Cardiovascular effects of nicotine
vs. cigarette smoke
Dr Konstantinos Farsalinos Researcher Onassis Cardiac Surgery Center, Greece University of Patras, Greece National School of Public Health, Athens-Greece
1st (and last) slide
• Please look at last year’s presentation by Prof. Neil Benowitz
Cardiovascular effects of nicotine
vs. cigarette smoke
Dr Konstantinos Farsalinos Researcher Onassis Cardiac Surgery Center, Greece University of Patras, Greece National School of Public Health, Athens-Greece
Emerging harm reduction (?) choices Tobacco heated products
Dr Konstantinos Farsalinos Researcher Onassis Cardiac Surgery Center, Greece University of Patras, Greece National School of Public Health, Athens-Greece
Tobacco heated products An old story
1998, RJ Reynolds launched Premier
Tobacco heated products An old story
• Premier replaced by Eclipse
Tobacco heated products New developments
Tobacco heated products New developments
• Tobacco companies: JTI, PMI, BAT
• Two of them (PMI-IQOS, BAT-Glo) are heating tobacco through a resistance
(maximum 350oC and 240oC respectively)
• PMI: heats tobacco by penetrating the stick with a metal blade (heat source)
• BAT: heats the tobacco through resistors (heat source) surrounding the tobacco stick
• JTI product (Ploom TECH) is an e-cigarette with a tobacco cartridge at the mouth
piece (indirect heating of tobacco by the aerosol passing through the cartridge)
Tobacco heated products marketing
• PMI launched product in Japan in late 2014 ▫ Market share > 14% in Japan
▫ Available in about 30 countries
• JTI launched product in March 2016
▫ Also available in Switzerland
• BAT launched product in late 2016
▫ Market share 1.8% in Japan
▫ Now in Canada, S. Korea, Switzerland, Russia
A lot of research Almost all by the manufacturers
• Chemistry
• Toxicology
• Clinical
Chemistry
Forster et al., Regul Toxicol Pharmacol 2017
Glo
average > 95% reduction in toxic emissions
Chemistry
Schaller et al., Regulatory Toxicol Pharmacol 2016 (PMI - IQOS)
IQOS
average 90%
reduction in toxic
emissions
Chemistry
JTI poster, Global Forum on Nicotine 2017 (Ploom TECH)
Ploom-Tech
average > 95%
reduction in toxic
emissions
Clinical studies
BAT, poster presentation at Global Forum on Nicotine 2017 (Glo)
Clinical confinement for 5 days
Comparison between continuous smoking and switch to THP product
Clinical studies
Clinical confinement study
Comparison between continuous smoking, smoking cessation and
switch to THP product
Haziza et al., Regulatory Toxicol Pharmacol 2016 (PMI – IQOS)
Clinical studies
Haziza et al., Regulatory Toxicol Pharmacol 2016 (PMI - IQOS)
SA = smoking abstinence
THS = THP
Research replication
• Although science should not be discarded, a critical and very cautious approach is need due to the source of the information (manufacturers, tobacco industry)
• It is of outmost importance to replicate the studies, carefully reviewing the methodology, testing several puffing regimes, checking the accuracy of the reported values
Independent studies
• Mainly 3 independent studies have attempted to replicate manufacturer publications for 1 HnB product (IQOS)
Independent studies
0
4
8
12
16
20
HnB regular HnB methol
Nic
oti
ne
lev
els
(mg
/g t
ob
acc
o)
Nicotine concentration (mg/g) in unused tobacco sticks of
IQOS appear to be similar to tobacco cigarettes
Farsalinos et al. Nicotine Tob Res 2017
0.00
0.50
1.00
1.50
2.00
2.50
Regular
2 s
Menthol
2 s
Regular
4 s
Menthol
4 s
Vapour 2
2 s
Vapour 2
4 s
Epsilon
2 s
Epsilon
4 s
Nautilus
Mini
2 s
Nautilus
Mini
4 s
Regular
2 s
HnB HnB Ciga-like EC eGo style EC Variable wattage Tobacco
cigarette
Nic
oti
ne
lev
els
(mg
/12
pu
ffs)
Independent studies
Lower nicotine levels (-30%) to the aerosol compared to
tobacco cigarette smoke Farsalinos et al. Nicotine Tob Res 2017
Independent studies
Farsalinos, Leischow et al. (under preparation for submission)
0.0
0.4
0.8
1.2
1.6
2.0
55/2/30 80/3/30 90/3/25
mg
/sti
ck
Puffing regime (volume, duration, interval)
Nicotine delivery to the aerosol (IQOS)
Independent studies
Auer et al. JAMA Int Med 2017
Independent studies
Auer et al. JAMA Int Med 2017
Independent studies
Auer et al. JAMA Int Med 2017
0
50
100
150
200
250
Auer et al. PMI
Acetaldehyde
3.2
0.9 1.8
5.5
0.2
5.53
11.3
1.45
16.8
0.53
0
2
4
6
8
10
12
14
16
18
Auer et al.
