By Henrylito Tacio

They are called heated tobacco products (HTPs) and they require the use of an electronic device to heat a stick or pod of compressed tobacco. But unlike conventional cigarettes, tobacco is heated at a lower temperature.

HTPs have been marketed as a better alternative to smoking. Tobacco companies claim that by heating the tobacco, rather than burning it, the formation of harmful substances created at high temperatures associated with combustion is significantly reduced.

Most smokers are aware that tobacco smoking is harmful to their health. Around the world, smoking is still the leading cause of premature death, claiming the lives of more than 6 million people every year due to cancer, heart disease, stroke, chronic bronchitis, and emphysema.

In the Philippines, recent data showed about 110,000 people die from tobacco-related diseases each year. About 21.8% of male deaths and 9.9% of female deaths are associated with tobacco smoking (18.6% overall). More than 23% of male deaths and 12% of female deaths are directly or indirectly caused by tobacco (16.6% overall).

Three out of four Filipino smokers want to quit the habit, former health secretary Paulyn Jean Rosell-Ubial reported. But quitting is easier said than done. As American humorist Mark Twain puts it: “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.”

The latest records released by the Philippine Statistics Authority (PSA) and the Department of Health (DOH) revealed only about 640,000 – out of the 15.9 million smokers – were able to quit smoking altogether.

Enter HTPs, which were first developed by tobacco companies in the 1980s to address concerns about second-hand smoke exposure. The Atlanta-based Center for Disease Control and Prevention (CDC) has this report: “Studies of secondhand emissions from heated tobacco products suggest that the products expose both users and bystanders to some of the same chemicals found in cigarette smoke, although at lower levels than cigarette smoke.”

Initially, HTPs were marketed as “a real game-changer.” This is particularly true for those who want to quit smoking. HTPs, however, should be prohibited to youth, young adults, and pregnant women, as well as adults who do not currently use tobacco products.

But for those who are currently smoking and want to kick the habit, HTPs are considered good alternatives to cigarettes. HTPs can be likened to that electronic cigarettes (e-cigarettes).

“E-cigarettes are way less harmful than cigarettes and they can and do help smokers switch if they can quit,” Dr. David Abrams, a New York University professor of social and behavioral sciences in the College of Global Public Health told CBS This Morning Tony Dokoupil.

E-cigarettes, which Public Health England describes as “at least 95% less harmful than tobacco cigarettes,” are battery-powered devices that release a vapor of flavored nicotine from a liquid heated by a coil.

Research on e-cigarettes is mixed. But in the last three to four years, science has gotten strong. “Probably the most powerful study is the randomized trial which is the gold standard that showed that in 12-month follow-up e-cigarettes doubled the successful quit rate among smokers compared to nicotine replacement therapy,” said Dr. Abrams, who has researched smoking cessation for 40 years.

A study conducted in 2019 showed that 19% of participants who used e-cigarettes to quit smoking were no longer smoking a year later. In comparison, those who used nicotine replacement therapy quit smoking at a rate of 9%.

Nicotine replacement therapy, which is approved by the US Food and Drug Administration (FDA), is a treatment to help stop smoking. It uses products that supply low doses of nicotine. The goal of therapy is to cut down on cravings for nicotine and ease the symptoms of nicotine withdrawal.

The Geneva-based World Health Organization (WHO), however, considered e-cigarettes “harmful” and called for better regulation of their use. But Dr. David Abrams said that anti-vaping policy and rhetoric may do more harm than good by preventing cigarette smokers from switching to the safer alternative.

“Completely discouraging vaping, without also discouraging smoking, is doing more harm than good,” Dr. Abrams said. Vaping is the term used for e-cigarette smoking.

But there’s a better device than e-cigarettes – and that’s where HTPs come in.

“Smokers may be rightfully considered as victims of an addictive disease, and those who cannot quit remaining part of the health equation of every nation, just as much as the healthy non-smokes,” says Dr. Rafael R. Castillo, a cardiologist at the Manila Doctors Hospital. “They actually need more understanding, more attention, and more care from their physicians, who should aim for a treatment goal of at least partially protecting them from the cardiovascular and other health hazards of cigarette addiction.”

Dr. Castillo is head of the Cardio-Metabolic Research Unit (CaMeRU) of FAME Leaders Academy, and the group has just completed two systematic reviews and meta-analyses comparing HTPs with conventional cigarette smoking.

“Compared to conventional cigarettes,” Dr. Castillo said in an interview, “HTPs have significantly less harmful effects on some cardiovascular risk factors, that is, heart rate, high-density lipoprotein (good cholesterol), and arterial function.” Such was the finding in their first meta-analysis.

