Health

Heat-Not-Burn Tobacco Products Could Overtake E-Cigarettes in Popularity

A study of interest in heat-not-burn tobacco shows a potentially large international market for the smoking devices, which remain largely unregulated.

Customers try IQOS device during demonstration at IQOS store in Tokyo, Japan on July 31, 2017. Phillip Morris is trying to sell IQOS, a new kind of cigarette called heat-not burn. | Shiho Fukada for The Washington Post via Getty Images
Customers try IQOS device during demonstration at IQOS store in Tokyo, Japan on July 31, 2017. Phillip Morris is trying to sell IQOS, a new kind of cigarette called heat-not burn. | Shiho Fukada for The Washington Post via Getty Images

The study looked at publicly available Google search data in Japan for heat-not-burn tobacco products between January 2015 and August 2017. Tobacco manufacturers have been aggressively marketing these products in Japan since 2014.

The surge in the consumption of heat-not-burn tobacco in Japan is, in part, because it imposes strict regulations on the sale of liquids that contain nicotine, commonly used in e-cigarettes. The nicotine-laced liquid is heated into a vapor and inhaled while smoking an e-cigarette.

On the other hand, a heat-not-burn tobacco product, is essentially a battery-powered device that heats leaf tobacco to approximately 500 degrees Fahrenheit to produce a smokeless aerosol inhaled through the mouth. Makers of heat-not-burn products claim these products are healthier than cigarettes and deliver the satisfaction of the “throat-hit,” which is the pleasurable feeling many smokers seek. E-cigarettes don’t provide that sensation.

The researchers found that in the last two years, the average number of search queries for heat-not-burn tobacco products by Internet users in Japan ranged between 6 and 7.5 million each month. The interest shown by internet users prior to 2015 was much less since there were almost no queries in Japan for heat-not-burn tobacco products, the researchers said.

The team, led by Theodore Caputi, currently a graduate student of public health at University College Cork in Ireland, compared these numbers to similar data on the rise of e-cigarettes in the United States in the last five years. They found that the spike in Google search queries for heat-not-burn tobacco products in Japan has been much more rapid than than those for e-cigarettes in the US, which they say could mean that the use of these devices will spread quickly in new markets, eclipsing the popularity of e-cigarettes.

The figure shows the Relative Search Volume (scaled from 0–100 and adjusted for number of total Google search volumes per month in Japan and the USA) for heat-not-burn and electronic cigarette products. | Theodore L. Caputi, Eric Leas, Mark Dredze, Joanna E. Cohen, and John W. Ayers

For smokers in Japan, the country’s regulatory blueprint makes heat-not-burn tobacco a more commonplace substitute for cigarettes. And for tobacco giants, the regulatory landscape around e-cigarettes has made Japan the ideal testing ground for heat-not-burn tobacco devices.

Japan Tobacco, the world’s third largest tobacco maker, launched Ploom Tech, an electronic tobacco heating stick, in the southern Japanese city of Fukuoka in March 2016. The following month, Philip Morris International released its IQOS (an acronym for “I quit ordinary smoking”) in Japan. IQOS is a heating device that looks and feels like holding a conventional cigarette. At the end of 2016, British American Tobacco introduced its heat-not-burn product Glo into the Japanese market. None of these are available in the US yet, although in December Philip Morris applied to the FDA seeking approval for IQOS as a tobacco product with a “modified risk.”

Although it is hard to tell if the trend in Japan will be duplicated in the United States, or elsewhere in the world, since prevalence and inclination to smoke differs across cultures, Caputi said the growing popularity of heat-not-burn tobacco in Japan needs to be taken seriously.

“Just the fact that we don’t know a lot about them, is dangerous,” he said.

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A scan through PubMed, a database that includes millions of citations from medical journals dating back to the 1950s, shows 26 studies mentioning heat-not-burn tobacco, Caputi added.

Market-research firm Euromonitor International estimates that the heat-not-burn sector will account for 45 percent of the tobacco alternatives industry and will bring in $15.4 billion by 2021.

In July, the US Food and Drug Administration announced plans to introduce a new regulatory framework to reduce nicotine in cigarettes. “The FDA plans to begin a public dialogue about lowering nicotine levels in combustible cigarettes to non-addictive levels through achievable product standards,” the agency said in a statement.

Alongside the crackdown on combustible cigarettes, the FDA said it would give newly regulated non-combustible tobacco products like e-cigarettes a reprieve by extending the deadline for manufacturers of these products to apply for a tobacco product review, the equivalent of a fitness test for tobacco products. Experts say developing new standards through public dialogue can be a lengthy process, giving tobacco companies enough room to influence outcomes.

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The World Health Organization warns of a knowledge gap around heat-not-burn tobacco products. “Conclusions cannot yet be drawn about their ability to assist with quitting smoking (cessation), their potential to attract new youth tobacco users (gateway effect), or the interaction in dual use with other conventional tobacco products and e-cigarettes,” according to health agency.

Just last  week, researchers writing in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine, found that e-cigarettes appear to trigger similar immune responses as regular cigarettes.

Mehmet Kesimer, senior author of the paper and an associate professor of pathology and laboratory medicine at the University of North Carolina School of Medicine, examined the harmful effects of e-cigarettes using sputum samples from human lungs.

"Comparing the harm of e-cigarettes with cigarettes is a little like comparing apples to oranges," Kesimer said. "Our data shows that e-cigarettes have a signature of harm in the lung that is both similar to what we see in cigarette smokers and unique in other ways.”

The United States, where an estimated 480,000 deaths each year are linked to cigarette smoking, is currently among forty countries where heat-not-burn products are being marketed.

The American tobacco industry spends nearly $25 million every day on advertising and promoting cigarettes.

“We don’t want to be caught off-guard as heat-not-burn products roll out in new markets and sales begin to grow. The health risks associated with them should be aggressively evaluated,” Caputi said. Public health agencies should start by surveying the use, interest and perception of heat-not-burn tobacco among the general population, he added.

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