PMI
Independent studies IQOS Tobacco cigarette % difference
• PMI responded that this is not a listed HPHC, but this is not good enough
justification
• Anything potentially toxic should be tested, irrespective of being listed in HPHC
lists
• Limited data on toxicity of acenaphthene, but it is a PAH produced during high
temperature carbonization – more studies are needed to verify the levels,
source and reasons it is formed
• Aldehyde levels were low in IQOS but were unusually low in tobacco cigarettes
Independent studies
Bekki et al. J UOEH 2017
Independent studies
Bekki et al. J UOEH 2017
19.2
34
4.5
12.3
0.44
6.7
20.5
3.15
6.7
0.53 0
5
10
15
20
25
30
35
40
NNN NAT NAB NNK CO
Bekki et al
PMI
Exhaled carbon monoxide
(Use by e-cigarette users) (Use by smokers)
Farsalinos et al. (unpublished data)
0
2
4
6
8
10
12
14
16
18
IQOS Tobacco cigarette
Before use
After use
Aldehydes in THP
Farsalinos, Leischow et al. under preparation for submission
0
1
2
3
4
5
6
7
IQOS REGULAR IQOS MENTHOL
Formaldehyde
PMI
Farsalinos et al.
Farsalinos, Leischow et al. under preparation for submission
0
50
100
150
200
250
IQOS REGULAR IQOS MENTHOL
Acetaldehyde
PMI
Farsalinos et al.
Aldehydes in THP
Farsalinos, Leischow et al. under preparation for submission
0
2
4
6
8
10
12
IQOS REGULAR IQOS MENTHOL
Acrolein
PMI
Farsalinos et al.
Aldehydes in THP
Farsalinos, Leischow et al. under preparation for submission
0
2
4
6
8
10
12
14
16
IQOS REGULAR IQOS MENTHOL
Propionaldehyde
PMI
Farsalinos et al.
Aldehydes in THP
Farsalinos, Leischow et al. under preparation for submission
0
1
2
3
4
5
IQOS REGULAR IQOS MENTHOL
Crotonaldehyde
PMI
Farsalinos et al.
Aldehydes in THP
Farsalinos, Leischow et al. under preparation for submission
0
5
10
15
20
25
30
35
40
IQOS REG IQOS MENTHOL
Formaldehyde
55/2/30
80/3/30
90/3/25
Aldehydes in THP different puffing regimes
Farsalinos, Leischow et al. under preparation for submission
0
50
100
150
200
250
300
IQOS REG IQOS MENTHOL
Acetaldehyde
55/2/30
80/3/30
90/3/25
Aldehydes in THP different puffing regimes
Aldehydes in THP different puffing regimes
Farsalinos, Leischow et al. under preparation for submission
0
5
10
15
20
IQOS REG IQOS MENTHOL
Acrolein
55/2/30
80/3/30
90/3/25
Aldehydes in THP different puffing regimes
Farsalinos, Leischow et al. under preparation for submission
0
5
10
15
20
25
30
IQOS REG IQOS MENTHOL
Propionaldehyde
55/2/30
80/3/30
90/3/25
Aldehydes in THP different puffing regimes
Farsalinos, Leischow et al. under preparation for submission
0
2
4
6
8
IQOS REG IQOS MENTHOL
Crotonaldehyde
55/2/30
80/3/30
90/3/25
Aldehydes in THP Comparing IQOS, tobacco cigarette and e-cigarette
Farsalinos, Leischow et al. under preparation for submission
0
10
20
30
40
50
60
70
IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W Tobaccocigarette
Formaldehyde (μg per 1 IQOS, 12 e-cigarette puffs, 1 cigarette)
Aldehydes in THP Comparing IQOS, tobacco cigarette and e-cigarette
Farsalinos, Leischow et al. under preparation for submission
0
200
400
600
800
1000
1200
IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W Tobaccocigarette
Acetaldehyde (μg per 1 IQOS, 12 e-cigarette puffs, 1 cigarette)
Farsalinos, Leischow et al. under preparation for submission
0
20
40
60
80
100
120
IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W Tobaccocigarette
Acrolein (μg per 1 IQOS, 12 e-cigarette puffs, 1 cigarette)
Aldehydes in THP Comparing IQOS, tobacco cigarette and e-cigarette
Farsalinos, Leischow et al. under preparation for submission
-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W
Formaldehyde % reduction compared to 20 cigarettes (for 20 IQOS and 5 gram e-liquid)
