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Heat not Burn “as bad as smoking” says study – but what’s the truth?

And so it begins. A new paper presented to the American Heart Association claims that Heat not Burn products harm blood vessel function in the same way as smoking. No doubt there are a dozen other studies underway right now that will soon produce papers linking HnB to heart attacks, lung disease and various cancers. Carefully tailored press releases, all including some form of the phrase “as bad as smoking”, will be leaked to sympathetic journalists. Public health activists don’t even need to go looking for friendly hacks; they can just get in touch with the ones who wrote negative articles about e-cigarettes.

If I sound cynical about the new paper, it’s because I am. I switched from smoking to vaping five years ago, just in time to see the tobacco control industry gearing up its campaign against e-cigs. I have to confess that, at the time, I watched it unfold with total incredulity. Here was a product that got smokers to stop smoking, but the activists and scientists who’re always demanding new action to stop smokers from smoking were opposed to it! What the hell was going on?

Well, five years later, I know what’s going on. The tobacco control industry is, in big-picture terms, split between two main factions – and neither of them is really interested in helping smokers to quit. One faction is motivated by a blind, unreasoning hatred of the tobacco companies; if Philip Morris invented a cure for cancer tomorrow, this group would try to have it banned.

The other faction is no fan of the tobacco companies either, but it has different priorities. Its goal isn’t to stop smokers from smoking; it’s to campaign to stop smokers from smoking. Obviously, if all the smokers become vapers or Heat not Burn users, there won’t be any smoking to campaign against – and that means they’ll have to find new jobs, which might involve some actual hard work rather than just being handed taxpayers’ money to complain about things.

Tinfoil hat time?

Claiming that public health campaigners are more worried about their jobs than public health sounds a bit paranoid, but what’s happening in the UK right now tends to back it up. Local councils who’re trying to save money are starting to take a good look at the stop smoking services they fund – and it appears that some of them don’t like what they see. Several services, including Smokefree South West, have had their council funding stopped, and for nanny state groups that’s usually a death blow. Nobody actually wants to give them money, so if the tax tap is turned off that’s the end of them. Smokefree Southwest announced its closure within 24 hours of being defunded.

The reason councils are starting to defund anti-smoking groups is that it’s obvious they aren’t doing anything. Most councillors aren’t daft; they see smokers switching to e-cigs by the thousand, and the UK’s smoking rate falling faster than ever before. Then they see so-called “public health” groups demanding that e-cigs are taxed, restricted and banned out of existence. Finally it occurs to them that not only are these groups not doing anything to reduce smoking; they’re actively campaigning against products that are. So they pull the plug, and another dozen tobacco controllers are forced to get a proper job.

And all this is happening because of e-cigs. Just imagine what’s going to happen when HnB goes mainstream. Personally, I wouldn’t be surprised if a decade from now the UK’s smoking rate has fallen from its current 16% to around 5%. If that happens a lot more tobacco control funding is going to evaporate, which is why all the usual suspects are already moving to condemn HnB.

What does the science say?

Anyway, back to the paper. What exactly is it saying, and should we take it seriously? The short answer is “Not much and no.” That isn’t very informative, though, so let’s look at it in slightly more detail.

The paper was written by the tobacco research department at the University of California, San Francisco. If you follow the vaping debate that’s probably ringing alarm bells already, because who runs UCSF’s tobacco research department? Yep, it’s Stanton Glantz, the failed aircraft engineer who’s managed to get a job as a professor of medicine despite never having studied medicine in his life. The reality is that Glantz is an activist, not an academic, and this department is shaped in his image: Before they even start doing any research, they know exactly what results they plan to get.

What they wanted to find here was evidence that HnB is just as bad for you as smoking. Now, this is obviously a ridiculous idea. Probably the most harmful single ingredient in cigarette smoke is carbon monoxide, which is produced by combustion, and HnB doesn’t involve combustion.

What they actually mean is that one specific effect of HnB is the same as an effect of smoking. That is obviously not the same thing as saying that using HnB is as bad for you as smoking is. In this case they’re talking about something that isn’t really bad for you at all.

