Possible hepatotoxicity of IQOS

Cigarettes, heated tobacco products and dual use: exhaled carbon monoxide, saliva cotinine and total tobacco consumed by Hong Kong tobacco users

BACKGROUND

Independent studies on exhaled carbon monoxide (CO) and saliva cotinine levels in regular heated tobacco product (HTP) users, and how they compare with conventional cigarette (CC) smokers, are lacking.

METHODS

A total of 3294 current users of CCs, HTPs or electronic cigarettes (ECs) from a household survey and a smoking hotspot survey were classified into seven groups: exclusive users of CCs, HTPs, ECs; dual users of CCs and HTPs, CCs and ECs, HTPs and ECs; and triple users. We measured exhaled CO level using the piCo Smokerlyzer (n=780) and saliva cotinine using NicAlert cotinine test strips (n=620). Among the seven groups, the differences in (1) CO and cotinine levels were examined using Kruskal-Wallis test, and (2) the average daily tobacco consumption in the past 30 days was examined using multivariable linear regression.

RESULTS

Both exclusive and dual users of CCs had a higher CO level than exclusive HTP or EC users (p<0.05). Exhaled CO levels were similar between HTP and EC users, as were saliva cotinine levels among the seven groups. Compared with exclusive CC users, those who also used HTPs or ECs smoked fewer CCs (CCs+HTPs: adjusted coefficient -2.79, 95% CI -3.90 to -1.69; CCs+ECs: -1.34, 95% CI -2.34 to -0.34), but consumed more tobacco sticks equivalent in total (2.79 (95% CI 1.61 to 3.96); 1.95 (95% CI 0.79 to 3.12)).

CONCLUSIONS

HTP or EC use showed lower exhaled CO but similar saliva cotinine levels compared with CC use. Dual users of CCs and HTPs/ECs smoked fewer CCs than exclusive CC users, but consumed more tobacco in total.

A scoping review of the toxicity and health impact of IQOS

This work aims to summarize the current evidence on the toxicity and health impact of IQOS, taking into consideration the data source. On 1 June 2022, we searched PubMed, Web of Science, and Scopus databases using the terms: 'heated tobacco product', 'heat-not-burn', 'IQOS', and 'tobacco heating system'. The search was time-restricted to update a previous search conducted on 8 November 2021, on IQOS data from 2010-2021. The data source [independent, Philip Morris International (PMI), or other manufacturers] was retrieved from relevant sections of each publication. Publications were categorized into two general categories: 1) Toxicity assessments included in vitro, in vivo, and systems toxicology studies; and 2) The impact on human health included clinical studies assessing biomarkers of exposure and biomarkers of health effects. Generally, independent studies used classical in vitro and in vivo approaches, but PMI studies combined these with modeling of gene expression (i.e. systems toxicology). Toxicity assessment and health impact studies covered pulmonary, cardiovascular, and other systemic toxicity. PMI studies overall showed reduced toxicity and health risks of IQOS compared to cigarettes, but independent data did not always conform with this conclusion. This review highlights some discrepancies in IQOS risk assessment regarding methods, depth, and breadth of data collection, as well as conclusions based on the data source.

Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults

BACKGROUND

IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for 'reduced exposure' marketing claims, which has been exploited globally.

METHODS

In November-December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates.

RESULTS

Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message ('IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers') was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers.

CONCLUSIONS

Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.

Potential Harm of IQOS Smoke to Rat Liver

The Food and Drug Administration has recently classified the IQOS electronic cigarette as a modified-risk tobacco product. However, IQOS cigarettes still release various harmful constituents typical of conventional cigarettes (CCs), although the concentrations are markedly lower. Here, we investigated the damaging effects of IQOS smoking on the liver. Male Sprague Dawley rats were exposed, whole body, 5 days/week for 4 weeks to IQOS smoke (4 sticks/day), and hepatic xenobiotic metabolism, redox homeostasis and lipidomic profile were investigated. IQOS boosted reactive radicals and generated oxidative stress. Exposure decreased cellular reserves of total glutathione (GSH) but not GSH-dependent antioxidant enzymes. Catalase and xanthine oxidase were greater in the exposed group, as were various hepatic CYP-dependent monooxygenases (CYP2B1/2, CYP1A1, CYP2A1, CYP2E1-linked). Respiratory chain activity was unaltered, while the number of liver mitochondria was increased. IQOS exposure had an impact on the hepatic lipid profile. With regard to the expression of some MAP kinases commonly activated by CC smoking, IQOS increased the p-p38/p38 ratio, while erythroid nuclear transcription factor 2 (Nrf2) was negatively affected. Our data suggest that IQOS significantly impairs liver function, supporting the precautionary stance taken by the WHO toward the use of these devices, especially by young people and pregnant women.

