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

Comparison of Publications on Heated Tobacco Products With Conventional Cigarettes and Implied Desirability of the Products According to Tobacco Industry Affiliation: A Systematic Review

INTRODUCTION

Heated tobacco products (HTPs) have been advertised as "reduced-harm" tobacco products compared to conventional cigarettes (CC); however, no direct evidence supporting HTPs being desirable for human health exists. A previous systematic review reported that evidence on HTPs published in 2017 or earlier was primarily drawn from industry-related papers. We aimed to investigate whether tobacco industry-affiliated studies are more likely to conclude that HTPs are more desirable than CC.

METHODS

PubMed and Ichushi-Web were searched up to March 15, 2022, for studies on HTPs published in 2017 or after. We selected studies that assessed any measures of HTPs and CC, including secondary analyses using gray literature in English or Japanese. We excluded review articles except for a meta-analysis that met the aforementioned criteria. Data on the authors' affiliations, grant, conflict of interest, category of research subjects, and interpretation were extracted. Research members in two groups independently assessed the papers; discrepancies were solved by discussion between the groups.

RESULTS

Overall, 134 studies met the criteria. Eighty-seven (64.9%) of them were affiliated with the tobacco industry. Of the 134 studies, 56.3% (49/87) of the industry-affiliated studies versus 19.1% (9/47) of nonindustry-affiliated studies concluded that HTPs were more desirable than CC (p < .01). No study investigated clinically relevant outcomes, such as disease occurrence.

CONCLUSIONS

Publications on HTPs in the biomedical literature from January 2017 to March 2022 were dominated by tobacco industry-affiliated studies. More than half of them concluded that HTPs were more desirable than CC compared to independent studies.

IMPLICATIONS

Tobacco industry advertises HTPs as "reduced-harm" tobacco products compared to CC. HTP users tend to consider HTPs as alternative tobacco products less harmful than CC (ie, products for "harm reduction"). Our results demonstrated that papers written by tobacco industry-affiliated authors concluded that HTPs were more desirable than CC compared to papers by independent authors. However, all their judgments were based on surrogate outcomes. Surrogate outcomes are not necessarily linked to clinically relevant outcomes such as disease occurrence. Further studies on HTPs using clinically relevant outcomes are warranted by independent authors from tobacco industry.

Human vasculature-on-a-chip with macrophage-mediated endothelial activation: The biological effect of aerosol from heated tobacco products on monocyte adhesion

Heated tobacco products (HTPs) are expected to have the potential to reduce risks of smoking-associated cardiovascular disease (CVD). However, mechanism-based investigations of the effect of HTPs on atherosclerosis remain insufficient and further studies under human-relevant situations are desired for deeper understanding of the reduced risk potential of HTPs. In this study, we first developed an in vitro model of monocyte adhesion by considering macrophage-derived proinflammatory cytokine-mediated endothelial activation using an organ-on-a-chip (OoC), which provided great opportunities to mimic major aspects of human physiology. Then biological activities of aerosol from three different types of HTPs in terms of monocyte adhesion were compared with that of cigarette smoke (CS). Our model showed that the effective concentration ranges of tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were close to the actual condition in CVD pathogenesis. The model also showed that monocyte adhesion was less induced by each HTP aerosol than CS, which may be caused by less proinflammatory cytokine secretion. In summary, our vasculature-on-a-chip model assessed the difference in biological effects between cigarettes and HTPs, and suggested a reduced risk potential of HTPs for atherosclerosis.

Comparative Health Risk Assessment of Heated Tobacco Products versus Conventional Cigarettes

BACKGROUND

Smoking is the largest preventable cause of death in the world with around eight million estimated premature deaths per year. In response to the harmful effects of conventional tobacco products the tobacco industry has launched a new type of products called Heated tobacco products (HTP) and e-cigarettes, which are considered safer for human health than conventional cigarettes.

MATERIALS AND METHODS

The research was conducted by searching the scientific literature using platforms "Google scholar," "PubMed" and "Science Direct." To compare the non-carcinogenic and carcinogenic risk of HTP products and conventional cigarettes, margin of exposure and lifetime excess cancer risk were calculated using data obtained from a scientific literature search.

HTP products have shown a reduced risk to human health compared to the conventional cigarettes, although they still contain compounds that can be dangerous to human health. There is not enough data obtained from independent studies that could safely indicate that these reduced amounts of toxic chemical entities in the composition of HTP do not induce any harmful effect.