The paper claims that using a HnB product – specifically, iQOS – has the same effect on “Flow-Mediated Dilation”, a way of measuring the efficiency of blood vessels, as smoking a cigarette. In general terms this is true; it’s likely (not certain, but we’ll come back to that) that iQOS will cause a similar short-term effect on blood vessels to a cigarette. Where it all comes unstuck is that the authors go on to say that HnB “does not necessarily avoid the adverse cardiovascular effects of smoking cigarettes”. That statement is a massive problem.

Smoking cigarettes is really bad for your heart. Smoking cigarettes also causes short-term stiffness in your arteries every time you light up and take a puff. But these two facts are not connected. It isn’t the short-term stiffness that makes cigarettes bad for your heart; it’s the couple of hundred daily doses of carbon monoxide, which causes long-term stiffness and the build-up of arterial plaque. Many other things also cause short-term stiffness – caffeine, watching scary movies and exercise are among them. It doesn’t matter, though, because it only lasts a few minutes. Smoking is dangerous because it makes your arteries stiffer all the time, plus promote the build-up of plaque which slowly blocks them. iQOS, being free of carbon monoxide, doesn’t do this.

So what’s really going on with this paper? Leading e-cig expert and cardiologist Dr Konstantinos Farsalinos has the answer, as already reported on this site. According to the UCSF paper, the iQOS delivered 4.5 times as much nicotine to the test subjects (who, it should be pointed out, weren’t people – they were mice) as a cigarette did. As nicotine is known to cause temporary stiffening, that would certainly explain the effect. It would also suggest that it’s nothing to worry about. After all, licensed nicotine products like patches and gum cause an identical effect, and they’re sold over the counter and approved for long-term use.

If we take its data at face value, this paper shows that HnB has the same effect on blood vessels as a nicotine patch, which is regarded as very safe – in other words, there’s nothing to worry about. In fact, what the data show is that the researchers have made a very serious mistake somewhere. According to them, iQOS delivers about 350% more nicotine than a cigarette does – but three independent studies all agree that it delivers about 30% less nicotine. As Dr Farsalinos points out, it is impossible for iQOS to deliver that much nicotine. Therefore the UCSF team have screwed up somewhere, and if they’re working on terminally flawed data, that the whole paper can safely be ignored.

Unfortunately, while this one might be (it doesn’t seem to have gained much traction outside crank medical websites), as HnB becomes more popular we can expect to see more “research” being done and negative stories starting to appear in the press. It’s likely that all the smear stories that have been aimed at e-cigs will be recycled to attack HnB too. If you doubt that, consider this: Just two months ago, a paper from Sweden claimed that e-cigs have the same effect on arterial stiffness as smoking does. Sound familiar?

Heat not Burn is going to get exactly the same treatment as vaping did; I guarantee it. In fact, if anything it will be worse, because the leading HnB products actually are made by the dreaded tobacco companies. Vapers couldn’t really believe what was happening at first, and lost a lot of ground to bad science and scaremongering media before advocates started fighting back. If you’re a fan of HnB, don’t make the same mistakes; start pushing back now.

 

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More Heat not Burn science – Glo has been tested!

Back in April we looked at the latest research on the safety of iQOS compared to traditional cigarettes, and it looked very encouraging for heat not burn devices. Studies carried out for PMI by independent labs found that the vapour from an iQOS had much lower levels of toxic chemicals than cigarette smoke – in most cases, 90% or 95% lower. That’s impressive, especially considering that the tests looked at a much larger range of chemicals than any research done by public health groups.

The down side to this research was that it only looked at iQOS. Yes, that particular product is much safer than smoking, but does it apply to HnB in general? Realistically it’s going to be a while before we know that for sure, but this week some more results were released, this time by British American Tobacco. We recently did the first full UK review of BAT’s new Glo, their entry in the HnB market; now there’s some science to go with our impressions of this device.

