Heated tobacco products: The safer choice?

by Admin-Phmp

Text by Henrylito D. Tacio

Photos courtesy of Philip Morris Ltd and Wikipedia

It’s a fact: smoking is bad for your health. For one, a person who smokes is more likely to get heart disease. Roughly one out of 5 deaths from heart disease, according to studies, is directly related to smoking.

“People who smoke are two to four times more likely to get heart disease,” states the website webMD.com. “The risk is even greater for women who smoke and also take birth controls.”

Smoking is bad for your heart due to the nicotine which tobacco contains. Nicotine in the form of smoke reduces how much oxygen your heart gets, raises your blood pressure, speeds up your heart rate, makes blood clots more likely (which can lead to heart attacks or strokes), and harms the insides of your blood vessels, including those in your heart.

Stop smoking

This is the reason why heart specialists always recommend to heart patients to quit smoking. “Doctors like me have persuaded, motivated, even threatened patients to make them stop smoking,” says Dr. Rafael R. Castillo, an internist, and cardiologist at the Manila Doctors Hospital. “We’re only successful in around three out of 10 cases.”

When it comes to recalcitrant smokers, some heart specialists even “reach exasperation point” that they advise them to see another physician if they’re not able to quit smoking in six months.

“Occasionally, a few eventually succeed in quitting smoking, and we welcome them back,” says Dr. Castillo, who is past president of Philippine Heart Association and Philippine College of Cardiology. “A few who have already licked the vice slide back and voluntarily go somewhere else for a follow-up. Some just maintain the initial drugs they’re given, and simply stop seeing a specialist for their heart issues.”

According to Dr. Castillo, it was their “standard policy in our practice” until coronavirus disease 2019 (COVID-19) hit the country last year. “We realized we might have been too harsh on our recalcitrant smoker-patients,” he admits.


Smoking and COVID-19 definitely make a killer team. A study published in The New England Journal of Medicine shows that compared to non-smokers, “smokers are 2.4 times more likely to be admitted to an intensive care unit, need mechanical ventilation or die.”

In a study done outside of Wuhan, China, it was found that “smokers accounted for 8% of the total cases but 12% of severe cases.”

Building on data from China and Italy, documenting risk factors for severe disease progression with COVID-19, the US Centers for Disease Control and Prevention (CDC) noted in its Morbidity and Mortality Weekly Report: “(P)atients with underlying health conditions and risk factors, including, but not limited to… smoking, might be at higher risk for severe disease or death from COVID-19.”

“COVID-19 was really tragic news for those who continued smoking,” says Dr. Castillo, who writes a regular weekly column for Philippine Daily Inquirer. “It always pained us to hear of a former patient whom we’ve ‘expelled’ from the clinic being hospitalized for severe COVID-19 or succumbing to it. Some of them get admitted to the intensive care unit or die, either because of complications in the lungs or cardiovascular complications like heart attack, heart failure and stroke, which may all be COVID-related also.”


Since last year, heart specialists have eased up their strict policy on smokers. “Rather than ‘expel’ them as we used to do, we’re now trying all other options that can at least reduce their risk,” Dr. Castillo says. “We’re trying to look for the best middle ground, hoping that, eventually, we could push them up to the real safe, high ground of completely not smoking.”

Between two evils, choose the lesser one. That’s what heated tobacco products (HTPs) are all about. Based on preliminary less harmful effects of HTPs, “we’re allowing our smoker-patients to shift to this alternative, but always reminding them that quitting smoking is the ultimate goal.

“We don’t know yet if these less harmful effects of HTPs could really translates to long-term beneficial outcomes. It’s a middle ground that appears to be relatively safer than traditional smoking,” Dr. Castillo contends.

HTPs 101

Sometimes marketed as “heat-not-burn” products, HTPs come in many forms, CDC reports. Some HTPs use electronic heating elements. There are those specially designed sticks, plugs, or capsules containing tobacco. Others work by heating liquids that create an emission that then passes through a tobacco plug to absorb flavor and nicotine from the tobacco.

Some HTPs have a similar size and shape as regular cigarettes and have a carbon tip wrapped in glass fibers that the user heat with a lighter or match. 

