[Systematic analysis of the scientific literature on heated tobacco]

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.

210Po and 210Pb content in the smoke of Heated Tobacco Products versus Conventional Cigarette smoking

210Po is a radioactive component of conventional cigarette tobacco smoke and is a recognized carcinogen. Despite the expanding market of heated tobacco products, no data are available on the activity of 210Po in the smoke of IQOS Heets cigarette. We determined the 210Po activity in the mainstream smoke of thirteen cigarette brands available on the Swiss market using a smoking machine and compared the results to the 210Po activity measured in the mainstream smoke of the IQOS system. In addition, we measured the 210Po and 210Pb loss on heating after uniform heating from 50 to 600 °C for several cigarette brands and the Heets cigarettes. 13.6 ± 4.1% of 210Po activity was found in the mainstream smoke in conventional cigarette smoking (7% for 210Pb). This dropped to 1.8 ± 0.3% in the mainstream smoke of IQOS Heets. Conversely, when the tobacco was heated uniformly at 330 °C, a loss of 210Po of more than 80% was observed for all type of cigarettes. Apparently, IQOS significantly reduced the 210Po and 210Pb activities in the mainstream smoke. However, our results show that only 15% of the Heets tobacco reaches 330 °C with IQOS. While IQOS reduces the 210Po and 210Pb activities in the mainstream smoke compared to conventional cigarettes, it only heats a marginal fraction of the tobacco present in the Heets cigarette. Because smoking is an addiction (mostly due to nicotine), IQOS could possibly deliver an unsatisfactory dose of nicotine to a Heets cigarette smoker, as most of the tobacco is left unaltered.

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.

A systematic review of group therapy programs for smoking cessation in Asian countries

INTRODUCTION

Tobacco causes more than 8 million deaths each year. Behavioral interventions such as group therapy, which provides counselling for smoking cessation, can be delivered in group form and smokers who receive cessation counselling are more likely to quit smoking compared to no assistance. We review the evidence of group-based counselling for smoking cessation for smokers in Asian countries.

METHODS

The review aims to determine the availability of group-based therapy for smoking cessation in Asian countries. The outcome measured was abstinence from smoking following group therapy. Electronic database searches in PubMed, OVID Medline, SCOPUS, Google Scholar, and PsycINFO, using keywords such as: ‘smoking’, ‘cigarette’, ‘tobacco’, ‘nicotine’, ‘group therapy’ and ‘cessation’ (smok*, *cigarette*, tobacco, nicotine, group therap*, cessation) were used. The results were reported following PRISMA and PROSPERO guidelines. Review Manager was used for data analysis.

RESULTS

A total of 21251 records were retrieved for screening the abstracts. In all, 300 articles for review were identified and assessed for eligibility. Nine articles, including Cochrane reviews, randomized control trials, cohort, observational and cross-sectional studies, were included in the final review. There were three observational qualitative studies, two prospective cohort studies, two crosssectional studies, one non-randomized quasi-experimental study and a single cluster-randomized, controlled trial. Group therapy was found to significantly increase the abstinence rate. Group therapy provided at the workplace, smoking cessation services, availability of pharmacotherapy, and socioeconomic status, appear to be key factors determining success.

CONCLUSIONS

Evidence of the use of group therapy for smoking cessation in Asian countries is still lacking despite publications in the Western population showed that group therapy was effective. Further research on group-based interventions for smoking cessation in Asian countries is required and direct one-to-one comparisons between group therapy and individual therapy for smokers who want to quit smoking, are needed.

The FCTC dilemma on heated tobacco products

BACKGROUND

In October 2018, the Conference of the Parties of the Framework Convention on Tobacco Control (FCTC or Convention) adopted its first decision on novel and emerging tobacco products, including heated tobacco products (HTPs). The decision remains ambiguous, e.g. by making a distinction between tobacco sticks and HTP devices. Against this background, the article seeks to answer two interrelated questions: whether and to what extent HTPs are covered by the FCTC, and whether regime provided by the Convention is suitable for their regulation.

RESULTS

HTPs need to be classified under the FCTC as tobacco products. The distinction made by the Conference of the Parties between sticks and devices leads however to unsatisfactory results as it creates loopholes in tobacco control standards existing at the international level. A better approach, as argued in this article, is to conceptualize the notion of 'tobacco products' in functional terms as a combination of both a device and stick. While subjecting HTPs to all FCTC disciplines is, in light of our current scientific knowledge, a rational approach, such classification can be modified in the future once a sufficient amount of new evidence on their risk profile is collected. Any decision on the optimal regulatory model for HTPs will need to take into account not only health risks and potential benefits for individual users, but also the specific systemic concerns (e.g. HTPs as a gateway product). The state of scientific research is however not the only factor that will determine the fate of HTPs under the Convention. What is equally important is a conceptualization of the FCTC's objectives. If a complete eradication of the tobacco epidemic is the ultimate goal, reduced levels of risk may not be enough to justify the different (i.e. more lenient) regulatory regime for HTPs.

