Heated tobacco products in Italy| Tabaccologia

Article

We often read in the Italian lay press – less often in scientific journals – supportive articles for heated tobacco products (HTP) written by researchers linked to the tobacco industry. In the same magazines we also read enthusiastic statements by tobacco company executives who dream of a smoke-free Italy in the next 10 years, through a transition from traditional cigarettes to their new tobacco products.

The harsh reality is that scientific evidence – the one independent of any conflicts of interest - says something very different. Manufacturers state with certainty that HTPs are less harmful than conventional cigarettes since some of the harmful substances are emitted in lower concentrations. But what do we know about the other toxic and potentially carcinogenic substances emitted by these devices, which are not even present in conventional cigarettes [1]? Many speculate that these products can do less harm than traditional cigarettes, but the truth is that no one knows yet whether these products are less harmful than conventional cigarettes. We will ignore it for several years, until the publication of the results from large longitudinal cohort studies. The only certainty we have, to date, is that HTPs are not safe [2, 3]. In fact, we should keep in mind that these products remain tobacco products, consequently they are and will be the cause of cancers and other chronic diseases, and consequently of new deaths.

We know that, at least in Italy, electronic cigarettes and HTPs do not help to reduce the number of smokers. In fact, independent scientific evidence shows that novel products were not only unable to accelerate the consolidated favourable trends of tobacco sales of the last few decades but for the first time in twenty years these products even contributed to a significant growth in tobacco sales in Italy. Moreover, for the first time in 70 years we observed an increase in the prevalence of conventional cigarette smokers in Italy. These changes in trends are observed in concomitance with the spread of electronic cigarettes and of HTPs [4].

We have recently published the data of a prospective cohort study, in which we followed a cohort of more than 3000 Italian adults for about 7 months [5]. This study - the first one with such a study design in Europe - gave unequivocal findings, showing that among those who had never smoked, users of electronic cigarettes and HTPs had 6 to 9 times the risk of starting smoking conventional cigarettes compared to those who did not consume these novel products; furthermore, among those who had quit smoking conventional cigarettes, users of e-cigarettes and HTPs had 3 to 4 times the risk of relapse. On the contrary, among current smokers, those who quit smoking were more frequent among non-users of electronic cigarettes and HTPs.

The claim that the majority of smokers starting using HTPs quit smoking conventional cigarettes completely is false. In fact, from the latest survey conducted in 2022 in collaboration with the National Institute of Health (Istituto Superiore di Sanità), only 15% of those who started using HTPs successfully stop smoking; the vast majority of HTP users instead become dual user (i.e., they consume HTPs where they cannot consume conventional cigarettes, without however giving up the latter product).

Furthermore, it seems that these products are not appealing for “heavy smokers”, those who are unable to quit with other smoking cessation support and who could theoretically benefit from a less harmful product. If we define “heavy smokers” as those who have accumulated more than 30 “pack-years” (i.e. those who have smoked at least one pack per day for 30 years or ten cigarettes per day for 60 years) it is clear that an heavy smoker is unlikely aged less than 60 years old. We dont need complex epidemiological studies to observe that in Italy HTP did not became successfully among those aged over 60 years. It is no coincidence that the target of the advertisements for these products are young or very young people and certainly not elderly adults [6].

For all the above-mentioned reasons, we do not support promoting HTPs as tobacco harm reduction tools. Instead, we recommend denying the fiscal and regulatory benefits HTPs enjoy. We also do not support electronic cigarettes as consumer products, but we recognize that there might be some debate about whether electronic cigarettes should be considered effective for smoking cessation in a clinical setting. This is the welcome choice made by Australia, where the sale of liquids for electronic cigarettes containing nicotine is prohibited, but where the medical prescription of electronic cigarettes for smokers who wish to quit has recently been introduced [7]. For HTPs, on the other hand, there is no debate within the independent scientific community: the only ones who support or strongly support these products are those researchers who receive fundings directly or indirectly by the tobacco industry. Philip Morris has invested hundreds of millions of US dollars to fund research that promotes their products, setting up, among other initiatives, the “Foundation for a Smoke-Free World” [8-10]. We know that tens of millions of euros have transitioned from this Foundation to Italian organisations, institutes or universities - often not declaring their conflicts of interest - to finance biased researchers conniving with the tobacco industry [9-11]. Among the researchers who choose to remain independent of the tobacco industry, we do not know anyone supporting HTPs as a harm reduction tools.

References

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