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.

Impact of different health warning label and reduced exposure messages in IQOS ads on perceptions among US and Israeli adults

Heated tobacco products (HTPs; e.g., IQOS) are advertised as safer than cigarettes or an alternative, yet required health warning labels (HWLS) in many countries, including the US and Israel, do not consider whether HTP ads undermine HWLs, particularly those that do not explicitly address HTPs. In 2021, a randomized 4 × 3 factorial experiment among 2,222 US and Israeli adults examined IQOS ads with differing: 1) HWLs (i.e., smoking risks, prompt to quit, HTP-specific, control); and 2) ad messages (i.e., slight distancing: "cigarette-like satisfaction, no odor", clear distancing: "looking for an alternative?", control). Outcomes were perceived relative harm (vs cigarettes), exposure to harmful chemicals, and disease risk and likelihood of trying or suggesting IQOS to smokers. Ordinal logistic regression was used, adjusted for covariates. One HWL effect was found: risk (vs control) increased perceived relative harm (aOR = 1.21, CI = 1.03-1.41) and exposure (aOR = 1.22, CI = 1.04-1.42) and decreased likelihood of trying IQOS (aOR = 0.82, CI = 0.69-0.97). Both slight and clear distancing ads (vs control) decreased perceived harm (aOR = 0.85, CI = 0.75-0.97; aOR = 0.63, CI = 0.55-0.72, respectively) and increased likelihood of suggesting IQOS to smokers (aOR = 1.23, CI = 1.07-1.41; aOR = 1.28, CI = 1.11-1.47); slight distancing decreased perceived disease risk (aOR = 0.85, CI = 0.75-0.97); and clear distancing decreased perceived exposure (aOR = 0.73, CI = 0.64-0.83). Clear (vs slight) distancing decreased perceived relative harm (aOR = 0.74, CI = 0.65-0.85) and exposure (aOR = 0.82, CI = 0.71-0.93). One interaction effect was found: the quitting HWL and clear distancing led to particularly low perceived relative harm (aOR = 0.63, CI = 0.43-0.93). Regulatory agencies must monitor the impacts of advertising, including reduced risk/exposure messaging on perceptions of HWL messages, to inform future regulatory efforts.

Associations between the Frequency and Quantity of Heated Tobacco Product Use and Smoking Characteristics among Korean Smoking Adolescents

PURPOSE

Although heated tobacco product (HTP) use among adolescents is an emerging public health problem, little is known about the frequency and quantity of HTP use. Thus, we investigated the associations between the frequency and quantity of HTP use and smoking characteristics (i.e., combustible cigarette [CC] and electronic cigarette [EC] use, and attempts to quit smoking) among CC-smoking adolescents.

METHODS

We analyzed nationally representative data from 2,470 Korean adolescents who were current CC smokers. To investigate our aim, we conducted multinomial logistic and logistic regression analyses.

RESULTS

We found that daily and heavier CC users had greater likelihoods of more frequent and heavier HTP use. In addition, dual users of CCs and ECs were more likely to use HTPs more frequently and heavily than CC users who did not use ECs. Moreover, daily EC users had the highest risk of frequent and heavy HTP use. The frequency and quantity of HTP use were not associated with attempts to quit smoking. Compared to CC-only use, dual use of CCs and HTPs was not associated with quitting attempts, and triple use of CCs, ECs, and HTPs was associated with a lower likelihood of quitting attempts.

CONCLUSION

HTP use was less likely to displace CC use and promote attempts to quit smoking. Thus, strict regulations are required to prevent the promotion of HTPs as a substitute for CCs or as a means of quitting smoking. Additionally, health professionals should consider preventive interventions for HTP, as well as CC and EC use among adolescents.

Alpha-Lipoic Acid Modulates the Oxidative and Inflammatory Responses Induced by Traditional and Novel Tobacco Products in Human Liver Epithelial Cells

Smoking has been associated with NAFLD recently, thus might be a contributing factor for liver disease progression. In this study, we identified the modulative action of α-lipoic acid (α-LA), an organosulphur compound, towards heated tobacco product (HTP) and cigarette smoke extract (CSE)-induced oxidative stress and inflammation in human liver HepG2 cells. The cells were pre-treated with α-LA and exposed to tobacco extracts, and cytotoxicity, oxidative response (SOD, CAT activities and GSH, MDA levels), inflammation (nitrite, IL-6, AhR levels), and liver function (AST/ALT) were assessed. According to the results, a notable increase in oxidative response was observed with CSE, whereas GSH depletion and decreased SOD activity were the key toxicological events induced by HTP (p<0.05). The oxidative and inflammatory responses were ameliorated with α-LA treatment, particularly through GSH restoration and IL-6 modulation. To conclude, these findings on α-LA might contribute to the design of novel adjuvant therapies for people exposed to tobacco smoke.