HTPs are not the same as electronic cigarettes. HTPs heat actually tobacco leaf. In comparison, e-cigarettes heat liquids that typically contain nicotine derived from tobacco, as well as flavorings and other ingredients.

Insufficient data

“Based on some studies, the amount of toxic substances a smoker gets is up to 95% less, compared to traditional tobacco smoking,” Dr. Castillo reports. The CDC reports that the emissions created from HTPs “generally contain lower levels of harmful ingredients than smoke from regular cigarettes.”

“There are also short-term studies showing that it leads to a reduction in the substances released by the body that cause inflammation, compared to traditional smoking,” Dr. Castillo continues. “Any form of inflammation in the body, no matter how little, is always bad news, as it slowly causes damage to the vital organs such as the heart, brain and kidneys.”

On its website, the CDC reports of studies done on second-hand emissions from HTPs, which suggest that the products expose both users and bystanders to some of the same chemicals found in cigarette smoke, “although at lower levels than cigarette smoke.”

In an article published in The Conversation, authors Nham Tran and Fiona Deutsch wrote: “Heat not burn products do release fewer toxin and at a lower concentration than normal cigarettes because there’s no burning, or combustion, which would otherwise release toxins.”

They also noted: “Looking to the longer term, the fact heat-not-burn products release fewer toxins than normal cigarettes may have some benefits over a life history of smoking.”

But all these studies (some of which were funded by tobacco companies) are still “insufficient” to merit recommendation. As the World Health Organization (WHO) puts it: “There is no available evidence to conclude whether HTP use is associated with any long-term clinical outcome – positive or negative – from exposure to the mainstream or second-hand emission.”

But in 2019, the United Nations health agency said that “the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products (HTPs) may be lower relative to cigarettes.”

“With current data, it does look relatively clear that HTPs are less harmful than traditional smoking, but are still more harmful than not smoking,” Dr. Castillo says, adding that “it’s something that the medical community, legislators and regulators should discuss. After all, the lives of our 16 million Filipino smokers may hinge on the options we offer them if they really cannot quit smoking.”

Dr. Castillo, who doesn’t smoke, points out: “Less harmful alternatives to traditional smoking like HTPs seem to be a pragmatic middle ground. Our previous attitude was to give them up and allow them to suffer from the unhealthy state they’ve chosen. But with the smoker-patients we’ve lost to COVID-19 in the past 14 months, our attitude has somewhat changed.”


First launched in 2014, HTPs are now available in some parts of the world, including the Philippines. HTPs were made available right after the approval of the bill regulating the manufacture, sale, and distribution of vaping products and other electronic nicotine and non-nicotine delivery systems.

Total sales for HTPs in 2016 were reported as US$2.1 billion, and they are expected to reach US$17.9 billion by 2021, according to the WHO.

IQOS (Wikipedia)

Only a few HTPs have been marketed so far. The most famous among them is IQOS – which pundits say it is an acronym for “I quit original smoking” – which is being sold in the country by PMIFTC, a joint venture company by Philip Morris Philippines Manufacturing, Inc. (PMPMI) and Fortune Tobacco Corporation. It is sold strictly to anyone who is 21 years or older.

Dr. Castillo recommends that HTPs should only be used by recalcitrant smokers or those who can’t quit smoking. But some researchers have found that IQOS may appeal to youth and young adults because of the marketing strategies that depict the product as “sophisticated, high-tech and aspirational” and “sleek, exclusive items akin to iPhones.”

Youth and non-smokers

Dr. Castillo is very much aware of that. “The downside of HTPs is that the youth and non-smokers might be ‘seduced’ into trying them,” he says. “This is where legislation and regulation come in.”

According to him, “a strict but balanced regulation is important, but it should not be more restrictive than regulation for cigarettes. There must be control measures to prohibit sales of HTPs to non-smokers and the youth, but current smokers must be given the free choice to shift to it, if they wish to, and especially those with the guidance of their physician.”

Dr. Castillo also doesn’t recommend using HTPs in public places. “Though HTPs are supposed to be smoke-free, we don’t think they should be allowed in public,” he says. “The harmful particulate pollution they cause is relatively less, but the potential harm to second-hand smokers is still there.”

Remember, there is no safe level of tobacco use. As Howard Dean puts it: “I’m just deeply disappointed that once again we may have to settle for the lesser of two evils.”

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