Real science?

Although research done by the tobacco industry in the past has had a bad reputation, things have moved on a long way since the 1960s. Companies like BAT know that anything they publish is going to be scrutinised in minute detail by activist scientists looking for the slightest hint of foul play, so they don’t take any chances. These days they’re scrupulous about following good research procedures and releasing details of their methods, so the research can be studied and replicated. How well are they doing at that? Well, all the criticism of PMI’s research on iQOS has been about where the money comes from; nobody has said a word against the science. That probably tells us all we need to know.

BAT seem to have been just as careful with their own research, which makes the results worth looking at. For a start, they didn’t just bodge up some shonky equipment, like one university did recently when they used syringes to collect vapour from e-cigs. Instead, they studied how people actually use Glo then programmed a robot smoking device to replicate that. Then they tested Glo, collecting the vapour for comparison with a range of other products.

In total seven products were tested:

  • Glo
  • Three conventional cigarettes, including the standard 3R4F reference cigarette used in most smoking research.
  • “Another THP (tobacco-heating product)”, almost certainly an iQOS.
  • “A hybrid product”, BAT’s iFuse
  • An e-cigarette.

This is a good selection of products, covering all the main categories on the market right now. BAT also tested for a wide range of chemicals. They used the Health Canada testing method to collect vapour, because it’s one of the most thorough methods in use, combined with their own list of chemicals. The FDA test for 28 different toxins in cigarette smoke; the International Agency for Research on Cancer only measure fifteen. BAT’s list has 44 substances in it – not quite as extensive as the 58 that PMI look for, but still much more impressive than what most health researchers are doing.

Checking the chemistry

What’s really impressive is the results of all this testing. Unsurprisingly, most of the vapour from Glo consisted of water vapour and glycerine, which is added to increase the vapour output. That’s interesting, because when we looked at the innards of a NeoStik the tobacco in it looked much less processed than the contents of a Heet. Obviously, even though what the Glo is heating looks like normal cigarette tobacco, BAT have added a considerable amount of glycerine to it somehow. That doesn’t cause any worries, though; glycerine is perfectly safe to inhale.

The nicotine content of the vapour was about 62% of that found in cigarette smoke. This makes sense; using the Glo, it felt similar to a light cigarette, while the 3R4F cigarette is a full-strength blend. In any case, this sort of nicotine dose is close enough to a cigarette that it’s an effective replacement.

Moving on to the less welcome substances, the tests showed sharp reductions in all of them. The lowest reductions were for mercury, at 57.1%, followed by ammonia at 64.3%. Neither of these chemicals are at high enough levels in cigarette smoke to be much of a worry anyway, but any reduction is welcome. For the other 41 chemicals tested, 39 had a reduction of at least 80% and 36 saw levels reduced by 90% or more. Almost half had at least a 99% reduction. The total reduction in toxins was around 90%.

Does this mean it’s safe?

It’s worth pointing out that a 90% reduction in toxins is impressive, but it doesn’t tell the whole story. For example, the single most harmful chemical in cigarette smoke is carbon monoxide, and smoke contains a lot of it. The level in Glo vapour was 98.6% lower. Benzene is another major problem for smokers; Glo reduces the leve by 99.3%. Hydrogen cyanide – 98.8% lower. What this means is that while switching from cigarettes to Glo cuts total toxins by 90%, it almost certainly cuts the health risk by a lot more.

More good news from the study is that iQOS and the e-cigarette gave roughly similar results to Glo (although many of the toxins aren’t found in e-cig vapour at all).

Between this new research and what PMI have already released about iQOS, it seems obvious that HnB is much safer than smoking, and probably about the same as vaping an e-cigarette. A reduction in risk of at least 95% seems likely to be about right. Does this mean that switching to Glo cuts your risk of premature death by 95%? No – it almost certainly cuts it by a lot more than that. Jumping from a ground-floor window is about 95% less risky than jumping from a fourth-floor one, but the risk that’s left doesn’t mean your chance of dying drops from 50% to “only” 2.5%. It means that, if you’re really unlucky, you might twist your ankle.

