Prof Rima Nakkash: there was no evidence of improvement in pulmonary inflammation or pulmonary function in cigarette smokers who were switched to IQOS

Following up the media campaign regarding IQOS that Philip Moris is doing through media al-khabar interviewed  the Associate. Director of the Knowledge to Policy Center a and the WHO FCTC Knowledge Hub for. Waterpipe tobacco smoking at AUB Prof Rima nakkach To ask her if IQOS have really a positive impact on quitting smoking as the adds mentions.

 

  1. Why using IQOS is considered as Smoking?

Both eCigs and IQOS may represent a gateway for nicotine addiction among never-smokers rather than a substitute used for harm-reduction purposes in current smokers [4].

In a study that investigated reasons people smoked IQOS they reported six main factors influenced initiation and use of IQOS:

 

  • Health—wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm.
  • Financial—including high start-up costs, but cheaper ongoing costs than smoking.
  • Physical—mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes.
  • Practical—issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use.
  • Psychological similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology.
  • Social—improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some. (Tompkins et al, 2021)

 

IQOS is an electronic device, the FDA has classified it as a cigarette, which means the product is subject to all the same existing restrictions for traditional cigarettes. (The truth initiative, 2019)

WHO released a statement on heated tobacco products and the US FDA decision regarding IQOS (June 2020) saying that heated tobacco products are tobacco products, meaning that the WHO FCTC fully applies to these products. (Decision FCTC/COP8(22)) Specifically, Article 13.4(a) obliges Parties, to prohibit “all forms of tobacco advertising, promotion and sponsorship that promote a tobacco product by any means that are false, misleading or deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions.”

 

  1. How does this technology works?
  • Heat-not-burn tobacco products, also called heated tobacco products, are electronic devices that heat tobacco leaves to produce an inhalable aerosol, instead of burning tobacco like traditional cigarettes. Heat-not-burn products are different from e-cigarettes because they use actual tobacco, not the flavored e-liquid typically found in e-cigarettes. The concept behind heat-not-burn is that it allows users to experience what looks and feels like smoking a regular cigarette without inhaling combusted tobacco. (The truth initiative)
  • Heat not burn products release nicotine-containing, tobacco-flavored vapor without generating the hallmarks of combustion: fire, smoke, and ash. IQOS by Philip Morris achieves this by heating tobacco to a temperature of 350°C, compared with traditional cigarettes, which reach temperatures greater than 600°C. IQOS consists of a rechargeable holding device and a tobacco unit. The tobacco unit is made from tobacco leaves that have been ground, compressed into sheets, and compiled into a plug which resembles a short cigarette. This plug is inserted into the holder, which contains a heated blade and safety mechanisms to prevent burning (PMI, 2020)

 

  1. What are the differences between IQOS and the usual cigarette?
  • Tobacco companies claim that heat-not-burn products are less harmful than cigarettes because when tobacco burns, or combusts, it produces more than 7,000 chemicals that are found in cigarette smoke. (The Truth Initiative, 2019)

 

  1. Is there really any difference on the health of the smoker and why they proclaim so?
  • Research shows that although IQOS may have lower levels of some toxicants than cigarettes, it can still expose users to higher levels of other toxicants. Likewise, IQOS could expose users to lower risks of some diseases, but higher risks of others (The Truth Initiative, 2019).

 

  1. Is there really any difference on the health of the smoker and why they proclaim so?

Among rats exposed to IQOS, there was evidence of pulmonary inflammation and immunomodulation. In human users, there was no evidence of improvement in pulmonary inflammation or pulmonary function in cigarette smokers who were switched to IQOS.

IQOS is associated with significant pulmonary and immunomodulatory toxicities with no detectable differences between conventional cigarette smokers and those who were switched to IQOS in Philip Morris International’s studies. Philip Morris International also failed to consider how dual use and secondhand aerosol exposure may further impact, and likely increase, the harms associated with these products.

Short-term use of IQOSTM has a minimal impact on eCO, is equally effective in reducing cigarette craving and withdrawal symptoms as an e-cigarette, and is slightly preferred (Glantz, 2020)

 

  1. Is it true that IQOS will help the smoker to quit smoking and if it is not . why not and if yes how so ? does it really help ?

