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Ghazi S, Song MA, El-Hellani A. A scoping review of the toxicity and health impact of IQOS. Tob Induc Dis 2024; 22:TID-22-97. [PMID: 38832049 PMCID: PMC11145630 DOI: 10.18332/tid/188867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 05/14/2024] [Accepted: 05/18/2024] [Indexed: 06/05/2024] Open
Abstract
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.
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Affiliation(s)
- Sarah Ghazi
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus OH, United States
| | - Min-Ae Song
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus OH, United States
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus OH, United States
| | - Ahmad El-Hellani
- Division of Environmental Health Sciences, College of Public Health, The Ohio State University, Columbus OH, United States
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus OH, United States
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Berg CJ, Duan Z, Wang Y, Thrasher JF, Bar-Zeev Y, Abroms LC, Romm KF, Khayat A, Levine H. Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults. Tob Control 2024; 33:e69-e77. [PMID: 36428095 DOI: 10.1136/tc-2022-057639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Carla J Berg
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Zongshuan Duan
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Yan Wang
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia, South Carolina, USA
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Lorien C Abroms
- Department of Prevention and Community Health, The George Washington University Milken Institute School of Public Health, Washington, District of Columbia, USA
| | - Katelyn F Romm
- Department of Pediatrics, College of Medicine; TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
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Tao X, Zhang J, Meng Q, Chu J, Zhao R, Liu Y, Dong Y, Xu H, Tian T, Cui J, Zhang L, Chu M. The potential health effects associated with electronic-cigarette. ENVIRONMENTAL RESEARCH 2024; 245:118056. [PMID: 38157958 DOI: 10.1016/j.envres.2023.118056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/17/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
A good old gateway theory that electronic-cigarettes (e-cigarettes) are widely recognized as safer tobacco substitutes. In actuality, demographics also show that vaping cannibalizes smoking, the best explanation of the data is the "common liability". However, the utilization of e-cigarette products remains a controversial topic at present. Currently, there has been a widespread and substantial growth in e-cigarette use worldwide owing to their endless new flavors and customizable characteristics. Furthermore, e-cigarette has grown widespread among smokers as well as non-smokers, including adolescents and young adults. And some studies have shown that e-cigarette users are at greater risk to start using combustible cigarettes while e-cigarettes use was also observed the potential benefits to people who want to quit smoking or not. Although it is true that e-cigarettes generally contain fewer toxic substances than combustible cigarettes, this does not mean that the chemical composition in e-cigarettes aerosols poses absolutely no risks. While concerns about toxic substances in e-cigarettes and their widespread use in the population are reasonable, it is also crucial to consider that e-cigarettes have been associated with the potential for promoting smoking cessation and the clinically relevant improvements in users with smoking-related pathologies. Meanwhile, there is still short of understanding of the health impacts associated with e-cigarette use. Therefore, in this review, we discussed the health impacts of e-cigarette exposure on oral, nasal, pulmonary, cardiovascular systems and brain. We aspire for this review to change people's previous perceptions of e-cigarettes and provide them with a more balanced perspective. Additionally, we suggest appropriate adjustments on regulation and policy for e-cigarette to gain greater public health benefits.
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Affiliation(s)
- Xiaobo Tao
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Jiale Zhang
- The Second People's Hospital of Nantong, Nantong, Jiangsu, China
| | - Qianyao Meng
- Department of Global Health and Population, School of Public Health, Harvard University, Boston, USA
| | - Junfeng Chu
- Department of Oncology, Jiangdu People's Hospital of Yangzhou, Yangzhou, Jiangsu, China
| | - Rongrong Zhao
- Department of Oncology, Jiangdu People's Hospital of Yangzhou, Yangzhou, Jiangsu, China
| | - Yiran Liu
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Yang Dong
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Huiwen Xu
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Tian Tian
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Jiahua Cui
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China
| | - Lei Zhang
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China.
| | - Minjie Chu
- Department of Epidemiology, School of Public Health, Nantong University, Nantong, Jiangsu, China.