If you need a final vote of confidence in BAT’s new research it’s just been published in a peer-reviewed medical journal, Regulatory Toxicology and Pharmacology. Peer review means a panel of experts have examined and decided that the experiments were good science and the data has been properly interpreted. Of course some extremists will refuse to accept it simply because it was funded by BAT, but open-minded people like our readers can find it here.

 

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Heat Not Burn Safety Update

the cube neuchatel

Over the last year we’ve seen a lot of progress for heat not burn products, with the iQOS now available in several countries including right here on this website and a few new devices set to be released soon. The market looks like it could be on the brink of some serious growth, and within a few years HnB could have made as big a dent in smoking rates as e-cigarettes already have.

There’s one thing still missing, though. If heated tobacco products are really going to grab a sizable percentage of the cigarette market it’s important that their makers can show they’re safer than smoking. As we’ve mentioned before, common sense tells us they pretty much have to be a lot safer, because the tobacco isn’t being burned, but there’s a distinct lack of actual data. Isn’t anyone doing the research on this? It turns out the answer is yes.

Of course, you won’t see this research appearing in the medical journals just yet, because it’s actually being carried out on behalf of the tobacco industry. Philip Morris International have invested more time and money in HnB than anyone else, and a lot of that has gone towards looking into how much risk can be removed by switching from lit to heated tobacco. Some world-class laboratories have been asked to investigate how HnB is working and what that means in terms of health effects. Last week Heat not Burn UK got a chance to visit the Cube, PMI’s European research HQ at Neuchatel in Switzerland, to find out what’s going on.

How hot is too hot?

By now everybody knows that smoking-related diseases aren’t caused by tobacco; it’s the combustion process that creates the worst toxins and cancer-causing substances. Tobacco-free herbal cigarettes aren’t any better for you than Benson & Hedges, because you’re still inhaling burning plants. However, PMI have found out that making a safe HnB product isn’t as simple as not setting fire to the tobacco.

The tip of a lit cigarette, between puffs, is at between 600°C and 800°C; when you take a drag on it this rises to over 900°C. That’s the sort of temperature tobacco burns at. However, at much lower temperatures it goes through a process called pyrolysis, where it’s being broken down by heat but not actually burning. Pyrolysis starts at around 350°C, much lower than combustion temperatures – and pyrolyzing tobacco still gives off a lot of nasty chemicals. Not as much as burning it, of course, but probably still more than you really want to be inhaling.

So the trick to safe HnB is to heat the tobacco to just below the point where pyrolysis begins. If you were wondering why iQOS heats its sticks to 350°C when tobacco doesn’t start burning until hundreds of degrees above this temperature, now you know. PMI have opted for the highest safe temperature, where there’s little or no pyrolysis going on but the tobacco is still hot enough to generate a decent vapour. Because HnB products like iQOS, Glo and PAX 2 are electronically controlled it’s easy to get them to produce a constant temperature and avoid pyrolyzing or burning the tobacco.

Tracking the toxins

Obviously the big question is, what effect does HnB have on the levels of chemicals you’re inhaling? It’s unrealistic to insist on zero chemicals, because many of the toxins in cigarette smoke are very common substances. For example, smoke contains high levels of formaldehyde – but human bodies contain formaldehyde, too. Our metabolism produces it, and there are detectable levels of it in exhaled breath. What we’re looking for are levels that might not be zero, but are much lower than you’d get from a cigarette.

To test this, PMI analysed the smoke from a reference cigarette – this is a standardised cigarette used for lab testing – then compared it with the vapour from their two HnB products. One of these is iQOS; the other, known as Platform 2, hasn’t been released yet but works in a different way. What they found was that for every chemical they tested, levels were dramatically reduced in both HnB products. The highest levels were for ammonia, with iQOS having about half the level of a cigarette and Platform 2 around 40%. Is that enough to worry about? No; even cigarette smoke doesn’t have anywhere near enough ammonia to be an issue. For the other chemicals they tested levels were reduced by at least 80%, and in most cases 90 to 95%. Overall it looks like HnB eliminates more than 90% of the harmful chemicals found in cigarette smoke.