Chronic exposure to IQOS results in impaired pulmonary function and lung tissue damage in mice

The use of IQOS brand heated tobacco products (HTPs) is increasing worldwide; however, little is known about the long-term effects of HTPs aerosol exposure on the lungs. Herein, we exposed C57BL/6 J mice for 24 weeks to clean air, IQOS aerosol, or cigarette smoke, and determined pulmonary function, lung tissue pathology, inflammation, and oxidative stress. Compared with the control group mice, IQOS group mice showed substantially decreased weight and lung function. Levels of IL-6 and TNF-a, as well as oxidative stress markers, were comparable to those found in the cigarette group. In addition, hematoxylin and eosin staining showed that the alveolar space was enlarged and that emphysema had formed in the IQOS group. Masson staining showed that collagen deposition areas were substantially increased in the airway walls in the IQOS group than in the control group. Immunohistochemical staining showed epithelial-mesenchymal transition in the airways of mice in the IQOS group. In conclusion, chronic exposure to IQOS aerosol results in impaired pulmonary function and lung tissue damage; hence, concern should be raised regarding the long-term safety of this product.

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.

Exposure to the heated tobacco product IQOS generates apoptosis-mediated pulmonary emphysema in murine lungs

Pulmonary emphysema is predominantly caused by chronic exposure to cigarette smoke (CS). Novel tobacco substitutes, such as heated tobacco products (HTPs), have emerged as healthier alternatives to cigarettes. IQOS, the most popular HTP in Japan, is advertised as harmless compared with conventional cigarettes. Although some studies have reported its toxicity, few in vivo studies have been conducted. Here, 12-wk-old C57BL6/J male mice were divided into three groups and exposed to air (as control), IQOS aerosol, or CS for 6 mo. After exposure, the weight gain was significantly suppressed in the IQOS and CS groups compared with the control (-4.93 g; IQOS vs. air and -5.504 g; CS vs. air). The serum cotinine level was significantly higher in the IQOS group than in the control group. The neutrophils and lymphocyte count increased in the bronchoalveolar lavage fluid of the IQOS and CS groups compared with those in the control group. Chronic IQOS exposure induced pulmonary emphysema similar to that observed in the CS group. Furthermore, expression levels of the genes involved in the apoptosis-related pathways were significantly upregulated in the lungs of the IQOS-exposed mice. Cytochrome c, cleaved caspase-3, and cleaved poly (ADP-ribose) polymerase-1 were overexpressed in the IQOS group compared with the control. Single-stranded DNA and TdT-mediated dUTP nick-end labeling-positive alveolar septal cell count significantly increased in the IQOS group compared with the control. In conclusion, chronic exposure to IQOS aerosol induces pulmonary emphysema predominantly via apoptosis-related pathways. This suggests that HTPs are not completely safe tobacco products.

Perceived relative harm of heated tobacco products and electronic cigarettes and its association with use in smoke-free places: A cross-sectional analysis of Korean adults

INTRODUCTION

Electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are often considered to be less harmful and safer than combustible cigarettes (CCs). As a result, numerous tobacco product users opt to use e-cigarettes or HTPs as a safer alternative, though the safety of these products is not fully warranted. The present study aimed to assess the various attitudes towards e-cigarettes and/or HTPs among Korean tobacco product users and their associations with the practical use of e-cigarettes and/or HTPs in private or smoke-free public places.

METHODS

A cross-sectional study using self-administered questionnaires was conducted from March 2019 to July 2019 on 2971 adult tobacco product users. Attitude towards e-cigarettes and/or HTPs, as well as the relative harm perceptions, in association with their practical use in private or smoke-free areas, were also analyzed.

RESULTS

Among those surveyed, 46.8% were exclusive users (CC-only smokers 23.5%, e-cigarette-only users 10.7%, HTP-only users 12.7%), and 47.6% were poly-users. Compared with non-e-cigarette or non-HTP users, current e-cigarette or HTP users perceived e-cigarettes or HTPs as less harmful than CCs and they were more acceptable to e-cigarettes or HTPs being used indoors. Their positive attitudes were associated with their more frequent use at home or in their car. Less number of participants supported that the government should regulate e-cigarettes or HTPs in the same way as CCs, their attitude being associated with more frequent use in smoke-free public places.

CONCLUSIONS

E-cigarettes or HTPs users have more positive attitudes toward their tobacco products than non-e-cigarette or non-HTP users. Those with more positive attitudes toward e-cigarettes or HTPs are closely related to their use in smoke-free places.

