Strolling past the sleek, blue-lit pop-up stores and lounges that began peppering the city of Austin, Texas, this spring, passersby might pause to wonder about what trendy new tech product goes by the name of “IQOS.” Perhaps a smartwatch or a set of noise-canceling wireless earbuds?
The chicly futuristic branding of IQOS, a heated tobacco product owned by Philip Morris International, is one of several things worrying researchers and anti-tobacco advocates. The company is rolling out pilots of the device in Austin and Fort Lauderdale, peddling IQOS (pronounced “eye-koss”) as “the next step in tobacco harm reduction.” In its marketing, the company positions the devices as a better alternative for smokers compared to cigarettes, reducing the production of harmful chemicals while containing “real tobacco,” “less lingering smell,” and no fire or ash.
But critics worry the company’s marketing tactics — from retail fronts that look like Apple Stores to “happenings” at rooftop bars with free aura readings and a recent Miami event featuring performances by musicians Lauryn Hill and Wyclef Jean — could entice people who don’t already smoke to pick up an addictive habit with long-term costs to their health. They also warn that, for people looking to quit cigarettes, heated tobacco products may be worse than other alternatives like e-cigarettes and smoking cessation drugs. Why, critics ask, are U.S. regulators allowing heated tobacco products in the first place?
“The industry is trying to get them treated from a regulatory perspective and branding and messaging perspective as if they’re unequivocally safer and cause less harm than cigarettes, but they are much closer to a cigarette” than e-cigarettes because of the heating process, said Tim McAfee, the former head of the Office for Smoking and Health at the Centers for Disease Control and Prevention.
As their names suggest, heated tobacco products, or HTPs, are meant to warm, rather than burn, tobacco. Philip Morris has found the emissions of harmful chemicals from IQOS are 90% lower compared to cigarettes. That said, research funded by the Swedish government suggests that while heated tobacco releases fewer toxicants than cigarette smoke, their aerosol still contains some “harmful and potentially harmful” chemicals, including tar, nicotine, ammonia, and formaldehyde.
The upshot: Heated tobacco is likely less harmful than cigarettes but more harmful than e-cigarettes, according to a 2018 review by England’s public health agency. (Philip Morris also sells e-cigarettes.) Given that e-cigarettes were already widely available in the U.K. for people trying to quit smoking, the review said, “it is currently not clear whether heated tobacco products provide any advantage as an additional potential harm reduction product.” A 2019 German government assessment similarly concluded that because heated tobacco products still pose substantial health risks, they “should not be the first option to decrease smoking-related harm.”
But as smoking rates fall in the U.S. and elsewhere, the tobacco industry is aiming to diversify — which means looking beyond e-cigarettes to options like heated tobacco products and nicotine pouches. Philip Morris in particular promotes IQOS as part of its vision for a “smoke-free future,” and says 40% of its global net revenues last year came from smoke-free products.
“It is an absolute detriment to public health that some lobbyists continue to deny the scientific reality that IQOS is a better alternative than continued smoking by legal-aged adults,” Philip Morris said in a statement. (None of the researchers, experts, or anti-tobacco advocates who spoke with STAT said that IQOS was worse for one’s health than cigarettes, and the majority of researchers said the product was likely to be less harmful than smoking if people switched over entirely.) “The fact is IQOS is the only electronic nicotine system to be authorized by the FDA as Modified Risk Tobacco Products. More than 20 million adults around the world have switched to IQOS and stopped smoking. Americans deserve to make the same choice, despite what these prohibitionists think.”
Philip Morris also suggested that certain IQOS critics were “misguided and prohibitionist” because they received funding from Bloomberg Philanthropies’ initiative to reduce tobacco use. STAT also accepts funding from Bloomberg Philanthropies to support reporting on chronic diseases; the foundation is not involved in editorial decisions.
Yolonda Richardson, president and CEO of the advocacy group Campaign for Tobacco-Free Kids, said the group’s concerns had nothing to do with its funding from Bloomberg Philanthropies. Rather, she said, the debut of IQOS in the U.S. simply represents an unnecessary new risk to public health: “They’re banking on getting these products on the market and getting people addicted before science catches up.”
What are heated tobacco products?
Heated tobacco products have been around in various forms since the 1980s, but took off in popularity when Philip Morris launched IQOS in Japan and Italy in 2014. While IQOS has the biggest share of the heated tobacco market, generating 10% of Philip Morris’s annual net revenues with nearly 31 million global users, the rest of the “Big Four” tobacco companies — British American Tobacco, Japan Tobacco International, and Imperial Brands — now sell their own variations.
IQOS, available in more than 70 countries, comes in a kit with three parts: a charging pack, a handheld heating device that looks like a cigarette holder, and sticks made from what’s known as reconstituted tobacco. The devices come in a variety of colors (DJ Steve Aoki has a glow-in-the-dark limited edition), and can be accessorized with carrying cases. They’re priced at $60 in the U.S., and the tobacco sticks, called HEETS, cost $8 per pack.