One impressive point about PMI’s research is that they’ve been extremely thorough. Different agencies have different lists of chemicals in smoke that concern them. For example the FDA have a list of 28 different substances; the International Agency for Research on Cancer’s list has fifteen. To be on the safe side, Philip Morris have simply combined everyone else’s lists; they test for fifty-eight different chemicals – far more than anyone else does.

Attention to detail

PMI aren’t just measuring what’s in the vapour; they’re also testing smokers who’ve switched to their HnB products to see how they compare with people who’ve either quit entirely or continued to smoke. What they’re doing here is looking to see if switchers’ blood chemistry is more like a smoker or a quitter. For every chemical they’ve tested – including carbon monoxide, benzene and acrolein – HnB users either have identical levels to smokers who’ve quit entirely or (for acrolein) the level is slightly higher than a quitter but much lower than a smoker.

At Heat not Burn UK we might not be scientists, but we do know how science is supposed to be done. The research that’s being carried out on the health effects of HnB is very good science. It’s extremely thorough and detailed. The actual analysis is being carried out by independent labs, which should deal with any accusations of bias. PMI are being completely open about the experimental methods, so anybody who has doubts can replicate the research themselves.

Why so modest?

That leaves one question: With all this research to back them up, why aren’t PMI shouting from the rooftops about how safe HnB really is? Most likely that’s down to an understandable wariness of being sued. If they say that iQOS is 90% safer than smoking, and then at some point in the future evidence shows it’s only 89.9% safer, how long is it going to be until swarms of Californian lawyers descend on them with a fistful of class action suits? Not long, probably.

So, for now, they’re playing a cautious game. The data is there, and steadily growing. Sooner or later it will be presented to some government agency, probably the FDA, and they’ll confirm that these products are much safer than smoking. That’s when the manufacturers will start publicising it. Until then we’re just going to have to rely on common sense.

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How safe are tobacco vaporisers?

Rumours are circulating that tobacco vaporisers and other heat not burn products might not deliver on the reduced harm that justifies the products’ existence. Not all these health claims are new, of course – they’re as old as the products themselves. Heat not burn probably has more potential now than ever before, though. Earlier attempts to sell the technology failed, probably because it was just too different from what smokers were used to.

That’s all changed over the last few years. The popularity of electronic cigarettes has grown at a stunning rate, and despite the fake concerns of many public health charities almost all the people who use them are, or were until recently, smokers. The key point about that is that by any sensible definition e-cigarettes are far more different from traditional cigarettes than any heat not burn product is. E-cigs don’t even contain any tobacco, while heat not burn products do. In fact most of the ones in the pipeline just now include something that’s recognisably like a cigarette. The only exceptions are loose tobacco vaporisers like the excellent PAX 2. Phillip Morris’s iQOS uses cigarette-like tobacco sticks, while RJ Reynolds’ Revo looks just like a cigarette and even works like one; you simply put it in your mouth and light the end.

So the companies interested in heat not burn technology are gambling that if smokers are willing to switch to something as unfamiliar as a tank full of liquid with a battery to heat it, they’ll be even more enthusiastic about something that retains the familiar tobacco. They could be right; although vaping has become widely accepted among smokers there’s still a significant number who aren’t tempted.

The fear industry

The problem is that heat not burn is still at the stage where it’s very vulnerable to health scares. E-cigarettes have suffered badly from this; media coverage has been so bad, and misinformation from anti-vaping groups so vicious, that a majority of American smokers believe vaping is at least as harmful as smoking; the truth is it’s at least 95% safer. If so many terrifying rumours can be spread about vaping, though – where users are inhaling vaporised liquid – what can the fearmongers do with a product that contains actual tobacco?

