Lorenzo Spizzichino

Heat-not-burn tobacco products: concerns from the Italian experience

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 …

Food consumption and nutrient intake in Italian school children: results of the ZOOM8 study

Abstract The food consumption and food habits of Italian third-class-primary-school children were assessed and their energy and nutrient intakes were compared with requirements. The study involved 1740 subjects (900 males and 840 females) aged 8–9 years, from the north, centre and south of Italy. Body weight and height were measured. Parents filled in a semi-quantitative Food Frequency Questionnaire for their child. The results showed that the diet of Italian children is unbalanced in terms of macronutrients and deficient in fiber. The average daily intakes of fruit (234 g/d), vegetables (134 g/d) and legumes (17 g/d), were lower than the nationally recommended ones. The percentages of energy intake from fats (41%) and from carbohydrates (45%) were higher and lower respectively than recommended. Low intakes of fiber (13.5 g/d) were reported. A national nutrition policy in Italy should focus on nutrition education programs in schools and for parents.

Sales of different tobacco products in Italy, 2004-2012.

A recent report from the US CDC (2012), using excise tax data, showed a decrease by 33% (from 436 to 293 billion) of total cigarette consumption between 2000 and 2011, but an increase by 123% (from 15 to 34 billion cigarette equivalents) of loose tobacco and cigars over the sameperiod. Those divergent trends have been attributed to the different taxation between cigarettes and other tobacco products (CDC, 2012). We analyse the issue of sales of manufactured cigarettes and other combustible tobacco products using detailed legal sale data in Italy between2004 and 2012. These datawell reflect the real pattern of total tobacco trade in Italy, since in this country both illegal sales (tax evasion) and cross-border shopping (tax avoidance) covered less than 5% of total tobacco trade over the last decade (Gallus et al., 2009, in press-a; Joossens et al., in press). We used official three-month legal sale data on the amount (in grams) of different tobacco products (manufactured cigarettes, loose tobacco, cigars, small cigars) sold in Italy between 2004 (first quarter) and 2012 (last quarter). Over the observed time period, the Italian adult population increased from 48.0 to 50.4 million inhabitants. Since 2009we have also the possibility to disentangle the type of loose tobacco (pipe vs hand-rolled (HR) tobacco). Fig. 1 shows the trend in legal sales of manufactured cigarettes and other combustible tobacco products between 2004 and 2012. Over that period, all combustible tobacco decreased from 100,597 to 84,284 tonnes (−16.2%). Manufactured cigarettes decreased by 20.6% (from 98,846 to 78,486 tonnes), whereas other combustible tobacco products substantially increased. In particular, sales of large cigars and small cigars increased by 30% (from 668 to 865 tonnes) and 98% (from 424 to 838 tonnes), respectively, and sales of loose tobacco (pipe and HR tobacco) by 522% (from 659 to 4096 tonnes). Pipe tobacco sales remained stable between 2009 and 2012 (around 170 tonnes) and represented less than 5% of loose tobacco sales in 2012. We showed a substantial increase in non-manufactured cigarette combustible products over the last decade in Italy, particularly HR tobacco. When converting weights in cigarette equivalents, based on Italian data that one HR cigarette weighs 0.7 g (Gallus et al., in press-b; Lopez-Nicolas et al., 2012), 6.6% of all cigarettes in Italy in 2012 are HR cigarettes. This is still appreciably lower than the approximately 10% in the US (CDC, 2012), 17% in Canada, 24% in Australia and 28% in the UK (Gallus et al., in press-a; Young et al., 2006), but identifies a clear upward trend.

Smoking Habits among Italian Adolescents: What Has Changed in the Last Decade?

Tobacco use, alcohol abuse, overweight and obesity are risk factors for numerous diseases in Italy as elsewhere. However, children and adolescents are not usually included in official national surveys although it is at this stage of life when unhealthy habits are often established. Italian participation in HBSC and GYTS surveys allows our country to implement standardized surveillance systems providing reliable information on tobacco-related behaviors of this population. Data from three HBSC surveys (2002–2010) show that following the drop in the first half of the decade, prevalence of tobacco use stabilized in the second half. The decline was significant for younger age groups, while prevalence of regular tobacco use remained stable among 15-year-olds. Many adolescents reported being exposed to secondhand smoke, to have at least one parent who smokes, and having seen teachers and students smoking at school. Although the sale of tobacco products to minors is prohibited, the vast majority had no trouble in buying cigarettes. Data from GYTS and HBSC surveys provide a wealth of information about attitudes and behaviors of Italian adolescents with respect to smoking. Despite some progress, sizeable gaps remain in meeting standard recommendations for discouraging smoking initiation and motivating adolescent smokers to quit the habit.