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Braznell S, Campbell J, Gilmore AB. What Can Current Biomarker Data Tell Us About the Risks of Lung Cancer Posed by Heated Tobacco Products? Nicotine Tob Res 2024; 26:270-280. [PMID: 37210693 PMCID: PMC10882439 DOI: 10.1093/ntr/ntad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/18/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Heated tobacco products (HTPs) are marketed as less harmful alternatives to cigarettes, but the lung cancer risk of HTPs is unknown. In the absence of epidemiological data, assessing the risks of HTPs relies on biomarker data from clinical trials. This study examined existing biomarker data to determine what it tells us about the lung cancer risk posed by HTPs. AIMS AND METHODS We identified all biomarkers of exposure and potential harm measured in HTP trials and evaluated their appropriateness based on ideal characteristics for measuring lung cancer risk and tobacco use. The effects of HTPs on the most appropriate biomarkers within cigarette smokers switched to HTPs and compared to continued cigarette smoking or cessation were synthesized. RESULTS Sixteen out of eighty-two biomarkers (7 exposure and 9 potential harm) measured in HTP trials have been associated with tobacco use and lung cancer, dose-dependently correlated with smoking, modifiable upon cessation, measured within an appropriate timeframe, and had results published. Three of the exposure biomarkers significantly improved in smokers who switched to HTPs and were not significantly different from cessation. The remaining 13 biomarkers did not improve-in some instances worsening upon switching to HTPs-or were inconsistently affected across studies. There were no appropriate data to estimate the lung cancer risk of HTPs in non-smokers. CONCLUSIONS The appropriateness of existing biomarker data in assessing lung cancer risk of HTPs, both relative to cigarettes and their absolute risk, is limited. Furthermore, findings on the most appropriate biomarkers were conflicting across studies and largely showed no improvement following a switch to HTPs. IMPLICATIONS Biomarker data are fundamental to assessing the reduced risk potential of HTPs. Our evaluation suggests much of the existing biomarker data on HTPs is inappropriate for determining the risk of lung cancer posed by HTPs. In particular, there is a paucity of data on the absolute lung cancer risk of HTPs, which could be obtained from comparisons to smokers who quit and never smokers exposed to or using HTPs. There is an urgent need for further exploration of the lung cancer risks posed by HTPs, via clinical trials and, in the long-term, confirmation of these risks via epidemiological studies. However, careful consideration should be given to biomarker selection and study design to ensure both are appropriate and will provide valuable data.
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Affiliation(s)
- Sophie Braznell
- Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
| | | | - Anna B Gilmore
- Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
- SPECTRUM (Shaping Public Health Policies to Reduce Inequalities and Harm) Consortium, Bath, UK
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Berg CJ, Duan Z, Wang Y, Thrasher JF, Abroms LC, Khayat A, Romm KF, Levine H, Bar-Zeev Y. Impact of different health warning label and reduced exposure messages in IQOS ads on perceptions among US and Israeli adults. Prev Med Rep 2023; 33:102209. [PMID: 37223575 PMCID: PMC10201851 DOI: 10.1016/j.pmedr.2023.102209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 05/25/2023] Open
Abstract
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.
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Affiliation(s)
- Carla J. Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Zongshuan Duan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Yan Wang
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - James F. Thrasher
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Lorien C. Abroms
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Katelyn F. Romm
- TSET Health Promotion Research Center, Stephenson Cancer Center; Department of Pediatrics, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem, Israel
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Levine H, Duan Z, Bar-Zeev Y, Abroms LC, Khayat A, Tosakoon S, Romm KF, Wang Y, Berg CJ. IQOS Use and Interest by Sociodemographic and Tobacco Behavior Characteristics among Adults in the US and Israel. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3141. [PMID: 36833831 PMCID: PMC9961058 DOI: 10.3390/ijerph20043141] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
Heated tobacco products (HTPs) have expanded globally. IQOS, a global HTP leader, was launched in Israel in 2016 and the US in 2019. To inform tobacco control efforts, it is critical to understand who is likely to use HTPs in different countries with distinct regulatory and marketing contexts. Thus, we conducted a cross-sectional survey among adult (ages 18-45) online panelists in the US (n = 1128) and Israel (n = 1094), oversampling tobacco users, in the fall of 2021, and used multivariable regression to identify correlates of (1) ever using IQOS; (2) past-month vs. former among ever users; and (3) interest in trying IQOS among never users. Among US adults, correlates of ever use included being Asian (aOR = 3.30) or Hispanic (aOR = 2.83) vs. White, and past-month use of cigarettes (aOR = 3.32), e-cigarettes (aOR = 2.67), and other tobacco (aOR = 3.34); in Israel, correlates included being younger (aOR = 0.97), male (aOR = 1.64), and cigarette (aOR = 4.01), e-cigarette (aOR = 1.92) and other tobacco use (aOR = 1.63). Among never users, correlates of greater interest included cigarette and e-cigarette use in the US (β = 0.57, β = 0.90) and Israel (β = 0.88, β = 0.92). IQOS use prevalence was low (US: 3.0%; Israel: 16.2%) but represented in vulnerable subpopulations (younger adults, racial/ethnic minorities).