CONCLUSION

Further research is needed to determine the harmful effects of HTP aerosol, as well as to tighten the legislation that would limit the production, import and distribution of these products worldwide until their safety for human health is confirmed with a sufficient number of transparent and representative results obtained in independent scientific studies.

Preliminary study on the effect of using heat-not-burn tobacco products on indoor air quality

In this study, the effect of the use of heat-not-burn (HnB) products on indoor air quality (IAQ) was evaluated. To do this, the concentrations of nicotine, propylene glycol (PG), and vegetable glycerin (VG) directly emitted when using HnB products were analyzed and compared to those from conventional cigarettes. Furthermore, the levels of VOCs, aldehydes, nanoparticle, and particulate matter (PM) detected when subjects used HnB products in the exposure chamber were evaluated the effect on IAQ. As a result, the range of nicotine levels transferred by HnB products (0.8-1.2 mg cigarette^-1) is lower than that by conventional cigarettes (2.4-3.6 mg cigarette^-1). On the other hand, the range of VG levels emitted from HnB products (3.1-5.9 mg cigarette^-1) were higher than that emitted from conventional cigarettes (0.6-3.0 mg cigarette^-1). In addition, although the amount generated from HnB products was small compared to those from conventional cigarettes, various kinds of VOCs, aldehydes, nanoparticle and PM were produced, and these were confirmed to affect IAQ.

Challenges in Predicting the Change in the Cumulative Exposure of New Tobacco and Related Products Based on Emissions and Toxicity Dose-Response Data

Many novel tobacco products have been developed in recent years. Although many may emit lower levels of several toxicants, their risk in the long term remains unclear. We previously published a method for the exposure assessment of mixtures that can be used to compare the changes in cumulative exposure to carcinogens among tobacco products. While further developing this method by including more carcinogens or to explore its application to non-cancer endpoints, we encountered a lack of data that are required for better-substantiated conclusions regarding differences in exposure between products. In this special communication, we argue the case for more data on adverse health effects, as well as more data on the composition of the emissions from tobacco products. Such information can be used to identify significant changes in relevance to health using the cumulative exposure method with different products and to substantiate regulatory decisions.

A comparison of cigarette smoke test matrices and their responsiveness in the mouse lymphoma assay: A case study

No cigarette smoke test matrix is without limitation, due to the complexity of the starting aerosol and phase to phase dynamics. It is impossible to capture all chemicals at the same level of efficiency, therefore, any test matrix will inadvertently or by design fractionate the test aerosol. This case study examines how four different test matrices derived from cigarette smoke can be directly compared. The test matrices assessed were as follows, total particulate matter (TPM), gas vapour phase (GVP), a combination of TPM + GVP and whole aerosol (WA). Here we use an example assay, the mouse lymphoma assay (MLA) to demonstrate that data generated across four cigarette smoke test matrices can be compared. The results show that all test matrices were able to induce positive mutational events, but with clear differences in the biological activity (both potency and toxicity) between them. TPM was deemed the most potent test article and by extension, the particulate phase is interpreted as the main driver of genotoxic induced responses in the MLA. However, the results highlight that the vapour phase is also active. MLA appeared responsive to WA, with potentially lower potency, compared to TPM approaches. However, this observation is caveated in that the WA approaches used for comparison were made on a newly developed experimental method using dose calculations. The TPM + GVP matrix had comparable activity to TPM alone, but interestingly induced a greater number of mutational events at comparable relative total growth (RTG) and TPM-equivalent doses when compared to other test matrices. In conclusion, this case study highlights the importance of understanding test matrices in response to the biological assay being assessed and we note that not all test matrices are equal.

Volatile organic compounds released in the mainstream smoke of flavor capsule cigarettes

In this study, the composition of mainstream smoke was investigated with an emphasis on a list of volatile organic compounds (VOCs: e.g., isoprene, acrylonitrile, methyl ethyl ketone, benzene, toluene, m-xylene and styrene) using the two types of flavor capsule cigarettes (FCCs, here coded as F1 and F2) in reference to one commercial, non-flavored (NF) and 3R4F cigarette. The concentrations of all the target compounds from FCCs were quantified under two contrasting conditions (i.e., with and without breaking the capsules). The effect of breaking the capsule was apparent in the FCC products with the enhancement of VOC levels, specifically between after and before breaking the capsules (e.g., 1.10-1.58 folds (benzene) and 1.30-1.53 folds (acetonitrile)). Such increases were apparent in both FCC samples if assessed in terms of the total amount of VOCs (TVOC): (1) F1 (from 2159 to 2530 μg cig-1 (p = 9.42 × 10-6)) and (2) F2 (from 1470 to 2014 μg cig-1 (p = 0.05)). In addition, these TVOC levels determined from the FCCs were 1.62- to 1.83- and 1.29- to 1.46-fold higher than those of the NF cigarette and the 3R4F cigarette, respectively. Thus, these FCC products are suspected to play a role as stronger sources of VOCs than the general cigarette products.