Heat-Not-Burn Tobacco Products Are Getting Hot in Italy

Dear Editor, We read with great interest that the Journal of Epidemiology has recently decided not to consider for publication manuscripts on research carried out with funding from the tobacco industry.1 We strongly support such a decision. Until now, we have seen a lot of studies conducted by the tobacco industry, which are likely to be biased due to conflicts of interest. New tobacco products are not exempt from this phenomenon.2 Indeed, most of the knowledge on heat-not-burn tobacco products (HNB) comes from the tobacco industry.3,4 HNBs are hybrids between electronic and conventional cigarettes: on one hand, they are equipped with a device that heats the product, without reaching combustion, to generate aerosol (ie, a sort of “cold smoke”); on the other hand, the product used is not a liquid containing nicotine, but “real” tobacco.4,5 IQOS is the brand name of such a product by Philip Morris International (PMI). IQOS has pioneered the HNB market since December 2014, after having been launched in test markets in Milan (Italy) and Nagoya (Japan). To date, it is in commerce in 30 countries, including 22 from the WHO European region.4,6 In Italy, IQOS expanded the market to the whole country since December 2015, and, until December 2017, it was the only available HNB. We provide, hereby, independent data on sales of HNBs in Italy. Legal sales data of HNBs, obtained by the Italian Ministry of Finance, showed that the annual sale of IQOS remained negligible in 2015 (11 tonnes per year). Subsequently, it grew to 83 tonnes in 2016, up to 519 tonnes in 2017 (Figure 1). Correspondingly, the market share of IQOS in the whole tobacco market increased from 0.01% in 2015 to 0.11% in 2016 and up to 0.67% in 2017 and is now approaching the market share of cigars. These data reveal a quick exponential increase in IQOS sales in Italy over the last 3 years. This increase parallels the total IQOS online search-volume across Italy, according to Google Trends (https:==trends.google.com=trends=). IQOS online search-volume was in fact boosted by more than 10 times in a single year (2016) and continued to increase in 2017. These trends may be of concern, since we have previously shown that nearly half of Italian IQOS users (45%) and over half of the people interested in IQOS (51%) are never smokers.4 Therefore, such a product may represent, at least in Italy, a gateway for nicotine addiction among never smokers rather than a harm reduction substitution for current smokers.4 Moreover, the few independent toxicological studies have consistently found that HNBs release relatively high nicotine levels (similar to those released by conventional cigarettes)5,7 and non-negligible amounts of harmful substances, including various carcinogens.5,8 Nevertheless, due to the alleged belief in HNB harm reduction in Italy, these new products are exempted from the fiscal regimes of tobacco products. In fact, HNBs enjoy the same tax reduction as electronic cigarettes, which is half that of conventional cigarettes.9 Moreover, the enforcement of various tobacco control regulations is only minimally adopted for HNBs in Italy. First of all, health warnings are required to cover only 30% of the HNB packaging (instead of 65% for conventional cigarettes), without pictorial images.10 Second, comprehensive smoke-free regulations prohibiting smoking in all public places and workplaces do not apply to HNBs.9,10 Finally, advertising and promotions are not banned for these new products. This is evident by the presence in several strategic Italian cities of the “IQOS embassy” and “IQOS boutique”, which are fancy concept stores where IQOS is promoted as a status symbol and people can try it for free. Therefore, the most recognized tobacco control policies (ie, price=tax increase, smoking bans, advertising bans, and health warnings) have been compromised for HNBs in Italy. In conclusion, although the share of IQOS in the whole Italian tobacco market is still limited, given the exponential increase in sales observed over the last 3 years and the fiscal and regulatory benefits IQOS has,9,10 we expect a further expansion of IQOS in the Italian tobacco market, similar to that recently observed in Japan.6