 

Tobacco tactics from the university of bath, wrote a page on their website describes some of PMI’s attempts to enter the ‘cessation space’ with IQOS by reviewing independent academic peer reviewed research.

  • Use of the terms “cessation” and “quitting” varies, even within public health, and can be conceptualized in different ways, for example:

Quitting/cessation of smoked tobacco products

Quitting/cessation of any tobacco product

Quitting/cessation of any nicotine product

  • Products containing, or derived from, tobacco do not necessarily fall neatly into these categories, as definitions vary globally for the purposes of regulation and cessation. If it is accepted that HTPs are not ‘smoked’ (i.e. that the tobacco does not combust, or produce smoke, which is a contested claim) (Stopping Tobacco Organisations and Products/Tobacco Control Research Group, 2020; Auer et al, 2017) then HTPs could arguably be described in the same way as e-cigarettes, as tools for quitting smoked (combusted) tobacco. However, HTPs contain tobacco leaf sticks and therefore using them instead of cigarettes cannot be described as quitting tobacco products.

In the UK, the focus is on “stopping smoking”, generally referring to smoking cigarettes and other combustible products, and HTPs are not currently accepted as cessation tools (National Institute for Health Care and Excellence, 2018). The WHO defines tobacco cessation as “the process of stopping the use of any tobacco product, with or without assistance” (WHO, 2020; WHO, 2010).  This definition encompasses HTPs like IQOS. Some advocates, particularly those operating in low and middle income countries, might also include e-cigarettes in cessation goals, along with HTPs, and encourage their governments to ban them outright (the union, 2020).

  • The tobacco industry is able to take advantage of this diversity of opinion (Mowls Caroll et al, 2020)  and different attitudes towards harm reductionmore broadly, to further its own commercial interests
  • Countries like New Zealand, Australia and Mexico banned IQOS as a cessation tool (tobacco tactics, university of bath)
  • TCRG researchers have stated that until the relative health risks are determined, HTPs, including IQOS, have no public health role: (Gilmore & Braznell, 2020) “There is currently no evidence that IQOS helps smokers quit. Smokers wishing to quit should use products shown to be safe and effective in line with national and international guidance.” (Braznell, Gilmore & Rowell, 2020; Muanya, 2020)

 

  1. Any researcher proved that it really helps the smoker to quit smoking?

Academic research on “switching” and quitting (TCRG bath university)

  • Academic research published in 2020 by McKelvey et al. reviewed PMI’s IQOS evidence, which underpinned its pre-market tobacco product application (PMTA) and modified risk tobacco product application (MRTPA) to the FDA. The researchers identified a number of design flaws in PMI’s studies, notably around the concept of “switching completely” (McKelvey et al, 2018). While some terms, including ‘reduced’ and ‘eliminated’ were tested with participants, the term ‘completely switch’ was not validated to ensure it was understood. Respondents who reported to having ‘completely switched’ to IQOS, therefore, may have meant a variety of things, from exclusive use of IQOS to maintaining a low level of cigarette use. The authors noted that in PMI’s analysis there “was no category for ‘switching completely’ from cigarettes to IQOS. The ‘exclusive’ IQOS category included individuals at 95%–100% IQOS use, not necessarily completely switched” (McKelvey et al, 2018). See below for more details of these studies and their weaknesses.

 

  • Other research by Luk et al., published in September 2020, took a longer view than PMI and analysed data from a six month cessation trial in Hong Kong. While HTPs were not officially marketed in Hong Kong, they were easily obtainable online, and this study indicated rapid uptake with 10% of smokers starting to use IQOS in the trial period.  The researchers found that while HTP use alone was not associated with abstinence from cigarettes after six months, individuals also using cessation services were more likely to have quit (Luk et al, 2020).

