Is Big Tobacco misleading consumers and policymakers on heated tobacco products?

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And yet, this couldn't be further from the truth.

"From calling heated tobacco products 'reduced-risk products' to 'less harmful alternatives', the industry is continuously making claims that heated tobacco products present less risks to consumers' health than cigarettes.

"Leaked industry documents suggest that this is all part of the industry's strategy to try and get less restrictive regulation than what currently applies to cigarettes."

This was the message of Sophie Braznell, researcher and tobacco control expert at the University of Bath's Tobacco Control Research Group.

She was speaking during a Stopping Tobacco Organisations and Products (STOP) webinar that aimed to demystify heated tobacco products, introduce policymakers to the latest research and explore marketing strategies used by the manufacturers of these products, and other international companies that promote heated tobacco products around the world.

Also in attendance was Inti Barrientos, researcher and tobacco control expert at the National Institute of Public Health in Mexico, and Professor Lekan Ayo-Yusuf, director of the Africa Centre for Tobacco Industry Monitoring and Policy Research.

"It's important that we be really clear about what the evidence does and does not show," Braznell said.

"It's a very common claim by all of the Big Tobacco companies that their heated tobacco products (HTPS) are smoke-free or smokeless.

The tobacco industry tries to claim it’s a victim of the illicit tobacco trade & wants to be part of the solution. But research suggests it’s part of the problem. The same applies to industry claims about ending the tobacco epidemic while selling billions of cigarettes annually. https://t.co/Ge9Z45VnPQ

— exposetobacco (@exposetobacco) October 24, 2022

Recently, independent chemistry researchers from the University of Nottingham looked over all the chemical data on HTPs. In general, there was mostly data on one particular brand.

"They sought to evaluate the smoke-free claim. They found a number of things. Firstly, that [the brand's] emissions contain chemical markers of smoke, and can therefore be defined as both an aerosol and smoke.

"Secondly, existing data based on comparisons of emissions from one heat stick to one standard combustible cigarette, showed that one heat stick contains only about 30% less tobacco than that of a cigarette.

"There is evidence too that HTPs expose users and those around them to lower levels of some chemicals, namely 95 chemicals that are recognised by the US Food and Drug Administration as potentially harmful chemicals in tobacco and nicotine products."

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"There is also evidence both from the industry and independent studies that show that the brand in the Nottingham University study releases higher levels of other chemicals that are not featured on that FDA list.

"These include probable carcinogens, 90 potentially hazardous chemicals and nine chemicals of quite toxicological concern," Braznell said.

Furthermore, there's increasing evidence emerging, both from the industry and independent sources, that shows that heated tobacco products are not in fact being used as alternatives to cigarettes as is claimed by tobacco companies.

"Most heated tobacco product users actually do not manage to switch from cigarettes to heated tobacco products, and in fact, continue smoking HTPs alongside them," Braznell said.

To date, there's not a single clinical or epidemiological study out there that specifically looks at whether HTPs can help aid cessation, and there's no data at the moment to suggest that heated tobacco products do help with the cessation of cigarette smoking.

Redefining tobacco-harm reduction

The first step in holding Big Tobacco accountable is defining what tobacco-harm reduction really means, Braznell said.

"Tobacco-harm reduction essentially means any kind of strategies that we use, which aim to reduce individual and population-level harm caused by tobacco and nicotine use.

"Although abstinence from using any tobacco nicotine is obviously the ideal goal, directly reducing the prevalence of such an addictive behaviour is often unachievable. So instead, tobacco-harm reduction advocates for achieving a net reduction of harm by reducing the harm in those unwilling or unable to abstain from smoking.

"The primary goal, therefore, is to reduce harm in both users and those around them," Braznell said.

"Tobacco-harm reduction should aim to minimise second-hand smoke exposure and prevent uptake among non-smokers and youth, by typically switching users to less harmful alternative forms of nicotine, such as nicotine-replacement therapies like the patch.

"The tobacco industry, nevertheless, has co-opted the definition of tobacco-harm reduction in order to sell its products, including heated tobacco products, which it claims cost less and are less harmful than cigarettes.

"The tobacco industry has essentially redefined tobacco-harm reduction, and hyper-fixates only on strategies which involve switching smokers to its products.

"This, of course, ignores any kind of population-level tobacco control, or tobacco-harm reduction policies that don't utilise their products; such as nicotine-replacement therapies, and does not advocate for bans and age restrictions, which could reduce the net harm across the population.

"It also, of course, ignores non-smokers taking up these novel products (which could obviously increase net harm)."

Fact vs fiction

And yet Big Tobacco continues to position the heated tobacco product as a vaping product, which it is not, of course, and therefore should not be regulated as such, Ayo-Yusuf said

"Because HTPs and e-cigarettes are both new electronic-based products that look quite similar, they're often confused with one another. In other words, conflated. This is not only inaccurate, but could mislead consumers into thinking the products that harm and their potential benefits are all the same," Ayo-Yusuf said

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Researchers in the Tobacco Control Group have recently identified instances in New Zealand where a renowned company manufacturing and distributing both heated tobacco products and e-cigarettes are perpetuating this conflation.

"The company was selling these two products as a bundle, which essentially explicitly encourages the dual use of HTPs alongside e-cigarettes, and implies they are equal - interchangeable even," Ayo-Yusuf said.

"To this end, manufacturers of heated tobacco products can piggyback off of the markedly greater success of e-cigarettes (in many places, e-cigarettes are far more popular than heated tobacco products). They can also conflate the harm-reduction potential between the heated tobacco product and its e-cigarette by sometimes calling a heated tobacco product a vape.

"And just to be clear - the heated tobacco product is not a vape," Ayo-Yusuf said.

Braznell explained: "Electrically heated tobacco products are made up of a device that contains the heating element. The consumer then has to separately buy a tobacco stick, which obviously contains tobacco.

"The tobacco in a heated tobacco product is processed slightly differently to that in cigarettes. So typically instead of being finely cut and placed into a cigarette as we see in cigarettes, the tobacco leaves are ground.

"After that, we have water, glycerin, and a type of guar, gum, and cellulose fibres all added into that ground tobacco. Then the mixture is essentially reformed into thin tobacco sheets that are then folded very, very tightly into the plug that goes in the heat stick," Braznell said.

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An electronic cigarette or "vape" on the other hand, is a device that heats up a liquid to create a vapour you inhale.

The big issue to date, added Braznell, is that there is insufficient evidence that demonstrates HTPS reduce the risks or prevalence of diseases and deaths caused by tobacco.

"HTPS still contain tobacco.

"They still contain nicotine and they still release harmful chemicals, therefore they are not risk-free."

The case for regulation

With all evidence pointing to tobacco use being a major public health problem, tobacco products remain one of the few openly available commercial products that are virtually unregulated in some countries.

At least 8 million people die every year from using tobacco products. Millions more live every day with the health and economic consequences of tobacco use.

"Heated tobacco products, threaten the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC), and threaten to derail tobacco-control progress," Barrientos said. "Our position is that low- and middle-income countries must apply the precautionary principle and ban these products before they hook a new generation of users."

"We should be mindful when a heated tobacco product firm uses the term 'reduced risk'," Ayo-Yusuf said. "We already know there is no scientific basis for that."