US Arrival of Heat-Not-Burn Is Another Option for Smokers to Switch

May 7, 2019

Last week the Food and Drug Administration (FDA) approved IQOS, a device that delivers nicotine by heating, not burning, tobacco sticks with a ceramic blade to produce vapor—not smoke. The decision means that for the first time, a “heat-not-burn” (HNB) product will be sold in the US.

The FDA stated:

“Following a rigorous science-based review through the premarket tobacco product application (PMTA) pathway, the agency determined that authorizing these products for the US market is appropriate for the protection of the public health because, among several key considerations, the products produce fewer or lower levels of some toxins than combustible cigarettes.”

However, the agency added: “While today’s action permits the tobacco products to be sold in the US, it does not mean these products are safe or ‘FDA approved.’”

It falls on harm reductionists to hammer home that HNB products are much safer than cigarettesas the FDA grudgingly acknowledged with its “appropriate for the protection of the public health” comment. A 2018 literature review of 31 studies in the peer-reviewed journal Tobacco Control found: “Compared with cigarettes, HnB delivered up to 83% of nicotine and reduced levels of harmful and potentially harmful toxicants by at least 62% and particulate matter by at least 75%.”

Alex Clark, CEO of the Consumer Advocates for Smoke-Free Alternatives Association (CASAA), a nonprofit which champions tobacco harm reduction efforts, told Filter: “CASAA supports the FDA’s decision to approve IQOS for market in the United States. It is vital that people who smoke are aware of and have access to non-combustible alternatives to cigarettes and that these products are enjoyable.”

Access to HNB provides another option for smokers to switch. If that appeals to smokers who find that vaping isn’t for them, it’s a huge win for public health.

Whether manufacturer Philip Morris International (PMI) will be permitted to claim IQOS’s status as a modified risk tobacco product (MRTP) is still being reviewed by the FDA.

Disclosure: PMI is one of Filter’s funders, as stated on this site (and, like all funders, has no input in Filter’s editorial decisions). Yet as a journalist who covered tobacco harm reduction long before Filter existed and a social worker who works with marginalized smokers to switch to lower-risk nicotine products, I have to report what the evidence shows. The availability of IQOS is an incredibly important development for the millions of Americans who continue to smoke and who suffer almost half a million preventable deaths each year.

Access to lower-risk HNB nicotine delivery devices provides another option for smokers who want to switch. If that appeals to smokers who, for whatever reason, find that vaping—estimated by Public Health England to be 95 percent safer than smoking—isn’t for them, it’s a huge win for public health.

This assertion is based on the real-life experiences of other countries. HNB products have been available in Japan since 2014. The result? Cigarette sales in the country have plummeted. They fell by 11.7 percent last year and are expected to fall by over 7.5 percent this year, outstripping anything abstinence-only messages have achieved. Over 3 million Japanese smokers now use HNB.

Predictably, mainstream media coverage of the FDA’s decision has underplayed this, featuring no quotes from leading tobacco harm reductionists. Stories continue to use the lens of the so-called “teen vaping epidemic,” always referencing Juul, to frame tobacco harm reduction news. The New York Times reported:

“The FDA said it did not appear that the IQOS devices, which will be sold with Marlboro-branded regular and menthol sticks, would appeal to younger people. In Japan and Italy, the devices haven’t attracted use among teenagers, and the product isn’t sold in flavors except for menthol, the FDA noted in its report.”

Yet the Washington Post said: “Health experts worry the device could attract minors and people who did not previously smoke…”

The hyper-concern to prevent teen use and depiction of a teen vaping “epidemic” is misplaced. Concern needs to focus on promoting low-risk nicotine delivery devices to the groups that actually have sky-high rates of smoking and smoking-related mortality, right now: People from low-income backgrounds, people with psychiatric diagnoses, First Nation peoples, people who use drugs, and people who are homeless.

These vulnerable groups make up the vast majority of the 34 million adults who smoke in the US. Why are they not the priority?

Instead of backing an aggressive marketing plan to get low-risk nicotine products into the hands of marginalized smokers, the FDA focuses obsessively on how companies must restrict access to teens. It’s reserving the right to take IQOS off the market if it determines there is a youth increase. In that event, teen use of nicotinewhich has few harms and no deadly oneswould once again be used as a pretext to limit adult alternatives to smoking, which kills.

Tobacco harm reduction-haters have naturally condemned the FDA’s approval of IQOS. “FDA Must Not Allow IQOS to Become the Next Juul Among Kids,” was the title of a statement from Matt Meyers, president of the Campaign for Tobacco-Free Kids. And the Truth Initiative tweeted:

Expect these two organizations to launch a teen-IQOS panic: It’s what they do. Based on the JUUL-panic playbook, get ready to hear that HNB products are enslaving the next generation to nicotine; are a gateway to smoking; are enticing teens with sleek packaging; are as dangerous as cigarettes.

Long used to such attacks, the tobacco harm reduction community—including, for example, important organizations like the International Network of Nicotine Consumer Organizations (INNCO)must get ready to hit back, by proclaiming the evidence that low-risk nicotine products save smokers’ lives.


Photo via Wikimedia Commons

Helen is the senior editor of Filter. She has written about nicotine, mental health and drug policy for publications including Al Jazeera, AlterNet, Harper’s and The Influence. As an LCSW, she works with drug users in medical and community mental health settings. An expert on tobacco harm reduction, she provides training and consultation on mental health, nicotine use and THR, and in 2016 organized the first Tobacco Harm Reduction Conference in the US. Helen is also a documentary filmmaker.

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