Heated tobacco has never attracted the same level of scientific attention as vaping – only about 10% as much research seems to be catalogued on PubMed, for example – and for years what work did exist on it was often regarded as tainted by Big Tobacco funding.
Indeed, when the Cochrane Tobacco Addiction Group looked at research up to January 2021, it found that all the credible randomised controlled trials (RCTs) on heated tobacco had been funded by tobacco companies – and even more importantly, concluded that there was no useful evidence on efficacy in smoking cessation, although there was a limited amount of positive evidence on reduced risk.
That largely remains the case, or at least the reputation. Despite the US Food and Drug Administration (FDA) granting modified risk tobacco product (MRTP) status to Philip Morris International’s (PMI’s) Iqos product almost three years ago, on the basis that “it significantly reduces the production of harmful and potentially harmful chemicals compared to cigarette smoke”, heated tobacco is widely considered to be less understood than vapour.
But things may now be changing, at least where the cessation part of the question is concerned – and it may mean that heated tobacco could become more serious competition for e-cigarettes in smoking cessation.
This is thanks to a new study by the Center of Excellence for the Acceleration of Harm Reduction (Cohear) at the University of Catania in Italy – a well-established unit founded by Riccardo Polosa, one of the most prominent researchers in tobacco harm reduction – which reports what seem to be very promising results on the use of heated tobacco to give up smoking.
The study, based on a project termed Ceasefire, was funded by Philip Morris and published in JMIR Public Health and Surveillance. It covered 220 heavy smokers, people consuming around a pack of combustibles a day, who had no plans to quit. They were divided into two groups, one receiving heated tobacco products (Iqos) and the other e-cigarettes (Justfog); given a choice from a limited number of flavours; and provided counselling.
Astonishingly high figures
At the end of the study, about 39% of those given heated tobacco products had stopped smoking for eight weeks, against about 31% of those given e-cigarettes. Of those who did continue smoking, nearly 50% of the heated tobacco users had nevertheless reduced their cigarette intake by more than half, against about 40% of those given vapes.
The figures are not only astonishingly high in themselves, but are also notable in seeming to put heated tobacco ahead of vaping as well as nicotine replacement therapy (NRT).
Of course, much further study and replication is needed before we can leap to the assumption that a magic bullet has been unearthed – a follow-up study at six months planned by Cohear will be of crucial importance in demonstrating whether these individuals have managed to give up permanently, or have relapsed to smoking.
And so will further work on the health impacts of heated tobacco. The general assumption is that it sits somewhere between very safe vaping and very dangerous smoking on the continuum of risk, and that might intuitively feel right, but the precise location on the continuum is important and (as Cochrane noted) the evidence is not particularly strong anyway. The value of switching to a reduced-risk product must depend in large part on the degree to which risk actually is reduced.
In the meantime, though, even if firm conclusions are premature, the very unequivocal results of this study are likely to encourage more work on the topic of heated tobacco in cessation – and, perhaps, attract the attention of researchers who have been more preoccupied with vapour.
– Barnaby Page ECigIntelligence staff