.

FINDINGS

Among current combustible smokers, more e-cigarette ever versus never users believed e-cigarettes could assist smokers to completely quit (35.5% vs 20.4%) or cut down (51.7% vs 26.5%) (all p<0.05). Among ever-established smokers, the odds of sustained quitting at the 12-month mark were lower among those who used e-cigarettes once off/rarely (adjusted OR (AOR)=0.20, 95% CI=0.16-0.24), former e-cigarette users (AOR=0.30, 95% CI=0.24-0.38) and current e-cigarette users (AOR=0.23, 95% CI=0.18-0.29), compared with never e-cigarette users. Among ever-established smokers who had ever tried to quit, 53.6% relapsed into smoking after quitting for any length of time. The odds of relapsing among ever-established smokers who had made a quit attempt and had a quit intention were higher among those who used e-cigarettes once off/rarely (AOR=2.66; 95% CI=2.31-3.08), former e-cigarette users (AOR=1.41; 95% CI=1.18-1.69) and current e-cigarette users (AOR=1.85; 95% CI=1.55-2.22) than never e-cigarette users.

CONCLUSION

e-Cigarette use depressed long-term cessation. These findings can inform restrictions on unsubstantiated claims of e-cigarettes as cessation aids within South Africa.

Exposure Assessment of Environmental Tobacco Aerosol from Heated Tobacco Products: Nicotine and PM Exposures under Two Limited Conditions

It is too early to provide a clear answer on the impact of exposure to the second-hand aerosol of heated tobacco products (HTPs) in the planning of policy for smoke-free indoors legislation. Here, we conducted a preliminary study to evaluate indoor air quality with the use of HTPs. We first measured the concentration of nicotine and particulate matter (PM_2.5) in the air following 50 puffs in the use of HTPs or cigarettes in a small shower cubicle. We then measured these concentrations in comparison with the use equivalent of smoking 5.4 cigarettes per hour in a 25 m³ room, as a typical indoor environment test condition. In the shower cubicle test, nicotine concentrations in indoor air using three types of HTP, namely IQOS, glo, and ploomTECH, were 25.9–257 μg/m³. These values all exceed the upper bound of the range of tolerable concentration without health concerns, namely 3 µg/m³. In particular, the indoor PM_2.5 concentration of about 300 to 500 μg/m³ using IQOS or glo in the shower cubicle is hazardous. In the 25 m³ room test, in contrast, nicotine concentrations in indoor air with the three types of HTP did not exceed 3 μg/m³. PM_2.5 concentrations were below the standard value of 15 μg/m³ per year for IQOS and ploomTECH, but were slightly high for glo, with some measurements exceeding 100 μg/m³. These results do not negate the inclusion of HTPs within a regulatory framework for indoor tolerable use from exposure to HTP aerosol, unlike cigarette smoke.

Acute Eosinophilic Pneumonia Induced by Switching from Conventional Cigarette Smoking to Heated Tobacco Product Smoking

Acute eosinophilic pneumonia (AEP) is an acute respiratory illness with diffuse pulmonary infiltrates and pulmonary eosinophilia. While the etiology of AEP remains unclear, a relationship between cigarette smoking and AEP onset has been suggested. The use of heated tobacco products (HTPs) has been growing, but the impact of these products on our health is not fully understood. We herein report a case of AEP that developed after switching from conventional cigarette to HTP smoking. The patient's condition improved after the cessation of HTP smoking and corticosteroid treatment initiation. In cases of AEP, physicians should consider HTPs use as a possible cause.

Unboxed: US Young Adult Tobacco Users' Responses to a New Heated Tobacco Product

The heated tobacco product (HTP) IQOS was authorized for sale in the US in 2019. We investigated how young adults with experience using multiple tobacco products reacted to, perceived, and developed interest in IQOS, informing policies that might prevent HTPs from becoming ubiquitous. We used a novel qualitative method in which 33 young adult tobacco users in California (fall 2019) "unboxed" an IQOS device, tobacco sticks, and marketing materials and narrated their impressions and opinions. We conducted content and thematic analyses of participants' reactions, sensory experiences, and interest. Multiple attributes influenced appeal for participants, including sleek electronic design, novel technology, perceived harmfulness, complexity, and high cost. The "no smoke" claim and heating technology suggested that smoking IQOS was safer than smoking cigarettes. Public health programs should closely monitor HTP marketing and uptake, particularly as "reduced exposure" claims were authorized in July 2020. Evidence-based regulations (e.g., requiring plain packaging for tobacco sticks), actions addressing IQOS' unique attributes (e.g., regulating device packaging to reduce high-tech appeal), and public education might help to counter the appeal generated by potentially misleading IQOS marketing tactics.

