I used the IQOS device for the first time yesterday.

I hated it.

This is a really good thing, for two reasons, which I will explain shortly.

To begin at the beginning: IQOS is a “heat not burn” (HNB) cigarette alternative developed by Philip Morris International. It is an electronic device that heats up a small cylinder of tobacco without setting it on fire. This produces a tobacco-flavoured aerosol that the user inhales. It provides a source of the nicotine that many smokers need to avoid craving cigarettes, with far fewer of the dangerous chemicals that are created when tobacco is burnt. Based on the chemical composition of the aerosol, it seems likely that this product will prove to be about ten times safer than smoking, but probably about twice as dangerous as vaping, as vaping is tobacco-free, and vape contains even fewer toxic chemicals.

I hated it because I am not a smoker and I hate cigarette smoking. I did not like the feel of the warm aerosol in my throat, I did not like the smell of the cloud and I did not like the taste of tobacco in my mouth. I felt somewhat tainted and contaminated by the whole experience. But, the point is, this is exactly how I feel when I smoke a cigarette. The IQOS captures the spirit of the smoking experience but in a far less harmful product.

There was a brand of margarine that used the slogan “I cannot believe this is not butter”. My immediate response to IQOS was similar. It is so close to the experience of smoking it is hard to believe that it is in fact a so much safer alternative.

It is a good thing that I hated the IQOS, because that suggests two things:

Firstly, IQOS may not be attractive to people of any age who do not smoke. The limitations of IQOS (few flavours, only one nicotine strength, unable to adjust the amount of cloud, and no user-changeable parts) may make it a simple choice for smokers but offer nothing to people who want to experiment with the experience.

Secondly, IQOS seems to have been very carefully designed to very closely ressemble the experience of smoking, so that it is likely to be a very acceptable aternative for people who enjoy the experience of smoking cgarettes, but want a safer alternative.

The IQOS device uses small cylinders of tobacco that are called “Heets”. They look very similar to a baby cigarette. They come in packages of 20, divided into two foil packages of ten each. As you open the package you get the same fresh tobacco aroma that you get when opening a packet of cigarettes. In Canada, Heets only come in traditional tobacco and menthol flavours. (Berry flavour is available in Europe.)

Users put a Heet into the IQOS and turn it on. For about five minutes the tobacco is heated up so that the aerosol can be inhaled, and then it cuts out. Just like a cigarette, once you start it is not easy to stop, and once the time is up you have to begin again with a new Heet. This is unlike vaping, where you can vape for as short a time or as long a time as you want. Unlike cigarettes, both IQOS and vape do not release “sidestream” clouds when not being inhaled by the user. This limits second-hand exposure to the product.

At the end of the session, the used Heet has to be removed and discarded, just like a cigarette butt, closely mimicking the smoking experience.

So, where does IQOS fit into reducing the disease, disability and death due to tobacco smoking? That is a really complicated question.

If smokers completely switched from smoking to using IQOS it is likely that in the long term far fewer people would die. In Canada, cigarette smoking kills about 45,000 people every year. If everyone had always used IQOS instead of smoking, maybe only 4,500 Canadians would die. Saving over 40,000 lives is obviously a great thing to do, but if all those smokers switched to vaping instead that would probably save an additional 2,000 lives.

What happens in real life? In Japan, IQOS and other Heat-Not-Burn products have taken over more than 20% of the entire tobacco market, and as a result Japanese smokers consume 74 billion fewer cigarettes every year. This is obviously a huge step forward for public health, but again it could have been even better. The actual percentage of Japanese people who smoke has declined only slightly. It seems that many people are using HNB devices when in public spaces where smoking is forbidden, but continuing to smoke in private. This is bad for three reasons: Firstly, even smoking a few cigarettes a day is bad for your heart. Secondly, there is a greater risk of relapse into cigarette smoking if some cigarettes and smoking equipment are readily available. Thirdly, one of the goals of smoke-free public spaces is to encourage people to quit smoking. If a smoker can manage a whole day without smoking, he or she should be able to quit smoking entirely. If there are some times and places where people can use IQOS but not smoke, this allows them to keep on using nicotine throughout the day.

What approach should public health take to HNB devices?

In a medical model for smoking cessation, smokers should be encouraged to quit using approved standard methods. If these fail switching to vaping is safer, and therefore preferable to switching to a HNB device. However, vaping is a substantially different user experience compared to smoking. While some people may enjoy the range of nicotine concentrations and flavours, and the convenience of being able to “graze” by taking intermittent puffs on a vape, others miss the sensory experience of opening a tobacco package, the aroma of tobacco smoke, and even the experience of throwing a butt in an ashtray. For these smokers, HNB devices might be more acceptable than vaping.

In a consumer-orientated free market, heat-not-burn devices such as IQOS should be available to adults at least as readily as cigarettes.

The IQOS is an important addition to a confusing array of safer nicotine alternatives now available to smokers. Vape comes in open and closed systems, pods and mods. Oral nicotine products include both tobacco-based and tobacco-free products. Nicotine can be plant-based or synthetic, salted or not. There are HNB devices such as IQOS as well as a range of medically-approved nicotine sources such as gum and patches. Each product has advantages, disadvantages, and risks.

Nicotine consumers need a significant amount of unbiased information in order to make a rational choice between a wide range of products. Making the correct choice can literally be a matter of life or death. Unfortunately at present, they are badly misinformed and many lack even the basic knowledge needed to make an informed decision. Their health care providers are usually equally ignorant or misinformed.