Aldehydes in THP difference from tobacco cigarettes
Aldehydes in THP difference from tobacco cigarettes
Farsalinos, Leischow et al. under preparation for submission
-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W
Acetaldehyde % reduction compared to 20 cigarettes (for 20 IQOS and 5 gram e-liquid)
Farsalinos, Leischow et al. under preparation for submission
-100%
-90%
-80%
-70%
-60%
-50%
-40%
-30%
-20%
-10%
0%IQOS Regular IQOS Menthol E-cigarette 10W E-cigarette 14W
Acrolein % reduction compared to 20 cigarettes (for 20 IQOS and 5 gram e-liquid)
Aldehydes in THP difference from tobacco cigarettes
Aldehydes in the environment
0
200
400
600
800
1000
1200
1400
1600
Common indoor levels(WHO)
HnB (20/day) Tobacco cigarette(20/day)
Daily formaldehyde exposure
20m3 ventilation
volume/day
THPs and heart disease risk?
• Exposed rats (n=8/group) via nose cone to 15 seconds of iQOS
aerosol, Marlboro cigarette mainstream smoke, or air 10 times
over 5 min
• FMD was quantitated pre- and post-exposure by measuring
femoral artery diameter with micro-ultrasound before and after 5
min of transient surgically induced ischemia
• Results: Acute exposure to iQOS aerosol can substantially
impair endothelial function in rats comparably to cigarette
smoke
THPs and heart disease risk?
4.5-fold
higher
levels
3 studies (2 independent) showed IQOS delivers 30% lower
nicotine levels to the aerosol than tobacco cigarettes
FMD and acute nicotine intake
… nicotine (NRT) alone causes acute
endothelial dysfunction, although
to a lesser extent than smoking a
cigarette of the same nicotine yield.
… coffee exerts an acute unfavourable effect
on the endothelial function in healthy
adults... This effect might be attributed to
caffeine, given that decaffeinated coffee was
not associated with any change in the
endothelial performance.
• HnB products are not absolutely safe
▫ The presence of tobacco and the temperatures of heating (at least for 2 of them) result in the unavoidable
emission of some potentially toxic compounds
• Manufacturers report exposure reductions from 85% to 99% (the latter for JTI product)
• Almost all scientific data is coming from the manufacturers
▫ This is currently the biggest problem, related to the justified mistrust for the industry
• Currently available evidence suggest substantial reduction in toxins and reduction in
biomarkers of exposure – but more evidence is needed, especially from independent
sources
Conclusions (1)
• Other factors besides the safety/risk profile should be considered in assessing the public health effects of these
products.
• Public health impactTHP = (hazardSM-THP x smoking cessation) – (hazardTHP x use among non-smokers)
– (hazardSM x smoking initiation)
• Other key issues:
▫ Do they lead to sustained smoking cessation?
▫ Are they promoted and used by never-smokers?
▫ Is there a “gateway to smoking” effect?
• Eventually, it depends on whether tobacco harm reduction is considered an acceptable and viable additional tool
to combat the smoking epidemic
Conclusions (2)
• Current evidence (verified in a small part by independent studies) support that
THPs can be considered harm reduction products
• There is a risk-continuum among harm reduction products, with e-cigarettes (new-
generation) emitting lower levels of toxins compared to THPs
▫ The absolute difference in toxic emissions from tobacco cigarettes is much higher than the absolute
difference between harm reduction products – smokers should make informed decisions
• THPs could be a viable option for smokers unable to quit by themselves or with
medications or with e-cigarettes or with snus (where available)
Conclusions (3)