Comparative and cumulative quantitative risk assessments on a novel heated tobacco product versus the 3R4F reference cigarette

Novel tobacco products that heat rather than burn tobacco (heated tobacco products or HTPs) have been shown to produce lower levels of harmful and potentially harmful constituents than conventional combusted cigarettes. The present study uses a quantitative risk assessment approach to compare non-cancer and cancer risk estimates for emissions generated by an HTP with smoke from a reference cigarette (3R4F). Fifty-four analytes were evaluated from the HTP aerosol and the 3R4F cigarette smoke. Emissions were generated using the ISO and the Health Canada Intense smoking regimes. The measured values were extrapolated to define a conservative exposure assumption for per day use and lifetime use based on an estimated maximum usage level of 400 puffs per day i.e., approximately 8 HTP tobacco capsules or 40 combustible cigarettes. Non-cancer and cancer risk estimates were calculated using these exposure assumptions for individual and per health outcome domains based on toxicological reference values derived by regulatory and/or public health agencies. The results of this assessment showed a reduction of non-cancer and cancer risk estimates by more than 90 % for the HTP versus the 3R4F cigarette, regardless of the smoking regime.

The Impact of Heated Tobacco Products on Smoking Cessation, Tobacco Use, and Tobacco Sales in South Korea

Heated tobacco products (HTPs), a hybrid between conventional and electronic cigarettes, were first launched in South Korea in June 2017. Owing to advertisements stating that HTPs are odorless, tar-free, and less harmful to health, the sales of HTPs have grown quickly enough to account for about 10% of the total tobacco market in a year. HTP use by young, highly educated, and high-income groups had a significant impact on both the overall tobacco market over the past 3 years and the smoking and quitting behaviors of smokers. Based on national smoking rate statistics, tobacco sales trends, and the number of visitors to smoking cessation clinics, the following changes have been identified: (1) The decline in current smoking rates has slowed or rose in some groups. (2) The decline in total cigarette sales has slowed but rose again in the first quarter of 2020. (3) The number of visitors to smoking cessation clinics decreased just after the advent of HTPs. These results may be due to the insufficient support of tobacco regulation policies but also coincide chronologically with the appearance of HTPs in South Korea. It is necessary to investigate the usage rate of various tobacco products, including HTPs and e-cigarettes, to examine the health risks of novel tobacco products and provide accurate information to users and policymakers. Finally, tobacco companies are continuously developing new product concepts to escape the regulation of existing cigarettes; thus, comprehensive management measures for all nicotine-containing products are needed.

Could E-cigarette vaping contribute to heart disease?

INTRODUCTION

E-cigarettes have become a controversial topic. While their benefits are questioned by the scientific community, a part of the medical profession is still supporting them as an effective harm reduction tool for smoking cessation. The impact of E-cigarettes on the cardiovascular system is still elusive.

AREAS COVERED

We assessed results from animal, pre(clinical), and epidemiological studies to critically evaluate and synthesize evidence relevant to the cardiovascular effects of E-cigarettes. Animal studies have demonstrated that E-cigarette vapor exposure can cause endothelial and cardiac dysfunction. However, there have also been reports on the less harmful effects of E-cigarette vapor exposure in comparison to classical tobacco cigarettes. Measurements of flow-mediated dilation in acute human exposure settings have mostly demonstrated that E-cigarettes cause vascular endothelial dysfunction. Epidemiological studies have shown that E-cigarette use is associated with an increased risk for cardiovascular disease, although switching from classical tobacco cigarettes to E-cigarettes can have beneficial cardiovascular effects. Misinterpretation of scientific data by activists on either side is another problem.

EXPERT OPINION

In conclusion, we need more and better (pre)clinical data comparing the health effects of E-cigarette vaping as compared with tobacco cigarette smoking, in order to counsel the legislation for better health policies.

