Is IQOS a healthy alternative to smoking or vaping for an adult smoker?

IQOS Is Not a Healthy Alternative to Smoking or Vaping

IQOS (heated tobacco products) should not be considered a healthy alternative to smoking or vaping, as it delivers similar nicotine levels to combustible cigarettes, produces harmful emissions including reactive oxygen species and carcinogens, and poses significant cardiovascular and respiratory risks. 1, 2, 3

Why IQOS Is Not a Safe Alternative

Cardiovascular Risks Remain Substantial

• IQOS delivers similar total and free-base nicotine quantities as combustible cigarettes, maintaining the addictive potential and cardiovascular harm associated with nicotine exposure 4
• Nicotine has significant cardiovascular effects and plays a major role in the development of coronary artery disease, atherosclerosis, and aortic aneurysms, regardless of delivery method 2, 5
• Studies in current smokers demonstrate that IQOS produces similar acute effects on heart rate, blood pressure, and arterial stiffness as traditional cigarettes 3
• Animal studies show that rats exposed to IQOS had similar vascular endothelial function impairment to those exposed to conventional cigarettes 3

Harmful Chemical Emissions Persist

• IQOS emits significant quantities of reactive oxygen species (6.26 ± 2.72 nmol H₂O₂/session) and carbonyl compounds (472 ± 19 µg/session), which are linked to cancer, pulmonary disease, and addiction 4
• The device produces mainstream and secondhand emissions of harmful chemicals including nicotine, particulate matter, benzene, acrolein, and tobacco-specific nitrosamines 3
• While these emissions are 77-85% lower than combustible cigarettes, they remain potentially harmful to cardiovascular health at levels significantly above background air 4, 6

Guideline-Based Position Against Heated Tobacco Products

• The American Heart Association, World Heart Federation, American College of Cardiology, and European Society of Cardiology have jointly stated that many countries have banned heated tobacco products using the precautionary principle, recognizing that products with unknown ultimate effects should be restricted until scientific evidence of safety is available 1
• These organizations call for stronger government actions to reduce use of all tobacco products, including heated tobacco systems 1
• The Forum of International Respiratory Societies recommends that electronic nicotine delivery devices (which includes heated tobacco products) should be restricted or banned until more information about their safety is available 7

Clinical Evidence on Health Outcomes

Dual Use Is the Likely Reality

• Real-world data shows that 96% of Korean IQOS users also smoke cigarettes, indicating that IQOS acts as a complement rather than replacement 3
• A clinical study found that when adults who smoke were provided IQOS, they were more inclined to dual use both products rather than switch completely over a 4-week period 8
• Dual use compounds cardiovascular and respiratory risks rather than reducing them 1

No Reduction in Inflammatory Markers

• Independent clinical research found no significant changes in nasal inflammatory biomarkers when adults who smoke incorporated IQOS into their daily habits over 4 weeks 8
• Nicotine exposure (measured by cotinine) remained consistent, suggesting that addition of heated tobacco products may not substantially reduce harm 8

Gateway Effect Concerns

• In Italy, 45% of IQOS users had never smoked cigarettes, demonstrating gateway potential 3
• Youth susceptibility to trying IQOS was higher than cigarette smoking in the United States, Canada, and England 3

What Should Be Recommended Instead

Evidence-Based Cessation Strategies

• Varenicline is the most efficacious pharmacotherapy for smoking cessation and should be first-line treatment 2
• Pharmacotherapy combined with behavioral counseling produces superior cessation rates compared to either intervention alone 1, 2
• The US Preventive Services Task Force recommends focusing on proven behavioral counseling and FDA-approved pharmacotherapy rather than e-cigarettes or heated tobacco products 1, 7

Timeline for Risk Reduction

• Complete nicotine cessation produces cardiovascular benefits that become apparent within 2 to 5 years, with return to non-smoker risk levels 2, 5
• For surgical patients, 4 to 8 weeks of complete cessation is necessary to reduce respiratory and wound-healing complications 2

Critical Clinical Pitfalls

Avoid the "Harm Reduction" Misconception

• While IQOS may expose users to lower levels of some toxicants compared to combustible cigarettes, it does not eliminate the risk of tobacco-related diseases 6
• The perception that heated tobacco products are "harmless" or significantly safer is incorrect and dangerous 5, 9

Screen and Document Appropriately

• Screen for tobacco, nicotine, and heated tobacco product use at every healthcare visit 2, 5
• Document frequency and duration, as daily use strongly predicts future dependence and complications 2
• Assess for dual use, as this is the most common pattern and compounds risk 3, 8

Risk Stratification for Clinical Care

• Classify IQOS users as high-risk patients for cardiovascular and respiratory complications, similar to conventional smokers 2
• For elective surgery, recommend complete cessation for at least 4 weeks prior to procedure 2
• Implement enhanced monitoring for respiratory parameters in perioperative settings 2