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BACKGROUND: Heated tobacco products (HTPs) are alternatives to cigarettes that heat rather than burn tobacco. The first HTP sold in Italy was _IQOS®_ (I-HTP), and while it has been available for nearly a decade, limited data are available on the use of these products. OBJECTIVE: To characterize how Italian adults (users of legal age) use tobacco- and nicotine-containing products (TNPs), including smoke-free products (SFPs), we surveyed this population about their current and past use of TNPs from 2018 to 2020. METHODS: Two consecutive cross-sectional surveys were conducted in representative samples of the general adult population (6,095 subjects from 2018 to 2019 and 6,118 from 2019 to 2020) and among adult I-HTP users (1,371 subjects from 2018 to 2019 and 1,401 from 2019 to 2020) in Italy. We assessed the prevalence of current TNP use in the general population sample and use patterns in the I-HTP_ _users sample. RESULTS: In the first cross-sectional study (2018-2019), cigarettes were the most used TNP (24.3%), while only a small proportion of the surveyed general population sample used e-cigarettes or I-HTPs (1.4% and 0.7%, respectively). Nearly all current I-HTP users were current adult cigarette smokers when they started using I-HTPs (98.0%). Both surveys showed low initiation, re-initiation, and relapse with I-HTPs, with the majority of current I-HTP users belonging to the intended audience of adults who already used TNPs. Some participants used both I-HTPs and combustible TNPs (38.6%); however, most (59.2%) used I-HTPs exclusively. I-HTP_ _users perceived the health risk (score 0 = no risk; score 100 = very high risk) associated with cigarette smoking higher (63.7) than that for I-HTP_ _use (42.6). Exclusive I-HTP users reported improved respiratory symptoms (reduced cough and phlegm) and exercise capacity compared to a year before they started using I-HTPs. Most current I-HTP users also reported improved smell and taste, better breath smell, and reduced stains or yellowing teeth. Overall, these results were more pronounced among exclusive I-HTP users. The results of the second cross-sectional study (2019-2020) were similar, except for an increase in I-HTP_ _use_ _(1.1% vs. 0.7% in 2018 to 2019). CONCLUSIONS: These studies show that most TNP users in Italy smoke cigarettes. The uptake of I-HTPs suggests that they are a viable alternative to cigarettes. Nearly all I-HTP users switched from cigarettes to I-HTPs. Furthermore, most I-HTP_ _users exclusively use the product. I-HTP users considered the health risk associated with I-HTP_ _use to be lower compared to cigarette smoking, but they did not perceive I-HTPs_ _as risk free. Study participants reported improvements on some health, hygiene, and appearance aspects after switching from cigarettes to I-HTPs. Our results suggest that SFPs can play a role in a harm reduction approach. Further studies are needed to continually monitor the prevalence of SFP use to provide long-term evidence of their impact.
BACKGROUND: Heated tobacco products (HTPs) are alternatives to cigarettes that heat rather than burn tobacco. The first HTP sold in Italy was _IQOS®_ (I-HTP), and while it has been available for nearly a decade, limited data are available on the use of these products. OBJECTIVE: To characterize how Italian adults (users of legal age) use tobacco- and nicotine-containing products (TNPs), including smoke-free products (SFPs), we surveyed this population about their current and past use of TNPs from 2018 to 2020. METHODS: Two consecutive cross-sectional surveys were conducted in representative samples of the general adult population (6,095 subjects from 2018 to 2019 and 6,118 from 2019 to 2020) and among adult I-HTP users (1,371 subjects from 2018 to 2019 and 1,401 from 2019 to 2020) in Italy. We assessed the prevalence of current TNP use in the general population sample and use patterns in the I-HTP_ _users sample. RESULTS: In the first cross-sectional study (2018-2019), cigarettes were the most used TNP (24.3%), while only a small proportion of the surveyed general population sample used e-cigarettes or I-HTPs (1.4% and 0.7%, respectively). Nearly all current I-HTP users were current adult cigarette smokers when they started using I-HTPs (98.0%). Both surveys showed low initiation, re-initiation, and relapse with I-HTPs, with the majority of current I-HTP users belonging to the intended audience of adults who already used TNPs. Some participants used both I-HTPs and combustible TNPs (38.6%); however, most (59.2%) used I-HTPs exclusively. I-HTP_ _users perceived the health risk (score 0 = no risk; score 100 = very high risk) associated with cigarette smoking higher (63.7) than that for I-HTP_ _use (42.6). Exclusive I-HTP users reported improved respiratory symptoms (reduced cough and phlegm) and exercise capacity compared to a year before they started using I-HTPs. Most current I-HTP users also reported improved smell and taste, better breath smell, and reduced stains or yellowing teeth. Overall, these results were more pronounced among exclusive I-HTP users. The results of the second cross-sectional study (2019-2020) were similar, except for an increase in I-HTP_ _use_ _(1.1% vs. 0.7% in 2018 to 2019). CONCLUSIONS: These studies show that most TNP users in Italy smoke cigarettes. The uptake of I-HTPs suggests that they are a viable alternative to cigarettes. Nearly all I-HTP users switched from cigarettes to I-HTPs. Furthermore, most I-HTP_ _users exclusively use the product. I-HTP users considered the health risk associated with I-HTP_ _use to be lower compared to cigarette smoking, but they did not perceive I-HTPs_ _as risk free. Study participants reported improvements on some health, hygiene, and appearance aspects after switching from cigarettes to I-HTPs. Our results suggest that SFPs can play a role in a harm reduction approach. Further studies are needed to continually monitor the prevalence of SFP use to provide long-term evidence of their impact.
Heated tobacco products (HTPs) are electronic devices that heat tobacco sticks to temperatures much lower than those which cause pyrolysis and combustion in cigarettes. While this electrical heating causes the formation of an inhalable aerosol which contains nicotine, the aerosol from HTPs contains significantly fewer and lower levels of the harmful and potentially harmful chemicals found in cigarette smoke. As a result, HTP use potentially conveys reduced risks to health compared to cigarette smoking. While this relative reduction in individual health risk is becoming clearer, what is less certain is the impact of HTPs on overall population-level health, taking into account both the potential positive impact on adult smokers who completely switch to using HTPs and any unintended impacts such as use by tobacco non-users and particularly by youth. The aim of this scoping review was to collate and evaluate the published scientific evidence to date, with a cut-off of 1 January 2024, investigating the impact of HTPs on population-level health. This evaluation suggests that HTP use is almost exclusively observed among those with a history of cigarette smoking, and there is a growing body of evidence for the ability of HTPs to provide support for adult smokers to transition away from cigarette smoking, in the absence of any significant "gateway" into tobacco use initiation. Many studies have reported a significant degree of dual use of cigarettes and HTPs, and efforts to assess the reasons for such patterns of use, whether these provide overall exposure reductions, and whether dual use acts as a bridge towards a complete transition away from cigarette smoking, requires further investigation. In addition, correction of the widespread and increasing misperceptions of HTPs among adult smokers is recommended to promote HTP uptake as a potentially less harmful alternative to smoking in this population.
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