 

  1. Why should the government consider the Users of IQOS as part of the smoking areas in public places?

 

  • Tobacco companies are attempting to undermine government regulation by using harm reduction claims as a strategy for reframing the industry as part of the solution instead of part of the problem, according to commentary in Tobacco Control.
  • “[Heated tobacco products] are the latest effort by tobacco companies to adapt to a changing regulatory landscape to maintain and expand their customer base amid declining social acceptability of tobacco use and declining cigarette consumption,” the commentary stated. “Where regulations are absent or loopholes exempt [heated tobacco products] from existing regulations, companies market [heated tobacco products] to increase social acceptability for all their tobacco products.” (tobacco control, 2018)
  • As mentioned before It is classified by the FDA as a cigarette which means that any law on cigarettes should cover IQOS too. (The Truth Initiative, 2019)

 

  1. Does it have any impact on the 2nd receiver ?

 

A research group at Sapienza University of Rome has conducted multiple studies on HNB tobacco product-associated particulate matter.

  • In one study by Protano et al (2020), participants were placed in a small room, given a tobacco product (a combustible cigarette, an electronic cigarette, or one of two HNB products) and asked to puff once every 30 s (12 puffs per 5 1/2-min session) (Fried & Particulate matter levels were assessed using a laser-based aerosol analyzer, placed to mimic the location of a second-hand smoke recipient. Particulate matter with diameters less than 1 µm, 2.5 µm, 4 µm, and 10 µm (PM1, PM5, PM4, and PM10) was elevated by all products, with most of the emissions falling into the PM1category. HNB tobacco products had significantly higher emissions of PM1 when compared with electronic cigarettes, but significantly lower emissions compared with the combustible cigarette
  • Another study by Protano et al (2016), followed a similar protocol to compare the submicronic particles (SMPs, diameter less than 560 nm) generated in the second-hand smoke of cigarettes, electronic cigarettes, and IQOS in a small room
  • IQOS generated one-fourth of the SMPs of combustible cigarettes, and ambient SMPs from IQOS reduced more rapidly than those from cigarettes. The particles comprising IQOS second-hand smoke were sufficiently small to result in significant alveolar deposition. The particulate emissions from IQOS systems may be especially detrimental to at-risk populations, such as young children. Particle dosimetry modeling of the second-hand emissions of multiple tobacco products showed an inverse relationship between age and dose received, with 3-mo-old infants receiving the highest dose (Protano, Anigrasso, Avino & Vitali, 2017).

 

  1. What the awareness campaigns regarding IQOS should focus on?

We don’t only need awareness campaigns in order to control use of this product . First we need to make clear the adverse effects of IQOS smoking on first and second-hand smokers . IQOS is not a safe and healthy alternative for cigarette smoking. What is more important is regulating the use of this tobacco product and the marketing and advertising of it as safe alternative to smoking.

 

References:

 

