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Heat-not-burn tobacco products: concerns from the Italian experience
  1. Xiaoqiu Liu1,
  2. Alessandra Lugo1,
  3. Lorenzo Spizzichino2,
  4. Takahiro Tabuchi3,
  5. Roberta Pacifici4,
  6. Silvano Gallus1
  1. 1 Department of Environmental Health Sciences, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
  2. 2 Prevention Department, Ministry of Health, Rome, Italy
  3. 3 Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
  4. 4 National Centre on Addiction and Doping, Istituto Superiore di Sanità, Rome, Italy
  1. Correspondence to Dr Silvano Gallus, Department of Environmental Health Sciences, IRCCS - Istituto di Ricerche Farmacologiche “Mario Negri”, Milan 20156, Italy; silvano.gallus{at}

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Heat-not-burn (HNB) tobacco products are disposable tobacco sticks heated, rather than combusted, by an electronic device to generate an aerosol containing nicotine.1 IQOS is the brand name of such a product by Philip Morris International, launched in 2014 in Italy as a pilot country for the European market. IQOS is now in commerce in 30 countries, including 19 European ones, and applications have been submitted to market it as a modified risk tobacco product in the USA.

Most safety data on this new tobacco product come from research conducted by the tobacco industry.2 The few independent toxicological studies confirm that HNBs release harmful and potentially harmful substances, although at reduced levels as compared with conventional cigarettes.1 3 4 To our knowledge, the only available studies on the use of HNBs are two repeated online surveys on Japanese adult population, showing a prevalence of IQOS users of 0.3% in 2015, 0.9% in 2016 and 3.6% in 2017.5 6 We investigated HNB awareness and use in Italy, where IQOS is the only available HNB.


In 2017, we conducted a face-to-face survey of 3086 subjects selected through multistage sampling to be representative of the general Italian population aged ≥15 years (52.4 million inhabitants).7 Besides information on general sociodemographics, smoking and e-cigarette use, participants were asked about their awareness and use of IQOS.


One in five (19.5%) respondents were aware of IQOS, 1.4% have tried it and 2.3% intended to try it (table 1). Overall, 1.0% of never smokers, 0.8% of ex-smokers and 3.1% of current cigarette smokers have tried IQOS. Correspondingly, 1.2% of never e-cigarette users, 2.9% of ex-e-cigarette users and 7.7% of current e-cigarette users have tried IQOS.

Table 1

Awareness and use* of IQOS, overall and according to selected characteristics. Italy, 2017


Almost 3 years after having been launched, use of IQOS is still limited in the Italian population. However, our data indicate that 739 000 Italians have already tried IQOS, including 329 000 never smokers. Moreover, another 1 205 000 Italian adults, including 619 000 non-smokers (ie, never or ex-smokers) expressed their intention to try IQOS in the future.

In Italy, HNBs enjoy the same tax reduction of e-cigarettes (ie, 50% lower as compared with conventional cigarettes).8 Moreover, they bypass the most important tobacco control policies: health warnings cover 30% of the HNB packaging without pictorial images, and the comprehensive smoking ban and the tobacco advertising bans are not applicable to HNBs.8 9 These fiscal and regulatory benefits are due to the alleged belief in HNB harm reduction.8 9 However, there is no evidence indicating that those products are effective for cessation from conventional cigarettes, and independent toxicological studies confirm that these products release measurable levels of carcinogenic compounds.1 3 4 Thus, HNBs likely carry less risk than cigarettes, but are not risk-free. Moreover, their nicotine levels are similar to (ie, around 80%) those of conventional cigarettes.1 3

Limitations include the relatively small sample size that does not allow us to obtain stable prevalence estimates in subgroups. Moreover, the self-reported data may carry some misclassification of information, although we specifically reminded survey participants not to confuse IQOS with e-cigarettes.

We found that the absolute number of never smokers who have already tried IQOS in Italy is comparable to that of current smokers. Among Italian adults with an intention to try IQOS, the number of non-smokers even exceeds that of current smokers. Therefore, these findings suggest that IQOS may create new nicotine addicted generations.



  • Contributors SG and RP had the original idea for the study; XL and SG drafted the research letter; AL and XL conducted the data analysis; XL, AL, TT and SG gave substantial contribution to conception, design and interpretation of data; RP and LS gave contributions to conception and design of the study and provided data from the survey; all authors critically revised the manuscript and approved its final version.

  • Funding The surveys were conducted with the contribution of the Italian Ministry of Health. The work of RP was partially funded by the Italian Ministry of Health (MADES project, chapter 4100/22). The work of AL was supported by a fellowship from the Italian Association for Cancer Research (AIRC). The work of SG and XL was partially supported by the Italian League Against Cancer (Milan).

  • Competing interests None declared.

  • Ethics approval The ethics committee of Istituto Neurologico Carlo Besta–Milano acknowledged the collection of anonymous data in face-to-face population-based, observational, cross-sectional studies (File number 37, 2017).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional unpublished data are available.