ERS position paper on heated tobacco products

A statement prepared by the ERS Tobacco Control Committee

What are heated tobacco products?

Heated tobacco is a new nicotine delivery system that is commonly referred to as “Heat-not-Burn” by the tobacco industry. Heated tobacco products consist of a small tobacco stick that is heated electronically, rather than burned. The tobacco industry is actively pursuing the market with sales on the rise of products such as ‘iQOS’, ‘glo’, and ‘revo’.

Tobacco industry research claims a 90-95% reduction in harm

According to a press release by the tobacco industry the main ingredient in their heated tobacco products is water, whereas the main ingredient is tar in conventional cigarettes. The tobacco industry claims that there is a 90-95% reduction in harmful and potentially harmful substances and toxicity1.

Digging deeper into tobacco industry research: not the full picture

However, tobacco companies have not informed the public that some harmful substances were found in high concentrations in their studies, e.g.: particulate matter, tar, acetaldehyde (a carcinogen), acrylamide (a potential carcinogen) and an acrolein metabolite (toxic and irritant)2-6. Some studies found much higher concentrations of formaldehyde (a potential carcinogen) in heated tobacco products than in conventional cigarettes7, 8. Independent research: a substantially higher risk than claimed by the tobacco industry

Historically, there is strong evidence that studies performed by the tobacco industry or by researchers funded by the tobacco industry cannot be trusted9-13. Former employees and contractors have detailed irregularities in the clinical experiments on heated tobacco products performed by the industry14.

Independent research shows that acrolein (toxic and irritant) is reduced by only 18%15, formaldehyde (a potential carcinogen) by 26%15, benzaldehyde (a potential carcinogen) by 50%15 and the level of TSNAs (carcinogens) is one fifth of those of conventional combustion cigarettes16. Furthermore, the potentially carcinogenic substance acenaphthene is found to be almost three times higher than in conventional cigarettes15 and nicotine and tar levels have been found to be almost identical to a conventional cigarette17. An experimental animal study found that exposure to iQOS led to decreased blood vessel function by 60% - comparable to that induced by cigarette smoke19. In addition, a study found that users of iQOS may be forced to smoke at a rapid pace which could lead to an increase in intake of carbonyls (potentially carcinogenic) and nicotine, inducing a high level of nicotine dependence19.

What does ERS recommend?

Even though heated tobacco products may perhaps be less harmful for smokers they nevertheless remain both harmful and highly addictive, and there may be a risk that smokers will switch to heated tobacco products instead of quitting. ERS cannot recommend any product that is damaging to the lungs and human health.

Why does ERS make this recommendation?

Heated tobacco products:

  1. Are harmful and addictive
  2. Undermine smokers’ wish to quit
  3. Undermine ex-smokers’ wish to stay smoke-free
  4. Are a temptation for non-smokers and minors
  5. Impose a risk of re-normalisation of smoking
  6. Impose a risk of dual use with conventional cigarettes

It is tempting to recommend smokers to switch to heated tobacco products without considering all the consequences. Experiences with e.g. filter cigarettes and light cigarettes have shown that ‘safer products’ undermine smokers’ wish to quit, and they have not improved smokers’ health20. Quoting the tobacco industry on ‘safer products’: “Quitters may be discouraged from quitting, or at least kept in the market longer …”21. We must remember that two to three out of four smokers want to quit22 and almost all smokers regret that they started to smoke23, 24. Also, many smokers want to quit because they want to regain control of their life25, 26, and get cured of their nicotine dependency – this will not happen if they switch to heated tobacco products. A majority of smokers want to quit, and there is not a ‘hardening’ of smokers27 – on the contrary there are fewer hard core smokers28 and they report being less dependent29. We have no evidence that heated tobacco products are efficient as a smoking cessation aid. Dual use is very frequent for other harm reduction products such as e-cigarettes (approx. 70-80%)30, 31 and snuff/snus (>40%)32, and dual use of heated tobacco cigarettes combined with conventional cigarettes cannot be ruled out. Finally, ex-smokers and never-smokers might be tempted to start using this ‘harmless’ product and a renormalisation of smoking in the public might occur33.

The European Commission underlines that “with regard to the sale, presentation and manufacturing of these products within the European Union, the relevant provisions of the Tobacco Products Directive apply and should be enforced. This includes the ban on misleading elements foreseen by Article 13 and notably any suggestions that a particular tobacco product is less harmful than others34.

