On April 30, 2019, the FDA approved Philip Morris’ iQOS, an electronic device that heats instead of burns tobacco, for sale in the United States.

Associate Professor Irina Stepanov talks about heated tobacco products, how iQOS works, and what the potential harms and benefits of iQOS are to public health. Stepanov’s areas of expertise include tobacco chemistry and toxicology, cancer risk, and using biomarkers of exposure and DNA damage to investigate cancer risk due to tobacco use.

Q: What are heated tobacco products?
Stepanov: Heated tobacco products like iQOS are designed to heat tobacco without reaching temperatures at which it starts burning. The devices use tobacco “sticks” that look like very short cigarettes. There is tobacco inside these sticks, but it is processed differently than what is found in regular cigarettes. Users insert the tobacco sticks into the device and draw on it to activate the heating element, which results in the formation of aerosol similar to e-cigarettes. In this way, heated tobacco products are somewhat of a hybrid between a regular cigarette and an electronic cigarette. It is yet another nicotine delivery alternative to smoking regular tobacco cigarettes.

Q: What do we know about the use of heated tobacco products in the United States?
Stepanov: Until this approval for sale by the FDA, heated tobacco products were not sold in the United States. However, we know that they became very popular in some other countries where they have been aggressively marketed over the past few years. It is too early to say whether this product will gain traction in the United States. Judging from its popularity in other countries and popularity of e-cigarettes here, it is possible that some users or non-users of other tobacco products will find iQOS attractive.

Q: How much research has been done on iQOS?
Stepanov: Unfortunately, because iQOS was not available in the United States, academic researchers had very limited options for conducting studies with these products. It was impossible to conduct human clinical trials in order to assess exposures and effects in users. Most of the available research data comes from the industry reports, that is from studies conducted by the manufacturer. They did look into a wide spectrum of effects, such as consumer perceptions, product toxicity in vitro, and short-term human exposure studies. There is no data on long-term product use.

Q: What are the potential harms and benefits, if any, of iQOS?
Stepanov: Looking into the research findings by the industry and some emerging research done by academic laboratories, the conclusion at this time would be that — if a smoker switches to these products — there will be a reduction in exposure to some, but not all harmful chemicals present in cigarette smoke. The reduction will not be as dramatic as with electronic cigarettes because iQOS contains tobacco. Even if it is not burning, many chemicals will still transfer from tobacco material to the aerosol that users are inhaling. Of course, we also need to think about the user, not just about the device. If e-cigarette users will switch to these products, they will most likely increase their exposures to some toxicants. Or, if these products will become popular among kids, there is a concern about the effects of nicotine on the developing brain, and also potential for addiction and harmful exposures.

Q: What are you doing to advance research on electronic tobacco devices, such as iQOS?
Stepanov: We have expertise and tools for investigating chemical composition of aerosols that are delivered by various tobacco products, including iQOS, and for measuring toxic exposures and effects in users. I think it would be important to reproduce studies that have been done by the industry, and take this research to the next level. It is possible that iQOS and other heated tobacco products produce aerosols with unique chemistry, different from cigarette smoke and e-cigarette aerosol, and it is not sufficient to just focus on toxicants that we have been studying in those products. Plus, we don’t know how iQOS will be perceived by smokers, e-cigarette users, and non-users of tobacco in the United States, and what this will do in terms of the overall prevalence of tobacco use here. It is important that the academic community generates independent research data as quickly as possible. It is also important to approach this research open-mindedly, without preconceived biases regarding harmfulness or safety of these products.