//Heated Tobacco: A history of harm reduction public health advocacy
Posted 15/09/2021 9:43am
As the comprehensive evidence-base substantiating heated tobacco builds, so does the number of endorsements from public health bodies, recognising the category’s dramatic harm reduction potential. Explore the timeline below to see some of its major milestones …
One of the most promising tobacco harm reduction (THR) innovations for adult smokers who would otherwise continue to smoke is heated tobacco (HT). By heating, not burning, a portion of refined tobacco an inhalable aerosol is produced that provides adult smokers with the nicotine, tobacco flavours and aromas they seek alongside far fewer and substantially lower levels of the harmful chemicals found in cigarette smoke.
In recent years, HT products have proven increasingly effective at transitioning adult smokers away from combustible cigarettes – providing the behavioural and sensorial elements of the smoking experience (including tobacco taste, aroma, and nicotine delivery), but in a potentially less harmful way. This ability to help adult smokers move away from combustible cigarettes, coupled with their lack of attractiveness to non-smokers, means they potentially have a key role to play in helping facilitate THR.
Now, both science and policy debates surrounding HT are developing apace. As the category’s significant THR potential becomes more apparent, more government health authorities and public health bodies are taking note and are proactively examining the substantial scientific evidence. This suggests that – to date – HT products are likely to be substantially less harmful than continued combustible cigarette smoking.
With increasing evidence that HT Next Generation Products have an important role to play in making a meaningful contribution to harm reduction strategies, many of these health authorities and public health bodies have conducted scientific literature reviews, or are even performing their own research on the category.
Below is a summary of recent findings from a number of health agencies and public health bodies following their review of the available scientific evidence underpinning HT products.
Milestones in THR
THR advocate Professor Riccardo Polosa publishes an academic paper investigating the long-term (3 years) health effects of heated tobacco use in patients with chronic obstructive pulmonary disease (COPD). His research suggests switching from cigarettes to heated tobacco products produce fewer exacerbations and better quality of life in COPD patients who either can’t or don’t want to quit smoking.
The German Cancer Research Center (Deutsches Krebsforschungsinstitut, Heidelberg) publishes an assessment on both vaping and HT in October 2020. The report states “presumably toxicants exposure due to consumption of heated tobacco products is lower compared to cigarettes but higher compared to EVP. Thus heated tobacco product are not risk-free / harmless. Given the yet unclear health risks and addictiveness of these products non-smokers should not use heated tobacco products and to protect non-smokers these products should only be used where smoking is permitted.”
After reviewing the extensive research, the US Food and Drug Administration (FDA) authorises a ‘modified risk tobacco product’ (MRTP) for a heated tobacco system, the second tobacco-containing product ever to receive the marketing order. It permits ensuing marketing to include the following statements:
- That the system “heats tobacco but does not burn it”
- In turn, this “significantly reduces the production of harmful and potentially harmful chemicals”
- Finally, “scientific studies have shown that switching completely from conventional cigarettes to the system significantly reduces your body’s exposure to harmful or potentially harmful chemicals.”
To understand the health impacts on individuals who transition to HT, compared to those who continued smoking, Dutch research institute the National Institute for Public Health and the Environment (RIVM) publishes a study on cumulative exposures to eight carcinogens in each product.
They found that – while not risk-free – HT was associated with 10 to 25 times lower exposure to these select carcinogens, and this could translate into a substantially reduced relative risk profile compared to combustible cigarettes.
The Superior Health Council issues an advisory report on heated tobacco, stating that in clinical studies, adults who transition from combustible cigarettes to heated tobacco show significant decreases in biomarkers of exposure to harmful chemicals. The Council said that while HTs are not deemed “completely safe”, favourable changes were noted in several biomarkers with biological impact – implying potentially the reduced risk of disease, provided smokers transitioned solely to heated tobacco.
Scientific media share study results comparing heated tobacco aerosol with cigarette smoke conducted by the China National Tobacco Quality Supervision and Test Centre (CNTQST), a member of the WHO Tobacco Laboratory Network. The CNTQST found HT contained fewer and lower levels of harmful toxicants than the combustible cigarette smoke, concluded this was caused by HT’s lower heating temperature.
The Eurasian Economic Commission (regulatory body of the Eurasian Union consisting of Armenia, Belarus, Kazakhstan, Kyrgyzstan and Russia) releases results of its own commissioned study. The research found significantly lower levels of toxicants in the aerosol generated by the device compared to combustible cigarette smoke.
The UK House of Commons Science and Technology Committee publishes a report of its inquiry into vaping and heated tobacco. The report concluded:
- HTs “contain tobacco which is heated rather than combusted, and is therefore likely to be less harmful compared to conventional cigarettes.”
- For those adult smokers who don’t accept vaping, HT may offer a public health benefit compared to continued smoking.
- Called for a risk-proportionate regulatory environment for both vaping and heated tobacco, noting that vapes should remain the least taxed, cigarettes the most taxed, with HT falling between the two.
The South Korean Food and Drug Administration (KFDA) (now known as the Ministry of Food and Drug Safety, or MFDS) issues a statement after completing tests on three HT products. Results confirmed the levels of the nine harmful or potentially harmful constituents in the aerosol of these products were on average 90% lower compared to levels in the smoke from South Korea’s top five cigarette brands.
The Federal Institute for Risk Assessment (BfR) releases a study on HT aerosol compared to combustible cigarette smoke using the Health Canada Intense smoking regime, finding reductions in select toxicants of between 80-99%. This publication indicates that significant reductions in the levels of selected toxicants are likely to reduce toxicant exposure, which BfR stated might be regarded as a “discrete benefit” compared to combustible cigarettes.
The National Institute for Public Health and Environment (RIVM) publishes a factsheet on HT. After analysing its aerosol, RIVM concluded that the use of HT, while still harmful to health, is probably less harmful for adults who would otherwise have continued to smoke.
For the first time, Public Health England (PHE) includes heated tobacco in its regular evidence review on cigarette alternatives. It states heated tobacco is “likely to expose users and bystanders to lower levels of particulate matter and harmful and potentially harmful compounds” compared with cigarette smoke. The review also concludes that the available evidence suggests heated tobacco may be much less harmful than cigarettes but more harmful than vaping.
At the request of the UK Department of Health and Public Health England, the UK Committee on Toxicity publishes an assessment of the risk of HT compared to combustible cigarette smoking. It concluded, while still harmful to health, compared with the known risks from smoking, heated products are probably much less harmful.
The Japanese Institute of Public Health releases a study comparing concentrations of several harmful compounds (tar, carbon monoxide and tobacco-specific nitrosamines) in the mainstream aerosol and filters fillers in a HT system, compared with those from combustible cigarettes. While nicotine levels in the heated tobacco aerosol were comparable, the concentrations of TSNAs were – according to researchers – 80% lower and carbon monoxide 99% lower to those in combustibles.