Heated Tobacco Products: Insights into Composition and Toxicity

Abstract

Heated tobacco products (HTPs) are novel products that allow users to inhale nicotine by heating (350 °C) reconstituted tobacco rather than combustion (900 °C) as in conventional cigarettes. HTP sticks containing reconstituted tobacco come in various flavours such as menthol, citrus, etc., like electronic cigarette liquids. Thus, the composition of HTP aerosol will also vary according to the flavouring agents added. Overall, the content of toxic chemicals in HTP aerosol appears to be lower than in cigarette smoke. However, the concentrations of more than twenty harmful and potentially harmful constituents have been reported to be higher in HTP aerosol than in cigarette smoke. Further, several toxic compounds not detected in cigarette smoke are also reported in HTP aerosol. Thus, the risks of HTP use remain unknown. Most of the available data on the composition and health effects of mainstream HTP aerosol exposure are generated by the tobacco industry. Few independent studies have reported short-term pathophysiological effects of HTP use. Currently available HTP toxicity data are mainly on the pulmonary and cardiovascular systems. Moreover, there are no long-term toxicity data and, therefore, the claims of the tobacco industry regarding HTPs as a safer alternative to traditional combustible cigarettes are unsubstantiated. Furthermore, HTP aerosol contains the highly addictive substance nicotine, which is harmful to the adolescent brain, developing foetuses, pregnant women, and also adults. Hence, comprehensive studies addressing the safety profiling related to long-term HTP use are warranted. With this background, the following review summarizes the current state of knowledge on HTP toxicity on four broad lines: composition of mainstream HTP aerosol compared to traditional combustible cigarette smoke, biomarkers of HTP exposure, health effects of HTP exposure, and the harm reduction aspect.

Keywords: IQOS; electronic cigarette; heat not burn; smoking; tobacco.

Figure 1

Graphical representation of the average amount of a few selected harmful and potentially harmful constituents in the mainstream heated tobacco product (HTP) emissions from: (A) one HTP stick relative to mainstream smoke from one traditional combustible cigarette. (B) Same as A, normalized for nicotine. Averages were calculated based on the midpoints (maximum − minimum/2) of each chemical shown in Table 2 and Table 3 [4,10,11,12,13,14,15].

Figure 2

Biomarkers of exposure effect sizes (expressed relative to the variation) and their 95% confidence interval in a group of heated tobacco product users versus a group of traditional combustible cigarette smokers (data from Drovandi et al., 2020 [22], Table 2).