Let’s not get burnt
Tobacco companies are promoting e-cigarettes and heat-not-burn products — but they’re dangerous, writes Sukhwinder S. Sohal
THE damaging health effects of active and second-hand cigarette smoking are well documented. Tobacco smoke is the primary cause of chronic obstructive pulmonary disease (COPD), estimated to become the third leading cause of death globally by 2030. In 2012 an estimated 1.8 million new cases of lung cancer occurred, making it the most common cancer.
Maternal smoking and exposure in the womb to tobacco smoke and nicotine have been linked to not only miscarriage and preterm birth, but numerous pathophysiological outcomes in the child including increased risk of asthma and COPD due to impaired lung development. Global rates of smoking during pregnancy particularly in lower socio-economic groups remain too high.
The World Health Organisation estimates that 20 per cent of the world’s adult population were smokers in 2015. Fortunately the prevalence of tobacco smoking is on the gradual decline.
Therefore, the tobacco industry is changing strategies, shifting the focus from tobacco cigarettes and promoting the “safer” alternative in ecigarettes. E-cigarettes still deliver nicotine and the number of dual-users (traditional cigarettes and ecigarettes) is alarming.
The popularity of vaping is increasing at a frightening rate. Global sales are expected to surpass traditional cigarettes within five years. Figures in the New England Journal of Medicine reveal the US alone had 1.3 million additional adolescents who vaped nicotine-containing products and 25 per cent of high school seniors (a 10 per cent rise from 2017) had vaped (with or without nicotine) in the 30 days before being surveyed. In New Zealand the numbers of teenagers who had tried e-cigarettes tripled from 2012 to 2014.
The latest nicotine delivery systems are the heat-not-burn (HnB) tobacco products, branded as IQOS. Previous HnB products failed to take off but the resurgence of this design of IQOS by Philip Morris International is dominating the market. In this device, ground tobacco is reconstituted into sheets with water, glycerine, guar gum and cellulose fibres. The tobacco sheets are fashioned into small plugs which are contained in products sold as HEETS or mini cigarettes and inserted into the device where it is heated but not ignited at a temperature of up to 350C, which generates an aerosol.
These devices are quite new, but their popularity will likely reach Australia in the same way as e-cigarettes. They are dominating the overseas market. In 2017 a 10-fold increase in HnB users in Japan was recorded in a single year.
Studies looking into human health effects are limited. However, a groundbreaking study investigated the effects of HnB devices on human lung cells and compared them with e-cigarettes and conventional cigarettes. The detailed outcome is now in the European Respiratory Journal of Open Research. The study, which I led, provides fresh evidence that the new HnB device, which heat solid tobacco instead of an e-liquid, are no less harmful to lung cells than ordinary cigarette smoke or vaping.
Professor Charlotta Pisinger, chair of the European Respiratory Society’s Tobacco Control Committee, who was not involved in the research, said: “These new heated tobacco devices are marketed as producing 95 per cent lower levels of toxic compounds because the tobacco is heated, not burned. However, the first independent studies have shown that combustion is taking place and toxic and carcinogenic compounds are released, some in lower levels than in conventional cigarette smoke, others in higher levels. A review of the tobacco industry’s own data on these devices has shown that, in rats, there is evidence of lung inflammation, and there is no evidence of improvement in lung inflammation and function in smokers who switch to heated tobacco. The introduction and vigorous marketing of new devices is very tempting to smokers who want to stop smoking and mistakenly believe they can switch to another harmless tobacco product. It is also opening another avenue for attracting young people to use and become addicted to nicotine.”
The trend of nicotine uptake is not going to slow in the near future. In Tasmania we have high smoking rates, particularly in lower socioeconomic areas. These devices are promoted as less toxic and safer than traditional tobacco smoke, but are equally damaging. In conjunction, we have high rates of obese smokers, who are quickly shifting from traditional cigarettes to these new devices and unaware of the equally damaging effects.
The latest addition to this trend is HnB devices. They are cited as next-generation products and we know very little about health effects, so we produced experimental designs to compare them with cigarettes and e-cig vaping.
The popularity of vaping is increasing at an alarming rate, particularly in the younger generation. Manufacturers place colourful labels of eliquids with attractive flavours such as rhubarb and custard, berry chill, red lemonade, cola, vanilla, cherry, butterscotch to lure new users and to maintain the nicotine addictions. Many flavours of e-liquids have now been found to be toxic. For example, diacetyl, a chemical that has been used to give butter-like and other flavours to food, including popcorn, has been linked with bronchiolitis obliterans syndrome (a highly destructive lung disease). We do know nicotine is as addictive as heroin and other drugs so, once hooked, most young e-cigarette users will become long-term users.
These devices are in 42 countries, mostly in Europe, and even though it is currently illegal to sell them in Australia, acquiring them may be a simple process. Organisations pushing legalisation and promotion of e-cigarettes and now HnB products do not have a clear understanding of the potential risks of these devices, especially for our youth, pregnant and unborn.
It took us nearly five decades to understand the effects of cigarette smoke and we don’t yet know the longterm impact of e-cigarettes.
These devices that heat tobacco are relatively new and it will be decades before we fully understand the effects.
What we do know is that damage to lung cells contributes to asthma, COPD and lung cancer, and increases the risk of pneumonia and other lung infections, so we should not assume that these are a safer option.
I hope this study will stimulate more research. We plan to continue this work by studying the effects of nicotine devices on human lung samples and in mouse models.
Doctors should be cautious in prescribing a product predominantly owned by the same industry that has created a global health burden.
I am very thankful to the Clifford Craig Foundation, collaborators, University of Tasmania, Respiratory Physicians at Launceston General Hospital, North West Regional Hospital and Royal Hobart Hospital for their continued support for healthy lungs.
I appeal to local and national health organisations to support this research further for a healthy Australia before it’s too late! Dr Sukhwinder S. Sohal (Romy) is Head of the Respiratory Translational Research Group, director of the Tasmanian Respiratory Tissue Bank and a Lecturer in Histopathology, Discipline of Laboratory Medicine in the School of Health Sciences/College of Health and Medicine at the University of Tasmania. Dr Sohal is the National Convenor of the COPD/ Thoracic Society of Australia and New Zealand and is a Visiting Fellow at Charles Darwin University.