The Emission of VOCs and CO from Heated Tobacco Products, Electronic Cigarettes, and Conventional Cigarettes, and Their Health Risk

The differences in aerosol composition between new tobacco types (heated tobacco products and electronic cigarettes) and conventional cigarettes have not been systematically studied. In this study, the emissions of volatile organic compounds (VOCs), carbon monoxide (CO), nicotine, and tar from heated tobacco products (HTPs), electronic cigarettes (e-cigarettes) and conventional cigarettes were compared, and their health risks were evaluated by applying the same smoking regime and a loss mechanism of smoking. Twenty VOCs were identified in aerosols from HTPs, 18 VOCs were identified in aerosols from e-cigarettes, and 97 VOCs were identified in aerosols from cigarettes by GC–MS and HPLC analysis. The concentrations of total VOCs (TVOCs) emitted by the three types of tobacco products decreased as follows: e-cigarettes (795.4 mg/100 puffs) > cigarettes (83.29 mg/100 puffs) > HTPs (15.65 mg/100 puffs). The nicotine content was 24.63 ± 2.25 mg/100 puffs for e-cigarettes, 22.94 ± 0.03 mg/100 puffs for cigarettes, and 8.817 ± 0.500 mg/100 puffs for HTPs. When using cigarettes of the same brand, the mass concentrations of VOCs, tar, and CO emitted by HTPs were approximately 81.2%, 95.9%, and 97.5%, respectively, lower than the amounts emitted by cigarettes. The health risk results demonstrated that the noncarcinogenic risk of the three types of tobacco products decreased as follows: cigarettes (3609.05) > HTPs (2449.70) > acceptable level (1) > e-cigarettes (0.91). The lifetime cancer risk (LCR) decreased as follows: cigarettes (2.99 × 10⁻⁴) > HTPs (9.92 × 10⁻⁵) > e-cigarettes (4.80 × 10⁻⁵) > acceptable level (10⁻⁶). In general, HTPs and e-cigarettes were less harmful than cigarettes when the emission of VOCs and CO was considered.

Measurement of harmful nanoparticle distribution among filters, smokers' respiratory systems, and surrounding air during cigarette smoking

This study was undertaken to investigate the filtration effect of filter on nanoparticle and the deposition behavior of nanoparticle in the human respiratory system from the aspect of nanoparticle number during cigarette smoking. For that, two kinds of experiments were designed. One is machine experiment, a well-controlled simulated respiratory system was designed to measure the raw emission and filter effect. Another is human experiment, volunteers were asked to inhale smoke into the oral cavity only and lungs, respectively, to distinguish smoke path. Results revealed that effective inhaled nanoparticle amount of a Taishan and a Hongtaishan cigarette were 5.8E + 9 (#) and 9.4E + 7 (#), respectively. The filter's integrated reduction rate was 41.65% for nanoparticle. For Taishan cigarette, 35.4% and 41.7% of raw emitted nanoparticles were deposited in the oral cavity and lungs, respectively, the rest of 22.9% was exhaled to surrounding air. The corresponding values were 25.6%, 41.5% and 32.9%, respectively, for Hongtaishan. The current findings are expected to provide basic assessments of filter effect and harm to human and to be a warning for smokers.

Incidence trends in bladder and lung cancers between Denmark, Finland and Sweden may implicate oral tobacco (snuff/snus) as a possible risk factor

Background

The dominant risk factor for urinary bladder cancer has been cigarette smoking, but, as smoking prevalence is decreasing in many populations, other risk factors may become uncovered. Such new risk factors could be responsible for halting the declining incidence of bladder cancer. We hypothesize that snuff use by Swedish men may increase the rate for bladder cancer, as snuff contains carcinogenic nitrosamines.

Methods

We carried out an ecological study by comparing incidence trends in lung and bladder cancers between Danish, Finnish and Swedish men in order to test if the Swedish bladder cancer rate deviates from the Danish and Finnish ones. We used the NORDCAN database for cancer data from 1960 through 2016 to test the hypothesis.