It’s complicated by the fact that heat not burn is a much broader category of device than e-cigarettes. There’s an incredible variety of vapour products, but no matter how different they look, they all function in basically the same way. The battery heats a coil, which draws up liquid through the wick and vaporises it. Once you’ve shown that one e-cig is relatively safe to use, you can be pretty sure that your conclusions apply to all e-cigs.

Heat not burn is different. Some devices heat loose tobacco in a chamber, using an electric heating element. Others wrap the element around a paper tube of tobacco. Revo doesn’t have any electronics at all; it uses a charcoal pellet to generate heat. These devices share the same basic principle – heating tobacco to liberate flavoured vapour and nicotine – but they work in very different ways. That means conclusions drawn from studying one product don’t mean much for others.

The product that’s causing the most concern is Revo. How much of that is down to the fact that it looks just like a cigarette, it comes in packs just like a cigarette and it’s used just like a cigarette? Who knows? There are some legitimate reasons to worry, though. For a start, heat not burn isn’t an entirely accurate description of the Revo. The tobacco isn’t burning – in theory, at least – but the charcoal pellet that heats the whole thing certainly is.

How much burning is too much?

Burning charcoal is a notorious producer of carbon monoxide; lighting half a dozen disposable BBQ grills in a closed room is an increasingly popular way of committing suicide. The level of carbon monoxide emitted by a Revo is obviously much lower – but regularly inhaling small doses of CO is one of the most dangerous things about smoking cigarettes. The constant respiratory stress caused by the gas eventually damages arteries and leads to heart disease. The fact that Revo relies on charcoal has to be a point against it.

There are also questions about what exactly the Revo is vaporising, and even if vaporising is all it’s doing to the tobacco inside. Electronic devices, like iQOS, can maintain precise control over the temperature of the heating element. There’s almost no way an iQOS or PAX 2 is going to burn the tobacco you load in, unless you abuse it. Is the same true of the Revo? RJ Reynolds say so, but it’s hard to be sure. Because it does involve combustion, adding more oxygen to the process can raise temperatures. Take an unusually hard puff, or use it outside on a windy day, and the temperature could easily spike above the point where the tobacco is actually burned.

There’s no evidence that this is happening with Revo, but it’s certainly a theoretical possibility. Even in normal use the tip gets hot enough that many of the chemicals found in tobacco smoke can be vaporised. These include acetone and ammonia, as well as the monoamine oxidase inhibitors (MAOIs) that make tobacco smoke many times more addictive than pure nicotine.

It’s still pretty safe

On the other hand, while these worries are real, they probably aren’t very significant. It still seems to be a no-brainer that, because the tobacco inside isn’t being burned to ash like it is in a cigarette, Revo is going to be much less dangerous than a traditional smoke. There is also a spectrum of risk with heat not burn products. Electronic devices are likely to produce a far cleaner vapour than anything that involves combustion. Are they as safe as e-cigarettes? Because they contain tobacco, probably not. Are they safer than burning anything and inhaling the result? Yes, they almost certainly are.

So far there’s no evidence that even begins to suggest smokers shouldn’t try heat not burn. Even a Revo is going to be a lot safer than a normal cigarette; iQOS should approach the safety of a typical e-cig. If you’re already a smoker, and thinking about giving heat not burn a go, safety is not something that should affect your decision. Compared to smoking they’re safe enough; that’s what matters.

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How safe is Heat not Burn?

One of the things you’ll hear a lot from anti-smokers is that 70% of smokers want to quit. If you actually talk to smokers you’ll probably hear a very different answer. Most of them don’t want to quit at all, because the truth is they enjoy smoking. They know they should quit, because smoking is undeniably bad for your health, but that’s not quite the same as actually wanting to. If scientists announced tomorrow that they’d got it all wrong and smoking was completely safe, you can bet nobody’d be interested in quitting. The appeal of Heat not Burn products is that, potentially, they can offer the enjoyment of smoking without most of the health risks. That raises a crucial question: How safe are HnB products really?

Continue reading How safe is Heat not Burn?