Comparative Indoor Pollution from Glo, Iqos, and Juul, Using Traditional Combustion Cigarettes as Benchmark: Evidence from the Randomized SUR-VAPES AIR Trial

Modified risk products (MRP) such as electronic vaping cigarettes (EVC) and heat-not-burn cigarettes (HNBC) are appealing alternatives to combustion cigarettes. Limited between- and within-device comparative data are available on MRP. We aimed at comparing indoor particulate matter (PM) emissions measured in a randomized trial enforcing standardized smoking sessions, testing different devices and flavors of MRP, using traditional combustion cigarettes (TCC) as benchmark. Overall, MRP yielded significantly lower levels of indoor PM in comparison to TCC (with median PM levels during smoking for MRP < 100 μg/m³, and for TCC > 1000 μg/m³). Despite this, significant differences among MRP were found, with Iqos appearing associated with a significantly lower burden of emissions for all the monitored fractions of PM, including total PM (all p < 0.05). Precisely, during use, PM ≤1 µm (PM₁) emissions were 28 (16; 28) μg/m³ for Glo, 25 (15; 57) μg/m³ for Iqos, and 73 (15; 559) μg/m³ for Juul (p < 0.001 for Glo vs. Iqos, p < 0.001 for Glo vs. Juul, and p = 0.045 for Iqos vs. Juul). Exploratory within-MRP analyses suggested significant differences between flavors, favoring, for instance, Ultramarine for Glo, Bronze for Iqos, and Mango for Juul, even if results varied substantially according to individual smoker. In conclusion, leading MRP have significantly less intense and persistent effects on indoor pollution in comparison to TCC. Yet, when focusing solely on MRP, between-product and between-flavor differences appear, with quantitative estimates suggesting lower polluting effects with Iqos. These results, if confirmed externally, could be used to individualize product and flavor choice to minimize the untoward effects of EVC and HNBC on indoor pollution.

Evaluation of the Opinions of Family Physicians on Some Tobacco Products

This study aimed to evaluate the opinions of family physicians, who have an important place in preventive health services, on some tobacco products. The sample of the descriptive study was composed of family physicians working in 408 family health centers serving Samsun, Turkey. The data were obtained by distributing a questionnaire prepared by the researchers to volunteer family physicians during in-service trainings organized by the Samsun Provincial Directorate of Health in February and March 2019. In all, 322 (79%) family physicians who participated in the trainings were included in the study. The average age of the participating physicians was 45.0 ± 7.6 years; 61.5% of them were male. More than one third (36.0%) of family physicians said that they had never smoked, while 23.6% of them were current smokers. Most (85.0%) said that they knew what an electronic cigarette was, 94.7% of them were familiar with hookahs, and 9.0% knew about I Quit Ordinary Smoking (IQOS). It is important to inform all healthcare professionals, and especially family physicians, about those products marketed by the tobacco industry as "less harmful" than cigarettes. It is thought that providing appropriate counseling services to these professionals will contribute to the fight against tobacco use.

Pharmacological Approach to Smoking Cessation: An Updated Review for Daily Clinical Practice

Tobacco use is one of the major public health concerns and it is the most preventable cause of morbidity and mortality worldwide. Smoking cessation reduces subsequent cardiovascular events and mortality. Smoking is a real chronic disorder characterized by the development of an addiction status mainly due to nicotine. This condition makes the smokers generally unable to quit smoking without help. Different strategies are available to treat smoking dependence that include both non-pharmacological (behavioral counselling) and pharmacological therapies. Currently, it is well accepted that smoking cessation drugs are effective and safe in real-world settings. Nicotine replacement therapy (NRT), varenicline, bupropion and cytisine are the main pharmacological strategies available for smoking cessation. Their efficacy and safety have been proved even in patients with chronic cardiovascular disease. Each of these drugs has peculiar characteristics and the clinician should customize the smoking cessation strategy based on currently available scientific evidence and patient's preference, paying particular attention to those patients having specific cardiovascular and psychiatric comorbidities. The present document aims to summarize the current viable pharmacological strategies for smoking cessation, also discussing the controversial issue regarding the use of alternative tobacco products, in order to provide useful practical indications to all physicians, mainly to those involved in cardiovascular prevention.

Vaping Cardiovascular Health Risks: an Updated Umbrella Review

Purpose of Review

Modified risk products (MRP) such as electronic vaping cigarettes (EVC) and heat-not-burn cigarettes (HNBC) are alternatives to traditional combustion cigarettes (TCC) with an expanding consumer base. Yet, their cardiovascular health risks are still unclear. We aimed to summarize the evidence base on this topic by conducting an updated umbrella review.