An Investigation of Influential Users in the Promotion and Marketing of Heated Tobacco Products on Instagram: A Social Network Analysis

While an increasing body of the literature has documented the exposure to emerging tobacco products including heated tobacco products (HTPs) on social media, few studies have investigated the various stakeholders involved in the generation of promotional tobacco content. This study constructed a social network of Instagram users who posted IQOS content, a leading HTP brand, between 1 January and 5 April 2021 and identified users who positioned near the center of the network. We identified 4526 unique Instagram users who had created 19,951 IQOS-related posts during the study period. Nearly half of the users (42.1%) were business accounts authorized by Instagram, among which 59.0% belonged to Personal Goods and General Merchandise Stores and 18.1% belonged to Creators and Celebrities. For users with higher in-degree, out-degree, betweenness, and closeness centrality in the network, the majority of them were accounts directly associated with IQOS (e.g., containing "iqos" in username) or related to tobacco business as self-identified in the bio. Our findings further refine the social media marketing presence of tobacco products and suggest that the current self-regulatory efforts led by social media platforms are far from enough.

IQOS Marketing in the US: The Need to Study the Impact of FDA Modified Exposure Authorization, Marketing Distribution Channels, and Potential Targeting of Consumers

IQOS, the leading heated tobacco product globally, recently received 'reduced exposure' authorization from the US Food and Drug Administration. Independent research focusing on IQOS marketing and potential impact on consumers' perceptions and behavior, and ultimately public health, is critical. The literature to date has underscored several concerns. First, Philip Morris's (PM's) marketing distribution requires scrutiny, particularly given its innovative promotional strategies. For example, IQOS is distributed via unique points-of-sale (POS; e.g., specialty and pop-up stores, "corners" in convenience stores) and uses various other opportunities (e.g., social media, sponsored events, direct-to-consumer). Second, although PM claims that IQOS' target market is current combustible tobacco users and not young people, the literature indicates that in some populations, IQOS use is equally prominent among smokers and nonsmokers, and that specific subgroups (e.g., young adults, women) are targeted. Third, the impact of IQOS' use of ad content promoting IQOS health benefits must be studied (e.g., how consumers interpret modified exposure messages). In conclusion, surveillance of IQOS marketing, particularly following reduced exposure authorization, is critical for obtaining valuable data to estimate population impact, particularly among population subgroups (e.g., young adults), and inform future tobacco regulation. These considerations have implications beyond IQOS-to other products and companies.

Heated Tobacco Products: Awareness and Ever Use Among U.S. Adults

INTRODUCTION

Heated tobacco products, also referred to as heat-not-burn tobacco, are among the latest products introduced to the market by the tobacco industry. However, data on heated tobacco product awareness and use from population-based probability surveys are limited. This study examines heated tobacco product awareness and ever use among U.S. adults.

METHODS

This study used data (n=42,477) from the 2019 Tobacco Use Supplement to the Current Population Survey, analyzed in 2020. Descriptive statistics, including a weighted prevalence of heated tobacco product awareness and ever use, were estimated. The awareness and ever use of heated tobacco products were also estimated by age, sex, cigarette smoking status, E-cigarette use status, and other tobacco product use status. Multivariable logistic regression examined the individual characteristics associated with the awareness and ever use of heated tobacco products.

RESULTS

Overall, approximately 8.6% of U.S. adults were aware of heated tobacco products. Awareness was higher among participants who were younger, male, cigarette smokers, E-cigarette users, and other tobacco product users. Ever use of heated tobacco products was uncommon among U.S. adults (0.51%) but more prevalent among E-cigarette users and cigarette smokers. In the general adult populations, the odds of ever use of heated tobacco products were significantly higher among cigarette smokers (AOR=2.19, 95% CI=1.63, 2.94), E-cigarette smokers (AOR=2.70, 95% CI=1.71, 4.25), and other tobacco product users (AOR=1.69, 95% CI=1.30, 2.20).

CONCLUSIONS

Although the ever use of heated tobacco products is uncommon among U.S. adults, recent regulatory approval of the marketing of IQOS as modified risk tobacco products may increase use. Therefore, ongoing monitoring of heated tobacco products use and their long-term health consequences are important for informing future decision making.

FDA's reduced exposure marketing order for IQOS: why it is not a reliable global model

The US Food and Drug Administration (FDA) issued orders in July 2020 authorising Philip Morris Products S.A. to market its heated tobacco product (HTP) IQOS inside the USA with claims that it reduces exposure to some dangerous substances. FDA's 'reduced-exposure' orders explicitly prohibit the marketing of IQOS with claims that IQOS will reduce harm or the risk of tobacco-related diseases. Under US law, FDA's IQOS orders are problematic because FDA disregarded valid scientific evidence that IQOS increases exposure to other dangerous toxins and that Philip Morris Products S.A. failed to demonstrate that consumers understand the difference between reduced-exposure and reduced-harm claims. Unfortunately, both 'reduced-exposure' and 'reduced-harm' are classified as 'modified risk tobacco products' under US law. Exploiting this confusion, Philip Morris International used the FDA decision as the basis for marketing and public relations campaigns outside the USA to press governments to reverse policies that ban or regulate the sales and marketing of HTPs, including IQOS. Parties to the WHO Framework Convention on Tobacco Control should reject tobacco companies' unsubstantiated explicit or implied claims of reduced harm associated with HTPs and resist Philip Morris International's and other companies' calls to relax HTP regulations based on the FDA's actions. Instead, parties should adopt policies aligned with the Framework Convention on Tobacco Control when dealing with HTPs and other novel tobacco products.