IQOS’s initial debut in the U.S. was short-lived. The Food and Drug Administration authorized its sale in 2019. (The chief science officer at the FDA’s Center for Tobacco Products, who played an important role in that decision, resigned a few years later to take a job at Philip Morris.) In 2020, the FDA allowed Philip Morris to market IQOS as a “reduced-exposure” product — meaning that it could claim that switching from cigarettes to IQOS would lessen people’s exposure to harmful chemicals because the devices heat, rather than burn, tobacco. (The FDA did not, however, allow Philip Morris to claim that IQOS reduces risk, which requires a higher level of scientific evidence that the products reduce tobacco-related disease and benefit public health. Critics have argued the distinction between the two is likely to be missed by the average consumer.)
Then a patent dispute with British American Tobacco forced Philip Morris International to pull the devices from the U.S. market in 2021, before they were available in most states. That’s since been resolved. Now IQOS is gearing up for a stateside comeback while waiting to see if the FDA authorizes the sale of its latest-generation device, Iluma. The Campaign for Tobacco-Free Kids, along with health organizations like the American Lung Association and the American Academy of Pediatrics, has urged regulators to take a critical view of IQOS ahead of the upcoming decision.
The health risks of IQOS and other heated tobacco products
While it’s hard to pinpoint exactly where IQOS falls on the risk spectrum, heated tobacco products are likely “more harmful than e-cigarettes and less harmful than combustible [cigarettes],” said Benjamin Toll, director of the Tobacco Treatment Program at the Medical University of South Carolina.
“I think an e-cigarette is probably a safer product, because it’s just nicotine and some other flavorings that you’re inhaling,” said Nancy Rigotti, a Harvard School of Medicine professor specializing in tobacco-related disease. E-cigarettes have their own health risks, but research generally supports their use as a way to help people stop smoking.
There’s a lot that’s not yet known about heated tobacco’s long-term impact on health, in part because much of the research so far has been funded by tobacco companies. Out of 40 clinical trials surveyed in a recent systematic review funded by Bloomberg Philanthropies, 29 were affiliated with or conducted by the tobacco industry, and 31 trials lasted just five days or less. Philip Morris told STAT there’s no dearth of independent research on the products, pointing to government reviews of IQOS, though such reviews typically also rely on tobacco industry data. The 2018 U.K. review, for example, notes that 12 of the 20 studies on heated tobacco products that it examined were funded by tobacco companies.
Given the availability of other products, like pharmaceutical drugs and e-cigarettes, with more robust evidence of efficacy in helping people quit smoking, the systematic review’s authors write that there are “critical questions about whether there is even a place for HTPs in the consumer market.”
That said, some data suggest that heated tobacco products can help people quit cigarettes. In Japan, where e-cigarettes are banned, smoking rates went down after IQOS was introduced. If someone who smokes a pack a day switches completely to IQOS, that should lower their exposures and lead to a better health outcome compared to cigarettes, according to Jodi Prochaska, a Stanford University professor specializing in addiction.
But Prochaska also notes that dual use of both cigarettes and IQOS may be common. Philip Morris’s data shows that smoking quit rates among IQOS users in Japan are around 70%. Survey data from the International Tobacco Control Policy Evaluation Project (ITC) at the University of Waterloo, however, suggest quit rates among IQOS users are more like 15-22%.
The root of the discrepancy may be that Philip Morris surveyed IQOS customers, while ITC polled the general population, said Geoffrey Fong, founder and chief principal investigator of ITC. Customers who respond to surveys from brands are more likely to be people who enjoy the product and have found it to be effective. Studies in Korea and Hong Kong also suggest it’s common for heated tobacco products to serve as a complement to cigarettes.
As for why people would want to use both, heated tobacco is sometimes allowed where smoking is not. Around the world, Philip Morris has partnerships with restaurants, bars, cabs, and hotels where cigarettes are banned but that are designated as “IQOS Friendly.”
Tobacco industry observers expect Philip Morris will hold off on a full-steam launch of IQOS in the U.S. as it awaits word from the FDA on authorizing sales of Iluma. But with the Trump administration’s dismantling of the Office of Smoking and Health, McAfee said, the U.S. will have a harder time monitoring trends as IQOS becomes more widely available.
His former office collaborated with the FDA on the first big study that showed the U.S. was in the early stages of a teen vaping epidemic — a finding that lent urgency to regulatory crackdowns on flavored e-cigarettes from Juul and other brands. Now, McAfee said, “it’s going to be much harder to quickly understand what’s going on and what the trends are.”
IQOS, however, will be hard to miss. Its recent event in Miami featured the “surrealist pop-up” that Philip Morris has submitted for a marketing award — a giant turquoise version of the IQOS device, with a sales bar waiting for people who walk inside.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
Correction: An earlier version of this story misstated Benjamin Toll’s affiliation and the contents of reconstituted tobacco.