Recent Findings

We identified 7 systematic reviews, totaling 183 studies and reports, ranging from in vitro and in animal studies to clinical studies in apparently healthy volunteers and patients at risk of cardiovascular disease. Overall, acute EVC use was associated with several toxic effects at molecular, cellular, tissue, organ, and system level. In addition, EVC impacted adversely on blood pressure (BP) management, caused tachycardia, and worsened arterial stiffness. Finally, EVC use was associated with an increased risk of adverse clinical events, including atrial fibrillation and myocardial infarction, even if the causal link is still debated. Most reviews highlighted that the detrimental impact of EVC was of lesser magnitude of that of TCC. In addition, the differential impact of liquids and nicotine was not clearly disentangled. Finally, no review included studies on HNBC.

Summary

The present umbrella review suggests that EVC, and likely HNBC, despite clearly causing an increase in overall cardiovascular risk, may represent a temporary lesser evil than TCC in a risk-reduction or risk-modification strategy, aiming for eventual abstinence from all tobacco or nicotine products.

[E-cigarettes: toxicological fiasco or better than not giving up smoking?]

E‑cigarettes are increasingly used to replace tobacco cigarettes and to stop smoking, but mainly in the sense of dual use. There is lively debate about the assessment of the health risks of e‑cigarettes, but so far there are no comprehensive data for direct comparison with tobacco cigarettes. Other points of controversy include the potential for smoking cessation and the risk of moving from e‑cigarettes to tobacco cigarettes (gateway hypothesis). The present overview comes to the conclusion that, in accordance with the health policy already largely implemented in Great Britain, e‑cigarettes represent a greatly reduced health risk compared with tobacco cigarettes and are certainly suitable for giving up smoking.

Comparing Factors Related to Any Conventional Cigarette Smokers, Exclusive New Alternative Product Users, and Non-Users among Japanese Youth: A Nationwide Survey

The impact of heated-tobacco-products (HTPs) and electronic cigarettes (e-cigarettes) on youth is a controversial public health issue, as it is unknown whether alternative products result in more youth using such products or smoking. In Japan, e-cigarettes with nicotine are prohibited, but e-cigarettes without nicotine are available. HTPs are marketed as tobacco products. Within this unique context, we aimed to compare any conventional cigarette smokers (including those who also used alternative products) with exclusive users of alternative products and examine factors relating to their use in Japan. In 2017, 22,275 students in grades 7–9 (age 12–15) and 42,142 in grades 10–12 (age 15–18) nationwide were surveyed. Overall, 1.8% were current users of any of the three products over the last month. Multivariable analysis revealed that risk factors for alternative product use were the same as those for cigarette use. Among all users, exclusive new product users were more likely to participate in club activities and intend to continue to higher education; any conventional cigarette users (including those who also used alternative products) were more likely to be exposed to secondhand smoke at home and to drink alcohol. Reducing adult smoking and disseminating health education remain relevant as strategies for preventing adolescents’ future tobacco use.

Impact of Electronic Alternatives to Tobacco Cigarettes on Indoor Air Particular Matter Levels

An aerosol study was carried out in a test room measuring particulate matter (PM) with an aerodynamic diameter smaller than 10, 4, 2.5 and 1 µm (PM10, PM4, PM2.5, PM1) before and during the use of electronic alternatives to tobacco cigarettes (EATC) IQOS®, GLO®, JUUL®, with different kinds of sticks/pods, as well as during the smoking of a conventional tobacco cigarette. The aerosol was mainly in the PM1 size range (>95%). All studied EATCs caused lower indoor PM1 concentrations than conventional tobacco cigarettes. Nevertheless, they determined a worsening of indoor-PM1 concentration that ranged from very mild for JUUL®-depending on the pod used-to considerably severe for IQOS® and GLO®. Median values ranged from 11.00 (Iqos3 and Juul2) to 337.5 µg m-3 (Iqos4). The high variability of particle loadings was attributed both to the type of stick/pod used and to the different way of smoking of volunteers who smoked/vaped during the experiments. Moreover, during vaping IQOS® and GLO® indoor PM1 concentrations reach levels by far higher than outdoor concentrations that range from 14 to 21 µg m-3, especially during the exhalation of the smoke. From these results emerge an urgent need of a legislative regulation limiting the use of such devices in public places.