USE AND AWARENESS OF HEATED TOBACCO PRODUCTS IN EUROPE

Background Heated tobacco products (HTP) are new forms of tobacco consumption with limited information available on their use among the general population. Our objective is to analyse the prevalence and associations of use of HTP across 11 countries in Europe.Methods Within the TackSHS Project, in 2017-2018 we conducted a cross-sectional study with information on HTP use in the following countries: Bulgaria, England, France, Germany, Greece, Italy, Latvia, Poland, Portugal, Romania and Spain. In each country, face-to-face interviews were performed on a representative sample of around 1,000 subjects aged ≥15 years, for a total of 10,839 subjects.Results Overall, 27.8% of study participants were aware of HTPs, 1.8% were ever HTP users (ranging from 0.6% in Spain to 8.3% in Greece), and 0.1% were current users. Men were more frequently HTP ever users than women (adjusted odds ratio, aOR=1.47; 95% confidence interval, CI: 1.11-1.95). Ever HTP use was inversely related to age (p for trend<0.001) and more frequent in ex-smokers (compared with never smokers, aOR=4.32, 95% CI: 2.69-6.95) and current smokers (aOR=8.35, 95% CI: 5.67-12.28), and in electronic cigarette past users (compared with never users, aOR=5.48, 95% CI: 3.46-8.68) and current users (aOR=5.92, 95% CI: 3.73-9.40).Conclusions In 2017-2018, HTP use was still limited in Europe among the general population, however the dual use of these products, their high use among younger generations and the interest of non-smokers in these products are worrying and indicate the need for close monitoring in terms of prevalence and the characteristics of users.

Are Heated Tobacco Product Users Less Likely to Quit than Cigarette Smokers? Findings from THINK (Tobacco and Health IN Korea) Study

Since the advent of heated tobacco products in June 2017 in South Korea, the sale of heated tobacco products accounted for 10.5% of total tobacco sales in 2019. However, the decreasing trend in total tobacco sales is gradually weakening and the number of visitors using stop smoking services has also dropped. This study examines the association between the use of new tobacco products and related products and cessation behaviors. A cross-sectional study using a self-administered questionnaire was conducted from March 2019 to July 2019 for 2831 adult tobacco users. The difference in rates of quit attempts using the type of tobacco products and related products in the past year were noted (55.6% (any cigarette smoker), 46.7% (any e-cigarette user), and 39.6% (any heated tobacco product user)). About a 30% increase in quit attempts was observed for the triple users of either conventional cigarette or heated tobacco product than exclusive users. Exclusive heated tobacco product and e-cigarette users were approximately 40% and 20% less likely to quit the product they used than exclusive cigarette smokers, respectively. These findings can explain recent occurrences in South Korea, such as the reduction of visitors at smoking cessation clinics and the attenuation of the decline in tobacco sales.

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.

Analysis of FDA's IQOS marketing authorisation and its policy impacts

BACKGROUND

Philip Morris Products SA (PMPSA) submitted a premarket tobacco application (PMTA) to US Food and Drug Administration (FDA) seeking an order permitting it to market IQOS in the USA. US law requires FDA to deny marketing authorisation if applicants fail to demonstrate that their product is 'appropriate for the protection of the public health'. FDA issued a marketing order for IQOS in April 2019, which Philip Morris is using to promote IQOS outside the USA.

METHODS

We analysed FDA's Technical Project Lead Review and marketing order for IQOS, relevant law and guidance on PMTAs and independent research on the health impacts of IQOS.

RESULTS

FDA found that the evidence PMPSA submitted did not demonstrate reduction in long-term disease risks and that IQOS aerosol emits toxins with carcinogenic and genotoxic potential, some at higher levels than conventional cigarettes. PMPSA did not appropriately consider the health impacts of dual use, the product's attractiveness to youth or data showing that consumers do not accurately perceive the addiction risks of IQOS. Despite FDA's own scientists' recommendations and independent research showing that IQOS presents serious risks to users including cytotoxic, genotoxic, hepatotoxic, cardiovascular and pulmonary risks, FDA concluded that IQOS is 'appropriate for the protection of the public health'.