Member states are currently assessing the toxicity of these products. For example, there is concern in the UK ”over the potential for non-smokers including children and young people, who would not otherwise start to smoke cigarettes, to take up using these products as they are not without risk. There was also concern over whether use of these products would lead people to take up smoking cigarettes”35.
An expert scientific panel has advised the Food and Drug Administration (FDA) to vote against the tobacco industry’s claim that heated tobacco products cut the risk of tobacco-related diseases and that iQOS is less risky than continuing to smoke cigarettes36.

Conclusion

Heated tobacco products, regular tobacco smoking and smokeless tobacco for oral or nasal use are all addictive and carcinogenic to humans37, 38. We should not allow debate around the new tobacco products to distract us from the main job at hand – promoting regulatory measures that we know are effective at reducing smoking and continue to support those who wish to quit smoking.


  1. Gilcrist M. Heat-not-burn products. Scientific Assessment of Risk Reduction. In: International PM, ed. Global Tobacco and Nicotine Forum 2015 Annual Meeting Sept 17, 2015
  2. Szostak J, Boue S, Talikka M, et al. Aerosol from Tobacco Heating System 2.2 has reduced impact on mouse heart gene expression compared with cigarette smoke. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association 2017;101:157-67. doi: 10.1016/j.fct.2017.01.013 [published Online First: 2017/01/24]
  3. Tricker AR, Stewart AJ, Leroy CM, et al. Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 3: Eight-day randomized clinical trial in the UK. RegulToxicolPharmacol 2012;64(2 Suppl):S35-S44.
  4. Tricker AR, Jang IJ, Martin LC, et al. Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 4: Eight-day randomized clinical trial in Korea. RegulToxicolPharmacol 2012;64(2 Suppl):S45-S53.
  5. Tricker AR, Kanada S, Takada K, et al. Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 5: 8-Day randomized clinical trial in Japan. RegulToxicolPharmacol 2012;64(2 Suppl):S54-S63.
  6. Tricker AR, Kanada S, Takada K, et al. Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 6: 6-Day randomized clinical trial of a menthol cigarette in Japan. RegulToxicolPharmacol 2012;64(2 Suppl):S64-S73.
  7. Urban HJ, Tricker AR, Leyden DE, et al. Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 8: Nicotine bridging--estimating smoke constituent exposure by their relationships to both nicotine levels in mainstream cigarette smoke and in smokers. RegulToxicolPharmacol 2012;64(2 Suppl):S85-S97.
  8. Stabbert R, Voncken P, Rustemeier K, et al. Toxicological evaluation of an electrically heated cigarette. Part 2: Chemical composition of mainstream smoke. JApplToxicol 2003;23(5):329-39.
  9. Proctor RN. Golden Holocaust. Origins of the Cigarette Catastrophe and the Case for Abolition. Berkeley and Los Angeles, California: University of California Press 2011.
  10. Barnes DE, Hanauer P, Slade J, et al. Environmental tobacco smoke. The Brown and Williamson documents. JAMA 1995;274(3):248-53.
  11. Hong MK, Bero LA. How the tobacco industry responded to an influential study of the health effects of secondhand smoke. BMJ 2002;325(7377):1413-16.
  12. Barnes DE, Bero LA. Industry-funded research and conflict of interest: an analysis of research sponsored by the tobacco industry through the Center for Indoor Air Research. JHealth PolitPolicy Law 1996;21(3):515-42.
  13. Barnes DE, Bero LA. Why review articles on the health effects of passive smoking reach different conclusions. JAMA 1998;279(19):1566-70.
  14. Reuters Investigates. The Philip Morris files. 2017.
  15. Auer R, Concha-Lozano N, Jacot-Sadowski I, et al. Heat-Not-Burn Tobacco Cigarettes: Smoke by Any Other Name. JAMA internal medicine 2017;177(7):1050-52. doi: 10.1001/jamainternmed.2017.1419 [published Online First: 2017/05/23]
  16. Bekki K, Inaba Y, Uchiyama S, et al. Comparison of Chemicals in Mainstream Smoke in Heat-not-burn Tobacco and Combustion Cigarettes. Journal of UOEH 2017;39(3):201-07. doi: 10.7888/juoeh.39.201 [published Online First: 2017/09/15]
  17. Li X, Luo Y, Jiang X, et al. Chemical Analysis and Simulated Pyrolysis of Tobacco Heating System 2.2 Compared to Conventional Cigarettes. Nicotine Tob Res 2018 doi: 10.1093/ntr/nty005 [published Online First: 2018/01/11]
