The Tobacco Control Research Group (TCRG) has investigated tobacco industry claims about Heated Tobacco Products.

Heated tobacco products (HTPs) are a type of newer nicotine and tobacco product created by the tobacco industry. They commonly have two components: a battery-powered heating device and a cigarette-like tobacco stick. HTPs are often misidentified as electronic cigarettes (e-cigarettes, a.k.a vapes) because both utilise an electronic device. However, HTPs heat actual tobacco leaf, while e-cigarettes heat liquids or salts typically containing nicotine.

HTPs are not a new concept, but earlier iterations sold in the 1980s and 90s were commercially unsuccessful. In the face of declining cigarette sales and a new market competitor (e-cigarettes), HTPs were modernised and re-introduced to market by the world’s largest tobacco companies. This time, the HTP market has grown rapidly and is projected to continue doing so, proving incredibly profitable for tobacco companies.

There are concerns over the impacts of HTPs on public health and whether they are, in fact, just another part of the industry’s wider strategy of exploiting transformation and harm reduction narratives to further its interests.

The principal idea behind HTPs is to heat tobacco, instead of burning it like cigarettes. In doing so, lower levels of harmful chemicals are released and thus inhaled by the user. Based on this, the tobacco industry claims that HTPs are scientifically substantiated better alternatives for adult smokers, but is that truly the case?

Are HTPs a “better alternative”?

Since their introduction, HTPs have been marketed as “smoke-free”, “reduced risk” or “less harmful” alternatives to cigarettes. But TCRG research questions these claims.

A systematic review and meta-analysis of the data from clinical trials investigating HTP use, revealed the health impact data are so mixed that they provide no clear indication of the relative risks of HTPs, even compared to cigarettes. According to lead author, Dr Sophie Braznell:

The data analysed indicated HTPs have the potential to be harmful to both smokers and non-smokers, and that any benefits in smokers who switched to HTPs were limited or inconsistent across studies. While this does not rule out their potential to reduce harm, the findings suggest caution is needed when considering the veracity of the available clinical evidence and any conclusive claims that HTPs are reduced risk alternatives to smoking.

Another analysis of these clinical trials looked at the data on all the biomarkers (i.e. markers of exposure to chemicals and their effects in the body) to assess the risk of lung cancer posed by HTP use. Of the 82 biomarkers measured across the trials, only 16 could be used to indicate lung cancer risk. And of those, only three improved in smokers who switched to HTPs. The other 13 either showed no improvement, worsened, or had inconsistent results.

They concluded there was limited appropriate data available to estimate the risk of lung cancer associated with HTP use and, thus, the risk remains unknown.

Contrary to the industry’s claims, independent scientists have also argued that the emissions released by HTPs, like IQOS, “fit the definition of being both an aerosol and smoke”. Further, independent research from around the world has also found many HTP users do not use them exclusively, either using them alongside other newer tobacco and nicotine products or, more commonly, cigarettes. This, and the fact HTPs have not been shown to aid smoking cessation, contradicts the notion that they are “alternatives”.

Are HTPs “Scientifically Substantiated”?

A pivotal issue within the HTP evidence base is industry interference. TCRG’s Science for Profit model and accompanying research have demonstrated how the tobacco industry has influenced science as part of its coordinated efforts to hide the harms of its products and practices, while seeking to influence opinion and policy in its favour, ultimately to maximise profits.

Across two systematic reviews, one critically appraising quality and another analysing the health effects, TCRG has reviewed 49 interventional clinical trials on HTPs. Of these:

• 34 were conducted by the tobacco industry

• 38 were conducted under confined conditions (i.e. controlled, unrealistic settings, like laboratories or clinics)

• 39 lasted only 5 days or less, with the longest being 12 months

• 39 were at high risk of bias and the remaining 10 had unclear risk of bias.

As stated in one of the reviews, the HTP clinical trials conducted to date are not representative of real world use and fall short of what is needed to determine the impact of HTPs on public health.