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Affiliation(s)
- Hagai Levine
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Zongshuan Duan
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Lorien C. Abroms
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, Faculty of Medicine, The Hebrew University of Jerusalem and Hadassah, Jerusalem 9112002, Israel
| | - Sararat Tosakoon
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Katelyn F. Romm
- TSET Health Promotion Research Center, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Yan Wang
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
| | - Carla J. Berg
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA
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El-Kaassamani M, Yen M, Talih S, El-Hellani A. Analysis of mainstream emissions, secondhand emissions and the environmental impact of IQOS waste: a systematic review on IQOS that accounts for data source. Tob Control 2022; 33:tobaccocontrol-2021-056986. [PMID: 35568394 DOI: 10.1136/tobaccocontrol-2021-056986] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 05/05/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To highlight the general features of IQOS literature focusing on the chemical analysis of IQOS emissions. DATA SOURCES PubMed, Web of Science and Scopus databases were searched on 8 November 2021 using the terms 'heated tobacco product', 'heat-not-burn', 'IQOS' and 'tobacco heating system' with time restriction (2010-2021). The search yielded 5480 records. STUDY SELECTION Relevant publications on topics related to IQOS assessment were retrieved (n=341). Two reviewers worked separately and reached agreement by consensus. DATA EXTRACTION Data on author affiliation and funding, article type and date of publication were extracted. Publications were categorised depending on their focus and outcomes. Data on IQOS emissions from the chemical analysis category were extracted. DATA SYNTHESIS Of the included publications, 25% were published by Philip Morris International (PMI) affiliates or PMI-funded studies. PMI-sponsored publications on emissions, toxicology assessments and health effects were comparable in number to those reported by independent research, in contrast to publications on IQOS use, market trends and regulation. Data on nicotine yield, carbonyl emissions, other mainstream emissions, secondhand emissions and IQOS waste were compared between data sources to highlight agreement or disagreement between PMI-sponsored and independent research. CONCLUSIONS Our analysis showed agreement between the data sources on nicotine yield from IQOS under the same puffing conditions. Also, both sources agreed that IQOS emits significantly reduced levels of some emissions compared with combustible cigarettes. However, independent studies and examination of PMI's data showed significant increases in other emissions from and beyond the Food and Drug Administration's harmful and potentially harmful constituents list.
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Affiliation(s)
- Malak El-Kaassamani
- Department of Chemistry, American University of Beirut Faculty of Arts and Sciences, Beirut, Lebanon
| | - Miaoshan Yen
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Soha Talih
- Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Mechanical Engineering, American University of Beirut Faculty of Engineering and Architecture, Beirut, Lebanon
| | - Ahmad El-Hellani
- Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
- Division of Environmental Health Sciences, The Ohio State University College of Public Health, Columbus, Ohio, USA
- Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
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Sánchez-Romero LM, Yuan Z, Li Y, Levy DT. The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use. Int J Health Policy Manag 2022; 11:592-609. [PMID: 33131221 PMCID: PMC9309926 DOI: 10.34172/ijhpm.2020.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 09/26/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model. METHODS Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060. RESULTS SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060. CONCLUSION Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.
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Affiliation(s)
| | - Zhe Yuan
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Yameng Li
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - David T. Levy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
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Berg CJ, Abroms LC, Levine H, Romm KF, Khayat A, Wysota CN, Duan Z, Bar-Zeev Y. IQOS Marketing in the US: The Need to Study the Impact of FDA Modified Exposure Authorization, Marketing Distribution Channels, and Potential Targeting of Consumers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10551. [PMID: 34639851 PMCID: PMC8508084 DOI: 10.3390/ijerph181910551] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Carla J. Berg
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA; (L.C.A.); (K.F.R.); (C.N.W.); (Z.D.)
- GW Cancer Center, George Washington University, Washington, DC 20052, USA
| | - Lorien C. Abroms
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA; (L.C.A.); (K.F.R.); (C.N.W.); (Z.D.)
- GW Cancer Center, George Washington University, Washington, DC 20052, USA
| | - Hagai Levine
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem and Hadassah Medical Organization, Jerusalem 9112102, Israel; (H.L.); (A.K.); (Y.B.-Z.)
| | - Katelyn F. Romm
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA; (L.C.A.); (K.F.R.); (C.N.W.); (Z.D.)
| | - Amal Khayat
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem and Hadassah Medical Organization, Jerusalem 9112102, Israel; (H.L.); (A.K.); (Y.B.-Z.)
| | - Christina N. Wysota
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA; (L.C.A.); (K.F.R.); (C.N.W.); (Z.D.)
| | - Zongshuan Duan
- Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA; (L.C.A.); (K.F.R.); (C.N.W.); (Z.D.)
| | - Yael Bar-Zeev
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem and Hadassah Medical Organization, Jerusalem 9112102, Israel; (H.L.); (A.K.); (Y.B.-Z.)