  • Adriaens, K., Gucht, D., & Baeyens, F. (2018). IQOSTM vs. e-Cigarette vs. Tobacco Cigarette: A Direct Comparison of Short-Term Effects after Overnight-Abstinence. International Journal Of Environmental Research And Public Health15(12), 2902. doi: 10.3390/ijerph15122902
  • Auer, R., Concha-Lozano, N., Jacot-Sadowski, I., Cornuz, J., & Berthet, A. (2017). Heat-Not-Burn Tobacco Cigarettes. JAMA Internal Medicine177(7), 1050. doi: 10.1001/jamainternmed.2017.1419
  • Başaran, R., Güven, N. M., & Eke, B. C. (2019). An Overview of iQOS® as a New Heat-Not-Burn Tobacco Product and Its Potential Effects on Human Health and the Environment. Turkish journal of pharmaceutical sciences, 16(3), 371–374. https://doi.org/10.4274/tjps.galenos.2018.79095
  • Braznell, S., A.B. Gilmore, A.B., Rowell, A. (2020). FDA does not rule that IQOS reduces tobacco-related harm, yet PMI still claims victory, STOP briefing https://exposetobacco.org/wp-content/uploads/STP054_FDA_IQOS_Brief_v3.pdf
  • Gilmore, A., & Braznell, S. (2020). US regulator adds to confusion around heated tobacco products. BMJ, m3528. doi: 10.1136/bmj.m3528
  • Glantz, S. 2020. PMI’s own data shows IQOS is as bad for lungs as a cigarette, including depressing immune function. University of California San Francisco, Center for Tobacco control Research and Education.
  • Luk, T.T, Weng, X., Wu, Y.S., et al. (2020). Association of heated tobacco product use with smoking cessation in Chinese cigarette smokers in Hong Kong: a prospective study, Tobacco Control, doi:10.1136/tobaccocontrol-2020-055857
  • McKelvey, K., Popova, L., Kim, M., et al (2018) IQOS labelling will mislead consumers, Tobacco Control, doi:10.1136/tobaccocontrol-2018-054333
  • Mowls Carroll, D., Denlinger-Apte, R.L., Dermody, S.S. et al. (2020) Polarization Within the Field of Tobacco and Nicotine Science and its Potential Impact on Trainees, Nicotine & Tobacco Research, https://academic.oup.com/ntr/article/23/1/36/5890529
  • Muanya, C. (2020)  Confusion over IQOS as modified risk tobacco product. The Guardian, https://guardian.ng/features/health/confusion-over-iqos-as-modified-risk-tobacco-product/
  • National Institute for Health Care and Excellence (2018). Stop smoking interventions and services, NICE website, https://www.nice.org.uk/guidance/ng92.
  • Philip Morris International (2021). QOS – Our tobacco heating system. Retrieved 21 May 2021, from https://www.pmi.com/smoke-free-products/iqos-our-tobacco-heating-system
  • Protano C, Manigrasso M, Avino P, Sernia S, Vitali M. (2016). Second-hand smoke exposure generated by new electronic devices (IQOS and e-cigs) and traditional cigarettes: submicron particle behaviour in human respiratory system. doi:10.7416/ai.2016.2089.
  • Protano C, Manigrasso M, Avino P, Vitali M. (2017). Second-hand smoke generated by combustion and electronic smoking devices used in real scenarios: ultrafine particle pollution and age-related dose assessment. Environ Int doi:10.1016/j.envint.2017.07.014.
  • Protano C, Manigrasso M, Cammalleri V, Biondi Zoccai G, Frati G, Avino P, Vitali M. (2020). Impact of electronic alternatives to tobacco cigarettes on indoor air particular matter levels. Int J Environ Res Public Health. doi:10.3390/ijerph17082947.
  • Stopping Tobacco Organisations and Products/Tobacco Control Research Group (2020). Addiction at any cost: Philip Morris International Uncovered, STOP Report https://exposetobacco.org/wp-content/uploads/STOP_Report_Addiction-At-Any-Cost.pdf
  • The truth iniative (2019). 6 important things to know about IQOS, the new heated cigarette product. The truth initative, May 13, 2019. https://truthinitiative.org/research-resources/emerging-tobacco-products/6-important-things-know-about-iqos-new-heated
  • The Union (2020). On World No Tobacco Day the International Union Against Tuberculosis and Lung Disease (The Union) advocates for the banning of e-cigarettes and heated tobacco product sales in low- and middle- income countries, press release, https://theunion.org/news-centre/press-releases/document/ENDS-Press-release_final_27-05-2020.pdf
  • Tobacco Control Commentary (2018). Heated tobacco products: from the health effects to the politics, commentary. Tobacco control BMJ. https://tobacco.ucsf.edu/sites/g/files/tkssra4661/f/wysiwyg/Full%20supplement-final%20proof.pdf
  • Tompkins CNE, Burnley A, McNeill A, et al. (2021). Factors that influence smokers’ and ex-smokers’ use of IQOS: a qualitative study of IQOS users and ex-users in the UK
  • WHO (2020) Guidelines for implementation of Article 14. Retrieved 21 May 2021, from https://www.who.int/fctc/guidelines/adopted/article_14/en/
  • World Health Organization (nd).  Quitting Tobacco, webpage, undated, accessed September 2020 https://www.who.int/activities/quitting-tobacco

About Rita Chahwan

ريتا بولس شهوان، صحافية وباحثة ساهمت في عدد من الكتب منها "الكويت وإرادة الاستقلال في الوثائق العثمانية" و "ماذا فعل مدحت باشا في الخليج"(ذات السلاسل) وعملت في عدد من الصحف والمواقع الالكترونية العربية. تلقت تدريبات دولية على الاستقصاء وتخصصت في الاستقصاء الاجتماعي – الاقتصادي كما تولي اهمية كبيرة للشأن السياسي.
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