JTI does not market any of its products including heated tobacco products as smoking cessation products,

“JTI does not market any of its products including heated tobacco products as smoking cessation products,” says a JTI spokesperson. “They are an alternative for smokers looking for products with the potential to reduce the risks associated with smoking.”

There are some who question the science that major companies are using to promote heated tobacco products. The European Respiratory Society Tobacco Control Committee published a position paper in February 2024 on the subject. The paper states that, while the tobacco industry claims a 90-95% reduction in harmful and potentially harmful substances and toxicity for heated tobacco products, this is not the full picture. Independent research shows these products emit substantial levels of carcinogenic, tobacco-specific nitrosamines, irritants and potential carcinogens, as well as similar nicotine and tar levels to a standard cigarette, the paper states.

Some researchers have also cast doubt on the clinical trials conducted by tobacco companies themselves. In 2022, a systematic review by the University of Bath’s Tobacco Control Research Group – which receives funding from Bloomberg Philanthropies and are part of STOP, a global tobacco industry watchdog – concluded that PMI’s clinical trials of its heated tobacco products were of poor quality and at high risk of bias.

PMI did not provide a response to these allegations when asked by the BBC, but it characterised the University of Bath’s Tobacco Control Research Group as an “unreliable and inaccurate source of information”. It did not provide any further evidence to support this accusation.

With other forms of smokeless tobacco also on the rise, which can be chewed, sucked or snuffed, many anti-tobacco lobbyists are frustrated by the lack of progress. Staying ahead of the proliferation of new forms of tobacco consumption is like playing a game of “whack-a-mole”, says Sandra Mullin, senior vice-president of policy, advocacy and communication at Vital Strategies, an international non-profit organisation that has partnered with governments around the world to develop tobacco control policies.

“I was in China in January, and they showed us these new models of heated tobacco products that don’t look like tobacco, they look like a toy,” she says, adding that she would like to have more data that demonstrates whether there are serious health impacts from such products.

One aspect that is particularly worrying public health officials, including the WHO, is that these devices may actually encourage people to consume more tobacco. A 2022 systematic review by researchers in the UK concluded that there was insufficient evidence to show they help people to stop smoking. The 2023 WHO report on heated tobacco also warns that the available data indicates that most smokers become dual users and “do not substantially reduce their risk from tobacco products”.

Gallus and his colleagues recently published a review of 26 studies on the use of heated tobacco products conducted around the world since 2022. Two out of three heated tobacco users are dual users, he and his colleagues concluded.

According to Gallus, dual users have a significantly higher risk of disease and premature death compared with smokers.

“If you’re not actually reducing tobacco consumption, it undoes any potential reduced harm effects, and the industry’s just making money from people twice over,” says Sophie Braznell, a researcher in the University of Bath’s Tobacco Control Research Group and a spokesperson for STOP.

PMI claims its own data demonstrates the majority of IQOS users have given up smoking. It estimates 72% of IQOS users are people who have fully switched from cigarettes. JTI and BAT did not respond to questions about dual use of their products.

But with IQOS returning to the US, starting with the devices going on sale in Austin, Texas in March 2025, Yolonda Richardson, president and chief executive of the Campaign for Tobacco-Free Kids, is concerned that more people will become users of multiple tobacco or nicotine products. E-cigarettes remain popular among younger people while nicotine pouches that are placed between the lip and gum are now showing signs of growing in popularity, with the CDC reporting a substantial increase in nationwide sales in the US since 2016.

However, Richardson says that it may take a long time before the full health consequences become apparent. When they do, it will be exceedingly difficult to pinpoint the underlying source, as individuals will have been exposed to different concentrations of nicotine in different forms, as well as varying sources of tobacco.

Zervas argues that the onus should be on the tobacco industry to prove that its products are not dangerous before they’re able to enter the market, rather than the other way round.

“It’s like with food or drugs,” he says. “We study them first and, if they’re safe, we allow them. With the tobacco industry’s products, we allow them into the market and then have to prove they’re dangerous, or very dangerous.”