18C.3 Health risks of heated tobacco products

Last updated: March 2018         

Suggested citation: Greenhalgh, EM. 18C. Heated tobacco (‘heat-not-burn’) products. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2018. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18c-non-combustible-cigarettes/18c-3-health-risks

Most studies to date on the health effects of heated tobacco products have been funded by the manufacturers of the products, so there is a lack of independent research. Manufacturers researching their own or competitor products experience a conflict of interest that can bias findings and interpretations.1  

Industry-funded studies generally conclude that compared with cigarettes, heated tobacco products expose users and bystanders to substantially lower levels of particulate matter and harmful and potentially harmful compounds.2-7 However, whether reduced exposure will lead to meaningful reductions in human health risks is yet to be established.8  

Research independent of the tobacco industry has found that the vapour from heated tobacco products is not free of toxic compounds, including carcinogens, highlighting the need for caution and regulation around the products.9-12 There is evidence that heated tobacco product vapour contains levels of nicotine approaching those found in cigarette smoke.9, 10 Exposure to nicotine can be particularly harmful to certain populations, including adolescents and pregnant women.13 The device’s limitations may also affect users’ levels of exposure: a study of iQOS users found that they speed up their “puff rate” in order to inhale more nicotine because the heat stick only lasts for six minutes, potentially increasing their intake of nicotine and other harmful chemicals.12

In terms of bystanders, an independent study concluded that despite emissions being lower than from combustible cigarettes, exposure to submicronic particles when heated tobacco products are used indoors does occur, and it is likely that a high proportion of the inhaled particles reach the alveolar region.14 A study in Japan found that more than one-third (37%) of participants who had been exposed to others’ heated tobacco aerosol, had reported at least one symptom because of it.15 Limited evidence comparing environmental emissions from heated tobacco products with those from e-cigarettes suggests that exposure from heated tobacco products poses a greater health risk.11, 16

Additional independent studies are needed to substantiate industry claims of reduced risk/harm.8


1. World Health Organization, Tobacco industry interference with tobacco control.  Geneva: WHO; 2009. Available from: http://www.who.int/tobacco/publications/industry/interference/en/.

2. Haziza C, de La Bourdonnaye G, Merlet S, Benzimra M, Ancerewicz J, et al. Assessment of the reduction in levels of exposure to harmful and potentially harmful constituents in Japanese subjects using a novel tobacco heating system compared with conventional cigarettes and smoking abstinence: A randomized controlled study in confinement. Regulatory Toxicology and Pharmacology, 2016; 81:489–99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27693654

3. Haziza C, de La Bourdonnaye G, Skiada D, Ancerewicz J, Baker G, et al. Evaluation of the tobacco heating system 2.2. Part 8: 5-day randomized reduced exposure clinical study in poland. Regulatory Toxicology and Pharmacology, 2016. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27816672

4. Ludicke F, Haziza C, Weitkunat R, and Magnette J. Evaluation of biomarkers of exposure in smokers switching to a carbon-heated tobacco product: A controlled, randomized, open-label 5-day exposure study. Nicotine & Tobacco Research, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26817490

5. Ludicke F, Baker G, Magnette J, Picavet P, and Weitkunat R. Reduced exposure to harmful and potentially harmful smoke constituents with the tobacco heating system 2.1. Nicotine & Tobacco Research, 2017; 19(2):168–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27613951

6. Ludicke F, Picavet P, Baker G, Haziza C, Poux V, et al. Effects of switching to the tobacco heating system 2.2 menthol, smoking abstinence, or continued cigarette smoking on biomarkers of exposure: A randomized, controlled, open-label, multicenter study in sequential confinement and ambulatory settings (part 1). Nicotine & Tobacco Research, 2018; 20(2):161–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28177489

7. Forster M, Fiebelkorn S, Yurteri C, Mariner D, Liu C, et al. Assessment of novel tobacco heating product thp1.0. Part 3: Comprehensive chemical characterisation of harmful and potentially harmful aerosol emissions. Regulatory Toxicology and Pharmacology, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29080848

8. World Health Organization. Heated tobacco products (HTPs) information sheet. 2017. Available from: http://www.who.int/tobacco/publications/prod_regulation/heated-tobacco-products/en/

9. Bekki K, Inaba Y, Uchiyama S, and Kunugita N. Comparison of chemicals in mainstream smoke in heat-not-burn tobacco and combustion cigarettes. Journal of UOEH, 2017; 39(3):201–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28904270

10. Auer R, Concha-Lozano N, Jacot-Sadowski I, Cornuz J, and Berthet A. Heat-not-burn tobacco cigarettes: Smoke by any other name. JAMA Internal Medicine, 2017; 177(7):1050–2. Available from: http://dx.doi.org/10.1001/jamainternmed.2017.1419

11. Ruprecht AA, De Marco C, Saffari A, Pozzi P, Mazza R, et al. Environmental pollution and emission factors of electronic cigarettes, heat-not-burn tobacco products, and conventional cigarettes. Aerosol Science and Technology, 2017; 51(6):674–84. Available from: https://doi.org/10.1080/02786826.2017.1300231

12. Davis B, Williams M, and Talbot P. iQOS: Evidence of pyrolysis and release of a toxicant from plastic. Tobacco Control, 2018. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/early/2018/02/20/tobaccocontrol-2017-054104.full.pdf

13. US Department of Health and Human Services. E-cigarette use among youth and young adults. A report of the surgeon general. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/index.htm.

14. Protano C, Manigrasso M, Avino P, Sernia S, and Vitali M. Second-hand smoke exposure generated by new electronic devices (IQOS(r) and e-cigs) and traditional cigarettes: Submicron particle behaviour in human respiratory system. Annali Di Igiene, 2016; 28(2):109–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27071321

15. Tabuchi T, Gallus S, Shinozaki T, Nakaya T, Kunugita N, et al. Heat-not-burn tobacco product use in Japan: Its prevalence, predictors and perceived symptoms from exposure to secondhand heat-not-burn tobacco aerosol. Tobacco Control, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29248896

16. Protano C, Manigrasso M, Avino P, and Vitali M. Second-hand smoke generated by combustion and electronic smoking devices used in real scenarios: Ultrafine particle pollution and age-related dose assessment. Environment International, 2017; 107:190–5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28750224 


      Previous Chapter Next Chapter