CONCLUSIONS

The Conference of the Parties should clarify the definition of tobacco products in light of recent changes in the market. When designing the regulatory regime for HTPs under the FCTC in the future, one has to consider not only scientific evidence but also pay attention to the objective of the Convention (or more generally to the values that underlie the current tobacco control paradigm).

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

This article investigates the effects of tobacco control policies on smoking initiation, cessation and prevalence by examining the papers published in the last 5 years. Twenty-one articles have been selected by two authors and sorted by four types of tobacco control: tobacco prices, anti-smoking campaigns for young people, mass media intervention and public smoking bans. Price/tax increase has deterrent effect on smoking initiation but does not promote smoking cessation; intervention on young people could reduce the smoking initiation if carried out at an early age and if acted on social skills and with peer-led approach, as opposed to restraining measures which hare generally easily circumvented by young people. The mass media campaigns showed positive effect on attempts to quit among smokers if carried forward over time and by involving multiple communication channels (TV, internet, radio). The bans in public have little effect on smoking cessation but could improve the overall well-being of non-smokers. Heterogeneous results have been described by different studies probably because of different research methodologies, cultural aspects and the really effective implementation of the rules for each country. In conclusion, comprehensive tobacco control interventions to reduce smoking prevalence and modify the smoking behavior are recommended. Moreover, the use of e-cigarettes and heat-not-burn (HnB) products, as possible helping tool for smoke cessation, currently remains controversial.

Perceptions of Harmfulness of Heated Tobacco Products Compared to Combustible Cigarettes among Adult Smokers in Japan: Findings from the 2018 ITC Japan Survey

In Japan, the tobacco industry promotes heated tobacco products (HTPs) as a reduced-risk tobacco product. This study examines: (1) smokers' harm perceptions of HTPs relative to combustible cigarettes; (2) differences in relative harm perceptions between exclusive smokers and smokers who use HTPs (concurrent users) and between concurrent users based on frequency of product use; and (3) if smokers who were exposed to HTP advertising hold beliefs that are consistent with marketing messages of lower harmfulness. This cross-sectional study included 2614 adult exclusive cigarette smokers and 986 concurrent users who reported their perceptions of harmfulness of HTPs compared to cigarettes, as well as their exposure to HTP advertising in the last six months. Among all smokers, 47.5% perceive that HTPs are less harmful than cigarettes, 24.6% perceive HTPs to be equally as harmful, 1.8% perceive HTPs as more harmful, and 26.1% did not know. Concurrent users are more likely than exclusive smokers to believe that HTPs are less harmful (62.1% versus 43.8%, p < 0.0001) and less likely to report that they did not know (14.3% versus 29.4%, p < 0.0001). Frequent HTP users are more likely than infrequent users to believe that HTPs are less harmful (71.7% versus 57.1%, p ≤ 0.001). Believing that HTPs are less harmful than cigarettes was associated with noticing HTP advertising on TV (p = 0.0005), in newspapers/magazines (p = 0.0001), on posters/billboards (p < 0.0001), in stores where tobacco (p < 0.0001) or where HTPs (p < 0.0001) are sold, on social media (p < 0.0001), or in bars/pubs (p = 0.04). HTP users were significantly more likely than non-HTP users to believe that HTPs are less harmful than cigarettes, with this belief being more prominent among frequent users. Smokers who have been exposed to HTP advertising were more likely to perceive HTPs as less harmful than cigarettes.

Adult Smokers' Awareness and Interest in Trying Heated Tobacco Products: Perspectives from Mexico, where HTPs and E-Cigarettes Are Banned

BACKGROUND

We evaluated smokers' perceptions of heated tobacco products (HTPs) in Mexico, where industry publically lobbied to introduce HTPs into this country that banned both HTPs and e-cigarettes.

METHODS

Online surveys (November 2018 to July 2019) were analyzed from adults who only smoked cigarettes (n = 2091) or who smoked and used e-cigarettes ("dual users"n = 1128). Logistic models regressed HTP awareness, interest to trying HTPs, and having seen HTPs for sale (only among aware participants) on sociodemographics and tobacco-related variables.

RESULTS

Of the 17.1% who were aware of HTPs, 52.7% reported having seen HTPs for sale. Of all respondents, 75% were somewhat or very interested in trying HTPs. Compared to their counterparts, more frequent smokers, dual users, those exposed to online e-cigarette ads, and those with friends who used e-cigarettes were both more aware of and interested in trying HTPs. Greater awareness was also associated with higher education, recent attempts to quit, receipt of email e-cigarette ads, and smoking among friends and family. Seeing HTPs for sale was higher for those who recently attempted to quit, were exposed to e-cigarette ads online or by email, or had friends who used e-cigarettes.

CONCLUSION

Interest in HTPs is high among smokers in Mexico, which already has a large black market for illegal e-cigarettes. HTPs use should be monitored in this context, especially given the public health impacts of HTPs are unclear.