  18. Nabavizadeh P, Liu J, Ibrahim S, et al. Poster presentation: Inhalation of Heat-Not-Burn Tobacco Aerosol Impairs Vascular Endothelial Function: Center for Tobacco Control Research and Education, 2017.
  19. Davis B, Williams M, Talbot P. iQOS: evidence of pyrolysis and release of a toxicant from plastic. Tob Control 2018 doi: 10.1136/tobaccocontrol-2017-054104 [published Online First: 2018/03/15]
  20. Harris JE, Thun MJ, Mondul AM, et al. Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982-8. Bmj 2004;328(7431):72. doi: 10.1136/bmj.37936.585382.44 [published Online First: 2004/01/13]
  21. Cunningham R. Smoke and mirrors : the Canadian tobacco war. Note on: Creative Research group, Project Viking, Volume 11: An Attitudinal Model of Smoking, 1986, February- March, prepared for Imperial Tobacco Limited (Canada). International Development Reasearch Center1996.
  22. Rosendahl Jensen H, Davidsen M, Ekholm M, et al. Danskernes Sundhed – Den Nationale Sundhedsprofil 2017. (National Health Survey 2017). www.sst.dk. Sundhedsstyrelsen, Islands Brygge 67, 2300 København S: Danish National Board of Health, 2018.
  23. Sansone N, Fong GT, Lee WB, et al. Comparing the Experience of Regret and Its Predictors Among Smokers in Four Asian Countries: Findings From the ITC Surveys in Thailand, South Korea, Malaysia, and China. NicotineTobRes 2013;15(10):1663-72.
  24. Fong GT, Hammond D, Laux FL, et al. The near-universal experience of regret among smokers in four countries: findings from the International Tobacco Control Policy Evaluation Survey. NicotineTobRes 2004;6 Suppl 3:S341-S51.
  25. McCaul KD, Hockemeyer JR, Johnson RJ, et al. Motivation to quit using cigarettes: a review. Addict Behav 2006;31(1):42-56. doi: 10.1016/j.addbeh.2005.04.004 [published Online First: 2005/05/27]
  26. Ahluwalia JS, McNagny SE, Clark WS. Smoking cessation among inner-city African Americans using the nicotine transdermal patch [see comments]. J GenIntern Med 1998;13(1):1-8.
  27. Edwards R, Tu D, Newcombe R, et al. Achieving the tobacco endgame: evidence on the hardening hypothesis from repeated cross-sectional studies in New Zealand 2008-2014. Tob Control 2017;26(4):399-405. doi: 10.1136/tobaccocontrol-2015-052860 [published Online First: 2016/07/07]
  28. Eriksen M, Mackay J, Ross H. The Tobacco Atlas: American Cancer Society. 250 Williams Street. Atlanta, Georgia, 30303 USA 2012.
  29. Bommel‚ J, Nagelhout GE, Kleinjan M, et al. Prevalence of hardcore smoking in the Netherlands between 2001 and 2012: a test of the hardening hypothesis. BMCPublic Health 2016;16
  30. Reid JL, Rynard VL, Czoli CD, et al. Who is using e-cigarettes in Canada? Nationally representative data on the prevalence of e-cigarette use among Canadians. PrevMed 2015;81:180-83.
  31. Christensen T, Welsh E, Faseru B. Profile of e-cigarette use and its relationship with cigarette quit attempts and abstinence in Kansas adults. Prev Med 2014;69:90-4. doi: 10.1016/j.ypmed.2014.09.005 [published Online First: 2014/09/18]
  32. Lund I, Scheffels J. Adolescent tobacco use practices and user profiles in a mature Swedish moist snuff (snus) market: Results from a school-based cross-sectional study. Scand J Public Health 2016 doi: 10.1177/1403494816656093 [published Online First: 2016/06/25]
  33. Wells Fargo: Probability Of PM/MO Combo Now Higher - iQOS Remains A Key Catalyst & Is Driving Transformative Growth. Wells Fargo Securities, LLC, 18. 12. 2016.
  34. Answer given by Mr Andriukaitis on behalf of the Commission, Parliamentary questions, available at: http://www.europarl.europa.eu/sides/getAllAnswers.do?reference=P-2016-009191&language=ES#def1 9 January 2017
  35. Statement on the toxicological evaluation of novel heatnot-burn tobacco products, COMMITTEES ON TOXICITY, CARCINOGENICITY AND MUTAGENICITY OF CHEMICALS IN FOOD, CONSUMER PRODUCTS AND THE ENVIRONMENT (COT, COC and COM), 11 December 2017.
  36. LaVito A. In high-stakes votes, FDA advisors say evidence doesn't back Philip Morris' claims. CNBC Health Care 25.01.2018.
  37. WHO. International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. 2014.
  38. IARC. IARC strenghthens its findings on several carcinogenic personal habits and household exposure, World Health Organisation, International Agency for Research on Cancer, 02 November 2009.