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Wang H, Chen H, Huang L, Li X, Wang L, Li S, Liu M, Zhang M, Han S, Jiang X, Fu Y, Tian Y, Hou H, Hu Q. In vitro toxicological evaluation of a tobacco heating product THP COO and 3R4F research reference cigarette on human lung cancer cells. Toxicol In Vitro 2021; 74:105173. [PMID: 33848590 DOI: 10.1016/j.tiv.2021.105173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/28/2021] [Accepted: 04/09/2021] [Indexed: 12/01/2022]
Abstract
Cigarette smoking increases health risks, such as respiratory diseases and heart diseases. Despite the decline in smoking rates in some countries, millions of adults still choose to smoke cigarettes. The use of next-generation nicotine delivery devices, such as tobacco heating products (THPs), may become a potentially safer alternative to smoking. Here, we report on the development of an electrically heated THP, coded as THP COO, with three different flavored tobacco sticks. The purpose of the study was to measure the levels of a list of harmful and potentially harmful constituents (HPHCs) in the total particulate matter (TPM) generated and to conduct a set of toxicological assessments of THP COO as compared with 3R4F reference cigarette. For all 55 HPHCs identified, the levels generated by the THP tobacco sticks were significantly lower in comparison to those in 3R4F TPM. The rate of reduction of HPHCs was between 68.6% and 99.9% under Health Canada Intense (HCI) smoking regimen. Human lung cancer cells (NCI-H292) exposed to 3R4F TPM showed dose-dependent responses for most of the 15 in vitro toxicity endpoints, whereas those exposed to comparable doses of THP COO TPMs did not. Therefore, exclusive use of the THP COO products may reduce the exposure of those tested HPHCs and thus potentially reduce health risk of smoking.
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Affiliation(s)
- Hongjuan Wang
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Huan Chen
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Long Huang
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Xiangyu Li
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Lulu Wang
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Shigang Li
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Min Liu
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Manying Zhang
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Shulei Han
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Xingyi Jiang
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Yaning Fu
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Yushan Tian
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China
| | - Hongwei Hou
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China.
| | - Qingyuan Hu
- China National Tobacco Quality Supervision and Test Center, Zhengzhou, China.
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11
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Lempert LK, Bialous S, Glantz S. FDA's reduced exposure marketing order for IQOS: why it is not a reliable global model. Tob Control 2021; 31:e83-e87. [PMID: 33811155 PMCID: PMC8486889 DOI: 10.1136/tobaccocontrol-2020-056316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Lauren Kass Lempert
- Center for Tobacco Control Research & Education, UCSF, San Francisco, California, USA
| | - Stella Bialous
- Department of Social and Behavioral Sciences, School of Nursing, UCSF, San Francisco, California, USA
| | - Stanton Glantz
- Center for Tobacco Control Research & Education, UCSF, San Francisco, California, USA
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12
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Association between Electronic Cigarette Use and Asthma in Never-Smokers. Ann Am Thorac Soc 2020; 16:1453-1456. [PMID: 31404509 DOI: 10.1513/annalsats.201904-338rl] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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13
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Lempert LK, Glantz S. Analysis of FDA's IQOS marketing authorisation and its policy impacts. Tob Control 2020; 30:tobaccocontrol-2019-055585. [PMID: 32601147 PMCID: PMC7952009 DOI: 10.1136/tobaccocontrol-2019-055585] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/29/2020] [Accepted: 05/05/2020] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Lauren Kass Lempert
- Center for Tobacco Control Research & Education, University of California, San Francisco, California, USA
| | - Stanton Glantz
- Center for Tobacco Control Research & Education, University of California, San Francisco, California, USA
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14
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Cruz-Jiménez L, Barrientos-Gutiérrez I, Coutiño-Escamilla L, Gallegos-Carrillo K, Arillo-Santillán E, Thrasher JF. Adult Smokers' Awareness and Interest in Trying Heated Tobacco Products: Perspectives from Mexico, where HTPs and E-Cigarettes Are Banned. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2173. [PMID: 32218161 PMCID: PMC7177513 DOI: 10.3390/ijerph17072173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Lizeth Cruz-Jiménez
- Evaluation and Surveys Research Center, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico;
| | - Inti Barrientos-Gutiérrez
- Evaluation and Surveys Research Center, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico;
| | - Liliana Coutiño-Escamilla
- Tobacco Research Department, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico; (L.C.-E.); (K.G.-C.); (E.A.-S.)
| | - Katia Gallegos-Carrillo
- Tobacco Research Department, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico; (L.C.-E.); (K.G.-C.); (E.A.-S.)
