‘Heat Not Burn’ Products May Be Almost as Harmful as Cigarettes

Heat-not-burn products are not cigarettes or vaping devices. Fiordaliso/Getty Images

Researchers say heat-not-burn devices are only slightly less harmful to your health than traditional cigarettes.They note that these heated products c…

Heat-not-burn products are not cigarettes or vaping devices. Fiordaliso/Getty Images
  • Researchers say heat-not-burn devices are only slightly less harmful to your health than traditional cigarettes.
  • They note that these heated products can cause damage to blood vessels and create other health issues.
  • They add that the devices can be more difficult to quit than cigarettes.

Devices that heat but don’t burn tobacco to deliver nicotine may be marginally less harmful to health than smoking cigarettes.

But they're hardly risk-free.

Like smoking, heat-not-burn products contribute to endothelial dysfunction and damage to the lining of the blood vessels.

That can lead to plaque formation, narrowing of the arteries, and other problems, according to new research published in the journal Thorax.

Also, while these products are sometimes touted as a smoking cessation tool as well as being a “less harmful” alternative to smoking cigarettes, a second study finds that users of these products may actually be less likely to quit them than those who only smoke conventional cigarettes.

Not cigarettes but also not vaping

Heat-not-burn products fall between traditional cigarettes and electronic vaping devices.

Like cigarettes, they derive nicotine directly from tobacco, but because they don’t burn tobacco leaves, they don’t deliver some other chemicals that smoking does. 

In the recent small observational study, researchers compared endothelial dysfunction, oxidative stress, and platelet activation among 20 nonsmokers, 20 long-term conventional cigarette smokers, and 20 long-term users of heat-not-burn products.

The cigarette users smoked an average of 13 cigarettes daily for 3.5 years, while the heat-not-burn users used about 11 products daily for an average of 5 years.

The researchers found that compared with not smoking, both smoking and use of heat-not-burn products were associated with reduced endothelial function, increased oxidative stress, and high levels of platelet activation, which can cause blood clotting and bleeding. 

The researchers found that the risk of endothelial dysfunction was the same for people who used traditional cigarettes and heat-not-burn products.

In a commentary accompanying the research, Dr. Irina Petrache, a pulmonologist with the National Jewish Health in Denver, Colorado, and Dr. Esther de Boer, a pulmonologist with the University of Colorado, said that despite the study’s small size and other limitations, the “findings are biologically plausible, given the toxic effects of nicotine alone on the endothelium and support health authorities’ assertion that replacing combustive tobacco with other products may not be safer.”

Quitting may be harder, too

Heat-not-burn products may also be harder to quit than cigarettes, according to a second study of a smoking cessation program offered to male workers in Japan.

The program achieved a 29 percent quit rate overall. It incorporated information about stopping smoking, counseling, the smoking cessation drug varenicline, and nicotine replacement therapy.

People who opted for pharmacological support, counseling, or both successfully quit at a higher rate than people who did not accept such support.

Users of varenicline (sold as Chantix and Champix), for example, quit at three times the rate of nonusers of this medication.

However, study participants who exclusively used heat-not-burn products or used both cigarettes and heat-not-burn products were 23 percent less likely to quit smoking than those who only smoked cigarettes, the study found.

These studies add to “the mounting evidence that [heat-not-burn products] are not safer than [conventional cigarettes], suggesting that any tobacco use should be strongly discouraged,” according to Petrache and de Boer.

Marketing questioned

In 2019, the American Heart Association issued an advisory urging greater federal regulation of nicotine delivery systems such as heat-not-burn products.

“Although in devices such as iQOS tobacco is heated and not burned, these products generate detectable levels of harmful and potentially harmful constituents such as volatile organic compounds, polycyclic aromatic hydrocarbons, and carbon monoxide, albeit at levels lower than cigarette smoke.

“Because there is no safe threshold of exposure to these harmful and potentially harmful constituents, heat-not-burn products should be included in all comprehensive smoke-free air laws and other tobacco control strategies,” according to the association.

However, in 2020 the Food and Drug Administration (FDA) permitted iQOS manufacturer Philip Morris to proclaim in its advertising that switching from conventional cigarettes to heat-not-burn products could reduce consumer exposure to harmful chemicals.

“Notably, the FDA did not authorize IQOS to market itself as reducing health risks associated with cigarette smoking, saying there wasn’t enough evidence to support the claim,” according to a report from the Truth Initiative, a smoking cessation and prevention program.

“The concern is that users may assume that the permitted ‘reduced exposure’ claim may translate to ‘reduced risk’ and encourage IQOS use, especially among those who have not used nicotine products before,” the report stated.