Beyond Combustion: The Role of Heated Tobacco Products in Harm Reduction

The latest evidence indicates that alongside vapes and other nicotine products, heated tobacco products slashe toxic exposure and boost fitness in those who switch from smoking

For decades, tobacco control has focused on discouraging smoking through taxation, advertising bans, and public education. While these measures may have saved some lives, eight million people still die from smoking each year. The persistence of smoking despite decades of policy highlights an urgent truth: for many adults, quitting is extremely difficult. This is where tobacco harm reduction—and the science behind smoke-free alternatives—can make the difference.

A major peer-reviewed analysis published in the International Journal of Environmental Research and Public Health has now reinforced what many in the harm reduction community have long argued: eliminating combustion is the key to reducing tobacco-related harm. Drawing on 15 independent studies that used validated methods and excluded industry funding, the review found that heated tobacco products (HTPs) and vapes cut exposure to toxic chemicals by more than 90 percent compared to traditional cigarettes.

Vapes and heated tobacco products slash risk
The numbers are striking and in line with previous findings. While vapes remain the safest option, with a reduced exposure to harmful substances by up to 98 percent per puff, HTPs are also significantly safer at 91 percent. In many cases, emissions from these products fell below detectable levels. By avoiding combustion—which occurs at over 500°C and produces more than 7,000 chemicals, including about 100 classified as harmful or potentially harmful—like vapes, HTPs sidestep the bulk of the toxic load.

The reductions covered every major toxicant group associated with smoking-related disease. Polycyclic aromatic hydrocarbons (PAHs) were down by 96 percent in HTPs and 99 percent in vapes. Volatile organic compounds (VOCs) dropped by 99 and 100 percent respectively. Tobacco-specific nitrosamines (TSNAs), key carcinogens, fell by 94 percent in HTPs and 99 percent in vapes. Carbon monoxide exposure, a driver of cardiovascular disease, plummeted by 98 percent with HTPs and 99 percent with vapes. Even heavy metals such as cadmium and lead were significantly lower.

Cutting smoke, saving lives
The review’s conclusion was clear: smoke-free alternatives present a far less harmful option for adult smokers who cannot or will not quit nicotine entirely. By substantially lowering exposure to toxicants, switching could reduce the risk of cancer, heart disease, and respiratory illness. The authors also emphasized that quitting nicotine altogether remains the safest choice—but acknowledged that alternatives play an essential role in harm reduction, particularly in countries where cessation services are limited.

Adding another dimension to this evidence, a clinical trial published in the American Journal of Preventive Medicine examined the role of HTP flavours in helping smokers transition to reduced-risk products. The Richmond, Virginia study followed thirty adult menthol smokers over two weeks. Participants were randomly assigned either menthol-flavoured HTPs (IQOS) or tobacco-flavoured versions. The results were dramatic: those given menthol HTPs cut their cigarette consumption by 80 percent, compared with just 37 percent for the tobacco-flavoured group.

The difference could not be explained by nicotine delivery or puffing patterns, which were similar across groups. Instead, the key was sensory satisfaction. Menthol’s cooling effect, long known to smooth smoke inhalation, also makes menthol-flavoured HTPs more acceptable substitutes. In simulated purchasing tests, menthol HTPs scored much higher on cross-price elasticity, meaning smokers were far more likely to replace cigarettes with them.

These findings land in the middle of ongoing regulatory debates, as many governments consider restricting or banning not only HTPs, but also menthol products due to concerns about youth uptake. Yet the evidence suggests that for adults who already smoke menthol cigarettes, access to menthol-flavoured alternatives could be decisive in whether they substantially cut down or continue smoking. A reduction of 80 percent in cigarette use may not equal complete cessation, but it represents a profound step toward harm reduction.

Beyond chemical exposure and consumer behaviour, switching to combustion-free products, among which HTPs, appears to deliver real physiological benefits. A randomized controlled trial published in Scientific Reports—part of the CEASEFIRE project by CoEHAR at the University of Catania—measured aerobic fitness among 220 participants who had no intention of quitting. Researchers assessed V̇O₂ max, the gold standard of cardiorespiratory fitness, after four and twelve weeks.

Flavours, fitness, and freedom
The results were remarkable. Participants who switched completely to vapes or HTPs improved their aerobic capacity by about 5.5 to 6 percent—comparable to gains seen in people who quit smoking entirely. Even partial switchers showed measurable improvements of 3 to 4.5 percent. According to lead researcher Dr. Riccardo Polosa, these gains exceeded the minimum clinically important difference, making them not just statistically significant but clinically meaningful. The improvements occurred within just four weeks, highlighting how rapidly the body can rebound once carbon monoxide and combustion toxicants are removed.

This finding may prove especially persuasive for younger smokers. While the threat of future cancer or cardiovascular disease can feel abstract, the promise of better fitness and athletic performance within weeks speaks directly to lifestyle and aspirations. It’s another example of how harm reduction can be framed not only as disease prevention, but also as immediate quality-of-life improvement.

Of course, challenges remain. Regulators must balance youth protection with adult access, ensure product standards to minimize risk, and continue funding long-term studies. But the weight of independent evidence now points firmly in one direction: combustion is the problem, and alternatives that eliminate it can save lives. For the millions who continue to smoke, the choice should not be framed as “quit or die.” Instead, harm reduction offers a third path: switch to something far less harmful, improve health, and reclaim control over one’s future.