The second meta-analysis showed that “HTPs have significantly less risk exposure to harmful elements found in conventional smoking.” Harmful elements are called biomarkers of exposure (BoE) associated with smoking-related complications in the heart, lungs, and other vital organs of the body.

According to Dr. Castillo, the two meta-analyses are currently undergoing peer review in international journals.

On why they are using HTPs among recalcitrant smokers, Dr. Castillo explained in his paper that was published recently in Cardiology and Cardiovascular Medicine: “Based on the potential to reduce health risk and also on patient feedback, we have allowed the use of HTPs in our recalcitrant smokers who really could not attain total smoking cessation despite smoking cessation measures.” 

Dr. Castillo added that the primary goal is to still make smokers quit smoking completely and permanently, but since the majority would fail to attain full smoking cessation despite all efforts and interventions, alternative tobacco products may be offered to them to reduce their health risks.

Dr. Castillo said that mitigating the health risks of recalcitrant smokers becomes more significant these days because of the COVID-19 pandemic since smoking confers a much higher risk of smokers developing severe COVID.

Citing studies from abroad, the research team found out that active smoking increases the risk of severe COVID-19 by around two folds, and those with chronic obstructive pulmonary disease – which many recalcitrant smokers are likely to have already – have a fourfold increase in risk translating to much poorer clinical outcomes.

“Based on studies, the number of toxic substances users of HTPs get is up to 95% less, compared to traditional tobacco smoking,” Dr. Castillo and his team at CaMeRU showed in their meta-analysis.

The decision of using HTPs among recalcitrant smokers wasn’t easy. Dr. Castillo considered dealing with heart patients who are recalcitrant smokers as a major challenge in his clinical practice. “They may show initial efforts of following the smoking-cessation programs we implement in our clinics, but there is an utter lack of perseverance and will to persist until the end goal of complete cessation is achieved,” he reported.

Persuasion, motivation, and even combining them with threats on the health hazards these recalcitrant smokers are likely to develop if they kick the habit for good are some of the measures the doctors employed. “At best, we are only successful in around three out of 10 cases,” Dr. Castillo said.

In exasperation, the doctors decided to implement a policy that “if they do not quit smoking in six months, we advise them to go to another clinic for their subsequent follow-up, as we consider ourselves a failure in effectively addressing a major risk factor that they have.”

Because of the stern policy, these recalcitrant smokers go to other clinics for their follow-up monitoring and management. “Some of them decide not to follow up with any doctor at all, and they just maintain the initial drugs they are prescribed until they develop complications, for which they are rushed to the emergency room,” Dr. Castillo lamented.

The policy was implemented before the pandemic. “The stern carrot-and-stick approach towards our smoker-patients has been the standard policy in our practice until the start of the pandemic when we realized we might have been too harsh on our recalcitrant smoker-patients,” Dr. Castillo recalled. “The pandemic has made us rethink our policy, and explore other means of assisting those who simply could not give up their nicotine addiction.”

From time to time, they hear of a former patient whom they had “expelled” from the clinical admitted to the intensive care unit for critical COVID-19, intubated for mechanical ventilation, and eventually succumbing to it. Some patients may be fortunate to survive but only after a stormy clinical course in the hospital.

Now, they are using HTPs to help those recalcitrant smokers in their clinics. “From a non-negotiable policy, we have decided to shift to whatever pragmatic middle-ground we could find for recalcitrant smokers, since at least half of these smokers, or more than half in the pre-COVID era, simply could not quit,” Dr. Castillo said.

But their mean goal is still to make these recalcitrant smokers quit the habit forever. “In our cardiovascular clinics, we are still trying to look for the best middle ground, and still hoping that eventually, we could push them up further to the real safe, high ground of having beaten their addiction completely and permanently.”

Dr. Castillo and his team emphasized that the youth and non-smokers should be prohibited to try HTPs, and this should be ensured with appropriate regulatory measures. “Regardless of whether they are heated by flame or electronically, HTPs still contain nicotine, which is highly addictive. This is where legislation and regulation come in. It is essential to have strict but balanced regulation.”

Dr. Castillo said the legislation should “not be more restrictive than currently enforced regulation for cigarettes.”

HTPs should not be allowed in public even though they are smoke-free, Dr. Castillo urged. “Although the harmful particulate pollution they cause is relatively less compared to passive cigarette smoking, the potential harm to second-hand smoke could not be completely discounted,” he explained.