CONCLUSION

FDA's decision allowing IQOS to be marketed in the USA disregarded valid scientific evidence and misapplied the public health standard mandated by law. This decision may have important health impacts, influence marketing IQOS outside the USA and erode public confidence in FDA's future PMTA decisions.

IQOS is not an acronym: a call to researchers and journals

In 2014, Philip Morris International (PMI) introduced the IQOS heated tobacco product system. It has been widely reported in the media that IQOS is an acronym for 'I quit ordinary smoking'. To our knowledge, PMI has never publicly used any acronym to describe or market IQOS. Moreover, PMI has repeatedly denied that IQOS is an acronym. The acronym, which is an implicit cessation claim, has also appeared in numerous peer-reviewed publications. While the origins of the acronym are unknown, PMI stands to benefit from the publicity and associated positive connotations. It is possible that early adopters of IQOS created the acronym online, which was then picked by reporters and the research community. Alternatively, given that tobacco manufacturers have used social media influencers to promote their products, it is also possible that PMI may have surreptitiously helped popularize the acronym. Regardless of its origin, researchers and journals should stop disseminating this internet myth that promotes a potentially misleading claim.

Young Adult Correlates of IQOS Curiosity, Interest, and Likelihood of Use

Objectives

Philip Morris International's heated tobacco product, Marlboro IQOS, is available internationally and will soon be marketed in the U.S. We examined correlates of curiosity, interest, and likelihood to use IQOS among U.S. young adults.

Methods

Young adults ages 18 - 30 years (N = 346) were recruited online, viewed a description of IQOS, and completed measures of sociodemographic characteristics, perceived risks, curiosity, interest, and likelihood to use IQOS.

Results

Males had greater curiosity, interest, and likelihood to use IQOS than females. Individuals with household income of $50,000 - $75,000 were more curious than those with household income of greater than $75,000. Cigarette smokers, e-cigarette and dual users had greater curiosity, interest, and likelihood of use than non-tobacco users. Non-white individuals and older young adults had greater likelihood of use. Greater perceived risks of IQOS were negatively associated with curiosity, interest, and likelihood of use.

Conclusions

Among young adults, IQOS has greater appeal among males, non-white individuals, those who are older, those with household income of $50,000-$75,000, cigarette smokers, e-cigarette and dual users, and those with less perceived risks of IQOS. Research on public education communicating the potential risks of IQOS to vulnerable young adults is warranted.

Prevalence and predictors of heated tobacco product use and its relationship with attempts to quit cigarette smoking among Korean adolescents

INTRODUCTION

Heated tobacco products (HTPs) have been available in the Korean market since June 2017. In this study, we examined the prevalence and predictors of HTP use among Korean adolescents and the association between HTP and electronic cigarette (EC) use and attempts to quit conventional cigarette (CC) smoking.

METHODS

We analysed the data of a representative sample (n=60 040) of 13-18-year-old middle-school and high-school students in Korea who had participated in the 14th Korea Youth Risk Behavior Web-based Survey in 2018.

RESULTS

The prevalence of ever HTP use among Korean adolescents was 2.9% (men: 4.4%, women: 1.2%), a year after the introduction of HTPs in the Korean market. Furthermore, 81.3% of the 1568 ever HTP users were triple users of HTPs, ECs and CCs. Multivariate analysis revealed that ever HTP use was greater among men, higher-grade students, current CC and/or EC users and risky alcohol drinkers. Among current CC smokers, ever users of ECs (28%-30%) and ever HTP users and current EC users (48%) were more likely to have attempted to quit CC smoking than those who had never used HTPs and ECs. However, there were fewer HTP and/or EC ever users among ever CC smokers who successfully quit smoking.

CONCLUSIONS

Many adolescents, especially CC and EC users, had already used HTPs shortly after the introduction of HTPs in Korea. The use of newer types of tobacco products is associated with lower odds of abstinence from CCs; therefore, it is important to protect adolescents from them.

Informing iQOS Regulations in the United States: A Synthesis of What We Know

The tobacco industry offers various products, including heated tobacco products (HTPs). Philip Morris International's (PMI) "iQOS" has the greatest HTP market share, as well as research on its use and impact. iQOS was released in 2014 and is now in more than 40 countries. The U.S. Food and Drug Administration announced permission for PMI to sell iQOS in the United States in April 2019, and iQOS was launched in October 2019. Decisions pending its modified risk tobacco product (MRTP) application will occur subsequently. The U.S. regulatory efforts regarding iQOS could be informed by examining (a) Philip Morris USA other product marketing efforts and (b) the iQOS market in countries where it is available. This article briefly addresses these two points with extant literature and suggests that future research should address important gaps in what is currently known, including strategic international collaborations and research, which historically has been critical for advancing tobacco control globally.