The industry’s influence also extends beyond each individual study. An examination of newly leaked documents from PMI and its Japanese subsidiary exposed how the company sought to manipulate and misuse science to create a favourable environment in which to sell its products, especially IQOS.

TCRG’s academic analysis revealed how PMI covertly funded a smoking cessation study by Kyoto University academics and were also paying a life sciences consultancy to undertake a range of science-adjacent activities on the company’s behalf, such as building a network of experts through which PMI’s science, products and messaging could be promoted. In the paper, the authors explained:

Japan is a key market for PMI, being a launch market for IQOS and having the highest heated tobacco product use globally. Our findings, in conjunction with other recent evidence, challenge PMI’s assertion that it is a source of credible science and cast doubt on the quality and ethical defensibility of its research, especially its studies conducted in Japan. This, in turn, brings into question the true public health impacts of its products.

Are HTPs marketed to “Adult Smokers”?

Even if HTPs were reduced risk cessation aids, which is unproven, they would only benefit public health if used by adult smokers. But such benefits could be diminished or even entirely negated if used by non-smokers, especially children, in which HTPs can only do harm.

Research published by the TCRG has highlighted several marketing tactics used by PMI to sell its HTP, IQOS, to a broad audience. In New Zealand, PMI has added to the confusion around e-cigarettes and HTPs. The IQOS branding was used for its HTP (IQOS 3) and an e-cigarette (IQOS VEEV), with the company offering them together in a bundle on its online store, potentially targeting e-cigarette users as well as smokers.

This also misleadingly implies the two very different products have similar risk profiles, and explicitly encourages dual use of a tobacco and non-tobacco product.

In the UK, analysis by TCRG showcased examples of PMI’s marketing of IQOS using both physical and online platforms. Pop-up stores, complimentary hospitality, celebrity partnerships, competitions, social media marketing, and even displays placed next to children’s confectionary were all used to promote IQOS.

PMI also markets IQOS via an online store in many countries. TCRG researchers discovered the website included a webchat platform through which visitors could converse with a customer agent.

A study of the communications made via this webchat across 22 countries found a variety of claims on the relative safety of IQOS were provided by agents, though not all were consistent with each other or with the evidence. For example, some claimed IQOS was 95% safer than cigarettes or less harmful than e-cigarettes – neither of which are supported by research, not even PMIs. Further, while age was consistently requested upon accessing the website, tobacco/nicotine use was not. 

This research adds to a growing body of evidence that suggests PMI is targeting a broader audience than just adult smokers, potentially including non-smokers and children. Consequently, data from around the world show growing youth use of HTPs, being possibly more than twice as likely as adults to have used HTPs globally.

What does this all mean?

The evidence brought to light by TCRG and other independent researchers around the world casts doubt on the assertion that heated tobacco products are scientifically substantiated better alternatives for adult smokers. This work has been cited by the World Health Organization (WHO) in its reports and contributed to policy discussions at the 10th Conference of the Parties to the WHO Framework Convention on Tobacco Control (an international treaty aimed at reducing harms caused by tobacco).

The work has also already helped inform advocacy, including briefs for STOP (a global tobacco industry watchdog) and a factsheet for ASH Scotland (Action on Smoking and Health; a health charity tackling the harms caused by tobacco and related products).

We must continue to raise awareness of the current state of evidence on HTPs, especially as their popularity and prevalence rises. Consumers, scientists, journalists and policy makers should be extremely sceptical of HTP science and marketing.

The industry’s approach to conducting, using and communicating science exacerbates the challenges already faced by policymakers to develop and implement effective measures. By demonstrating how the tobacco industry continues to manipulate and misuse science, this work has also contributed to broader ongoing discussions around tobacco industry tactics to influence science for profit. Find out more about our research exposing the industry’s efforts to influence science.

This research is part of a growing body of evidence suggesting HTPs do not primarily serve to improve public health, but to protect the tobacco industry’s bottom line. This is part of the industry’s wider long-term strategy to exploit harm reduction and a proclaimed transformation as a guise for its continued efforts to impede tobacco control.