Results

In the three countries, the incidence of lung cancer started to decrease after a peak incidence, and this was later followed by declining incidence in bladder cancer in Denmark from 1990 to 2016 by 14.3%, in Finland by 8.3% but not in Sweden (the decline of 1.4% was not significant). The difference in trends can be partly explained by the increasing incidence in Swedish men aged 70 or more years. Sweden differs from the two other countries by low male smoking prevalence but increasing use of snuff recorded by various surveys.

Conclusion

The stable bladder cancer trend for Swedish men was opposite to the declining trends in Denmark, Finland and globally. We suggest that this unusual finding may be related to the increasing use of snuff by Swedish men. Average users of snuff are exposed to at least 3 times higher levels of carcinogenic tobacco-specific nitrosamines than a smoker of one daily pack of cigarettes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08371-w.

A randomized controlled study in healthy participants to explore the exposure continuum when smokers switch to a tobacco heating product or an E-cigarette relative to cessation

Background

Cigarette smoking is associated with a number of diseases, such as cancer and cardiovascular diseases. Recently, there has been an increase in the use of electronic cigarettes (ECs) and tobacco-heating products (THPs) as an alternative to cigarettes, which may reduce the health burden associated with smoking. However, an exposure continuum when smokers switch to ECs or THPs compared to complete smoking cessation is not well established.

Methods

148 healthy smokers were randomized to either continue smoking cigarettes, switch to using the glo THP or a prototype EC, or completely quit any nicotine or tobacco product use for 5 days, after a 2-day baseline period. During this study breath and 24-h urine samples were collected for Biomarker of Exposure (BoE) analysis.

Results

After a 5-day switching period BoE levels showed a substantial significant decrease in levels from baseline in the groups using the glo THP, the prototype EC, and having quit all nicotine and tobacco use. On an exposure continuum, smokers who completely quit nicotine had the lowest levels of assessed BoEs, followed by those who switched to the EC and then those who switched to glo THP use. Participants who continued to smoke had the highest levels of BoEs.

Conclusions

THP or EC use over a 5-day period resulted in significant reductions in exposure to smoke toxicants, in some cases to levels similar to those for nicotine cessation. These results show that on an exposure continuum, nicotine cessation gives the greatest reduction in exposure to tobacco smoke toxicants, closely followed by the EC and the glo THP. These significant reductions in exposure to toxicants suggest that the glo THP and EC have the potential to be Reduced Risk Products.

Study Registration

ISRCTN80651909.

Systematic review of biomarker findings from clinical studies of electronic cigarettes and heated tobacco products

BACKGROUND

Worldwide adoption of electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) has increased exponentially over the past decade. These products have been proposed as non-combustible alternatives to traditional tobacco products such as cigarettes and may thus reduce the negative health consequences associated with tobacco smoke. However, the overall health impact and safety of using these products remains unclear. This review seeks to provide an updated summary of available evidence on changes to levels of tobacco-related biomarkers to aid the overall assessment of the consequences of using e-cigarettes and HTPs.

METHODS

A systematic review was conducted through major databases (Medline/PubMed, Scopus, EMBASE) searching for articles directly comparing biomarker levels in humans using e-cigarettes or HTPs and those using combustible cigarettes. We included peer reviewed articles with comparative or longitudinal design and extracted key information for our purpose (type of population, demographics, biomarkers measurements, and health effects). An initial qualitative analysis was performed followed by a summary of findings.

RESULTS

A total of 44 studies were included from initial citations. The vast majority of the literature reported reductions in levels of biomarkers of tobacco smoke exposure (BOE), especially nicotine, MHBMA, 3-HPMA, S-PMA, 1-OHP and NNAL, when using e-cigarettes and HTPs compared to combustible cigarettes. There was a slight tendency toward a larger reduction in these biomarkers levels with the use of e-cigarettes, although direct comparisons between e-cigarettes and HTPs were lacking. There was also a trend toward positive changes in levels of biomarkers of biological effect (BOBE) with the use of e-cigarettes and HTPs.

CONCLUSIONS

A comparison of levels of biomarkers of tobacco-related exposure collected in clinical studies revealed that the use of e-cigarettes and HTPs could lead to a significant reduction in exposure to harmful substances compared to combusted cigarettes. In tandem, the health status of e-cigarettes and HTP users, indexed by levels of biomarkers of biological effect showed potential for improvement compared to smoking. However, larger and longer-term population-based studies are needed to further clarify these findings.