Effects of Fetal Exposure to Heat-Not-Burn Tobacco on Testicular Function in Male Offspring

Several studies show that maternal conventional cigarette smoking during pregnancy has been associated with reduced sperm concentration in sons. The development of heat-not-burn (HnB) tobacco has gained a growing following. However, the effects of prenatal HnB tobacco smoking on male offspring are as yet unknown. Pregnant CD-1 mice were exposed to I-Quit-Ordinary-Smoking (IQOS) (HnB tobacco) aerosol from heat sticks, mainstream smoke from 3R4F (conventional cigarettes) or clean air, using a whole-body exposure system. Adult male offspring mice were divided into six groups: control (5- and 15-weeks-old offspring), IQOS (5 and 15-weeks-old) and 3R4F (5 and 15-weeks-old). Spermatogenesis, sperm characteristics, serum testosterone, and seminiferous tubule morphology were evaluated. Prenatal IQOS exposure increased abnormal seminiferous tubule morphology and decreased sperm production at 5 weeks, but 3R4F exposure did not. Prenatal exposure to IQOS aerosol delays sexual maturation of male offspring or adversely affects the male testicular function of the offspring more than smoke from a combustion cigarette.

Tobacco and electronic nicotine delivery systems regulation

The smoking of tobacco cigarettes by millions of people over the past 100 or more years has had devastating public health consequences around the world. In some countries, this has been mitigated by the introduction of multiple regulatory strategies that have taken decades to implement. But even in the countries with most success at tobacco cigarette regulation, some smokers find it very hard to quit and need better treatment. Electronic cigarettes and other electronic nicotine delivery systems (ENDS) have emerged in the last decade or so. Initially designed to help smokers quit and produced by small independent entities, ENDS have become big business, with major transnational tobacco companies competing hard for market share where, for example, in the United States, a single device came to dominate the market within a couple of years and where soaring uptake by adolescents reached levels high enough to alarm the FDA. No doubts remain about the damaging health consequences of tobacco cigarettes. Controversies persist about e-cigarettes-their efficacy, health impacts, development of addiction and whether or not they provide a "gateway" to tobacco cigarette smoking. The regulation of tobacco cigarettes falls under a global WHO treaty, the Framework Convention on Tobacco Control (FCTC); over 180 countries are party to the FCTC. The regulation of ENDS has no such treaty, varies considerably around the world and in many countries remains completely untrammelled by specific directives. This paper will not discuss the evidence for or against the of e-cigarettes in smoking cessation (effectively discussed in this issue by Dr. Wallace) but aims to review the current state of tobacco regulation around the world, identify key differences in ENDS regulation, examine the impact of industry influence on public health policy and determine how the lessons of tobacco control should apply to ENDS.

Awareness and interest in IQOS heated tobacco products among youth in Canada, England and the USA

Introduction

Heated tobacco products (HTPs), such as IQOS, have been introduced in a growing number of international markets. However, little is known about perceptions of HTP products among youth.

Methods

Data are from Wave 1 of the International Tobacco Control Youth Tobacco and E-cigarette Survey (2017), a web-based cohort survey of 16- to 19-year-olds from Canada, England, and the United States (US). Respondents (n=12,064) were shown an image of IQOS and asked about their awareness, interest in trying, and susceptibility to trying the product. Youth awareness, interest in trying, and susceptibility to trying IQOS were analyzed using descriptive statistics, and logistic regression models were used to examine correlates of these outcomes.

Results

Overall, 7.0% of youth reported awareness of IQOS (England=5.6%, Canada=6.4%, and US=9.1%) and 38.6% expressed interest in trying the product (England=41.8%, Canada=33.0%, and US=40.9%). Within each country, all key outcomes varied by smoking status: greater proportions of youth who were currently smoking or had a history of smoking reported being aware of, interested in trying, and susceptible to trying IQOS. Interest and susceptibility to trying IQOS were associated with male sex, current tobacco use, and current e-cigarette use. Across all countries, susceptibility to trying IQOS (25.1%) was higher than for tobacco cigarettes (19.3%), but lower than for e-cigarettes (29.1%).

Conclusions

Awareness of heated tobacco products, such as IQOS, is emerging among youth in Canada, England, and the US. Interest in trying these products is very high among smokers, but also present among non-smokers.