- Epidemiology and Health Services Research Unit, Mexican Institute of Social Security, Cuernavaca, Mor 62000, Mexico
| | - Edna Arillo-Santillán
- Tobacco Research Department, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico; (L.C.-E.); (K.G.-C.); (E.A.-S.)
- School of Demography, Australian National University, Canberra 0200, Australia
| | - James F. Thrasher
- Tobacco Research Department, National Institute of Public Health, Cuernavaca, Mor 62100, Mexico; (L.C.-E.); (K.G.-C.); (E.A.-S.)
- Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA
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15
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Berg CJ, Bar-Zeev Y, Levine H. Informing iQOS Regulations in the United States: A Synthesis of What We Know. SAGE OPEN 2020; 10:10.1177/2158244019898823. [PMID: 32719733 PMCID: PMC7384757 DOI: 10.1177/2158244019898823] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Carla J. Berg
- The George Washington University, Washington, DC, USA
| | | | - Hagai Levine
- The Hebrew University of Jerusalem, Israel
- Hadassah Ein Kerem Medical Center, Jerusalem, Israel
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16
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Cho HJ. Comparison of the risks of combustible cigarettes, e-cigarettes, and heated tobacco products. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.2.96] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hong-Jun Cho
- Department of Family Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Mallock N, Pieper E, Hutzler C, Henkler-Stephani F, Luch A. Heated Tobacco Products: A Review of Current Knowledge and Initial Assessments. Front Public Health 2019; 7:287. [PMID: 31649912 PMCID: PMC6795920 DOI: 10.3389/fpubh.2019.00287] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/20/2019] [Indexed: 01/29/2023] Open
Abstract
The health risks of tobacco smoking have been documented in numerous studies and smoking rates have declined in developed countries over the last 50 years. Today, we know that cigarette smoking is the major cause of preventable deaths due to tobacco smoke induced diseases. As a consequence of an increased awareness of smoking-related health risks, heated tobacco products (HTPs) are marketed as reduced toxicant alternatives to conventional tobacco products. Manufacturers claim that levels of toxicants and hazardous compounds are significantly reduced, implying that inhalation of the modified aerosol is less harmful compared to conventional cigarettes. In this manuscript, previous assessments of HTPs are briefly summarized, including a short discussion on challenges with the adaption of standard analytical methods used for tobacco smoke. The reliability of analytical data is important for risk assessment approaches that are based on reduced toxicant exposure. In order to assess a putative reduction of health risks, an integrated study design is required that should include clinical studies and epidemiology data. One manufacturer applied for a classification as a Modified Risk Tobacco Product (MRTP) in the United States, based on extensive toxicological studies that have also been published. However, data are not yet sufficient for a reliable assessment or recognition of putatively reduced health risks. Challenges regarding a classification in Europe are also discussed briefly in this review.
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Affiliation(s)
- Nadja Mallock
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Elke Pieper
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Christoph Hutzler
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Frank Henkler-Stephani
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
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18
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Ioannidis JPA. Lethal news: The dexterous infiltration of news media by the tobacco industry agenda. Eur J Clin Invest 2019; 49:e13125. [PMID: 31058313 DOI: 10.1111/eci.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California.,Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California.,Departments of Health Research and Policy, of Biomedical Data Science, and of Statistics, Stanford University, Stanford, California
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19
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Affiliation(s)
- Stanton A Glantz
- Department of Medicine, Center for Tobacco Control Research and Education, Cardiovascular Research Institute, Philip R. Lee Institute for Health Policy Studies, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA 94143-1390, USA
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20
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Bialous SA, Glantz SA. Heated tobacco products: another tobacco industry global strategy to slow progress in tobacco control. Tob Control 2018; 27:s111-s117. [PMID: 30209207 PMCID: PMC6202178 DOI: 10.1136/tobaccocontrol-2018-054340] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Stella A Bialous
- Center for Tobacco Control, UCSF, San Francisco, California, USA
- Social and Behavioral Sciences, School of Nursing UCSF, San Francisco, California, USA
| | - Stanton A Glantz
- Division of Cardiology, University of California, San Francisco, San Francisco, California, USA
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