Heated tobacco product regulation under US law and the FCTC

Tobacco companies are marketing new 'heated tobacco products' (HTPs) composed of battery-powered holders, chargers and tobacco plugs or sticks. The non-tobacco HTP components have escaped effective regulation under many countries' tobacco control laws because they are packaged and sold separately from the tobacco-containing components. In the USA, HTPs cannot be marketed unless the Food and Drug Administration determines that allowing their sale would be 'appropriate for the protection of the public health'. Philip Morris International (PMI) is seeking permission to market its IQOS HTP in the USA with 'modified risk tobacco product' (MRTP) claims that it reduces exposure to harmful substances and is less harmful than other tobacco products. However, PMI has not submitted adequate scientific evidence required by US law to demonstrate that the product is significantly less harmful to users than other tobacco products, that its labelling would not mislead consumers, or that its marketing-with or without MRTP claims-would benefit the health of the population as a whole. Parties to the WHO Framework Convention on Tobacco Control (FCTC) must take measures to reduce tobacco use and nicotine addiction, and prevent false or misleading tobacco product labelling, advertising and promotions; the introduction of new HTPs must be assessed according to these goals. All components of HTPs should be regulated at least as stringently as existing tobacco products, including restrictions on labelling, advertising, promotion and sponsorship, sales to minors, price and taxation policies and smokefree measures. There is nothing in US law or the FCTC that prevents authorities from prohibiting HTPs.

Heated tobacco products: another tobacco industry global strategy to slow progress in tobacco control

There has been a global decline in tobacco consumption that, if continued, will negatively impact the tobacco industry's profits. This decline led the industry to invent and market new products, including heated tobacco products (HTP). HTP are an extension of the industry's strategies to undermine government's tobacco regulatory efforts as they are being promoted as part of the solution for the tobacco epidemic. Under the moniker of 'harm reduction', the tobacco companies are attempting to rehabilitate their reputation so they can more effectively influence governments to roll back existing tobacco control policies or create exemptions for their HTP. Rolling back tobacco control policies will make it easier for the companies to renormalise tobacco use to increase social acceptability for all their products. When regulations are absent or when loopholes exist in classifying HTP as a tobacco product (thus subject to all tobacco control regulations), the industry's marketing of HTP is making these products more visible to the public and more accessible. Governments need to ensure that HTP are regulated as tobacco products or drugs and reject partnerships with the tobacco companies to promote 'harm reduction'. The tobacco companies remain the vector of the tobacco-caused epidemic and cannot be part of the global tobacco control solution.

Revolution or redux? Assessing IQOS through a precursor product

Background

Philip Morris International (PMI) currently claims that its heated tobacco product, IQOS, reduces health risk by reducing users’ exposure to harmful and potentially harmful constituents present in tobacco smoke. Given the tobacco industry’s long history of misrepresenting and obfuscating research, independent assessment of PMI’s claims is important. Analysis of Accord, a failed but strikingly similar precursor to IQOS, may help contextualise PMI’s claims in its Modified Risk Tobacco Product (MRTP) application.

Methods

We analysed previously secret internal Philip Morris (PM) and PMI documents, public communications and MRTP application.

Results

PM marketed Accord as a ‘cleaner’ tobacco product in an attempt to address smokers’ growing health concerns without making explicit health claims. While PM communications asserted that Accord reduced users’ exposure to harmful constituents, company scientists and executives consistently stressed to both regulators and the public that such reductions did not render Accord safer. IQOS’s design and marketing are similar to Accord’s. On the basis of aerosol chemistry data, IQOS reduces user exposure to some compounds compared with Accord but raises them for others.

Discussion

IQOS appears to be a variant of Accord without consistent improvements in exposure to aerosol toxic compounds. In contrast to PM’s past claims for Accord, PMI now claims in its MRTP application that IQOS reduces health risk. This shift in stance is likely not the result of any toxicological difference between Accord and IQOS, but rather a change in the social and regulatory landscape permitting these claims.

Light and mild redux: heated tobacco products' reduced exposure claims are likely to be misunderstood as reduced risk claims

Introduction

Heated tobacco products (HTPs) are being marketed in several countries around the world with claims that they are less harmful than combusted cigarettes, based on assertions that they expose users to lower levels of toxicants. In the USA, Philip Morris International (PMI) has submitted an application to the Food and Drug Administration (FDA) in 2016 seeking authorisation to market its HTPs, IQOS, with reduced risk and reduced exposure claims.

Methods

We examined the PMI’s Perception and Behavior Assessment Studies evaluating perceptions of reduced risk claims that were submitted to the FDA and made publicly available.

Results

Qualitative and quantitative studies conducted by PMI demonstrate that adult consumers in the USA perceive reduced exposure claims as reduced risk claims.

Conclusion

The data in the PMI modified risk tobacco product IQOS application do not support reduced risk claims and the reduced exposure claims are perceived as reduced risk claims, which is explicitly prohibited by the FDA. Allowing PMI to promote IQOS as reduced exposure would amount to a legally sanctioned repeat of the ‘light’ and ‘mild’ fraud which, for conventional cigarettes, is prohibited by the US law and the WHO Framework Convention on Tobacco Control.