Effects of Heated Tobacco Products compared to Conventional Cigarettes on Cardiovascular System: A Systematic Review

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Published Nov 9, 2025
https://doi.org/10.62438/tunismed.v103i9.6233
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Vol. 103 No. 9 (2025): Tunis Med sept 2025

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Soumaya Ben Saad
Respiratory department C. Abderahmen Mami Hospital. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Chahida Hrizi
Respiratory department C. Abderahmen Mami Hospital. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Nidhal Balloumi
Respiratory department C. Abderahmen Mami Hospital. Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
Amani Ben Mansour
Service de pneumologie C. Hôpital Abderahmen Mami. Faculté de médecine de Tunis, Université de Tunis El Manar, Tunis, Tunisie

Abstract

Introduction: Heated tobacco products (HTPs) are marketed as reduced-risk alternatives to conventional cigarettes, yet their true cardiovascular safety profile remains unclear. This systematic review aimed to evaluate the acute and short-term cardiovascular effects of HTPs compared to traditional cigarettes.


Methods: A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, and Embase from inception to March 2024. Eligible studies included randomized controlled trials and observational studies reporting on cardiovascular outcomes in adult users of HTPs compared to conventional smokers. Risk of bias was assessed using RoB 2 and ROBINS-I tools. Data were synthesized qualitatively; a meta-analysis was not feasible due to heterogeneity.


Results: Five studies (n = 460 participants) met the inclusion criteria. Risk of bias ranged from low to serious, with one industry-sponsored study. Acute HTP exposure induced hemodynamic and vascular changes comparable to those observed with conventional cigarettes. Endothelial dysfunction and persistent oxidative stress were reported across studies. One study (Ikonomidis et al.) suggested a minor reduction in oxidative biomarkers with HTP use, though clinical significance was uncertain. No study assessed mid- or long-term outcomes.


Conclusions:  HTPs do not appear to offer meaningful cardiovascular benefit over conventional cigarettes in the short term. The similarity in acute harmful effects raises concern over their widespread use and marketing. These findings underscore the urgent need for independent, long-term studies assessing clinically relevant cardiovascular endpoints.

Keywords:

adult, smoker, heated tobacco products, cigarettes, cardiovascular complications, blood pressure, biomarker

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References

  1. -Jankowski M, Brożek GM, Lawson J, Skoczyński S, Majek P, Zejda JE. New ideas, old problems? Heated tobacco products – a systematic review. Int J Occup Med Environ Health. 2019;32(5):595 634. doi:10.13075/ijomeh.01433
  2. - Leigh NJ, Lawton RI, Hershberger PA, Goniewicz ML. Flavourings significantly affect inhalation toxicity of aerosol generated from heated tobacco products. Tob Control. 2020;29(2):209 214. doi:10.1136/tobaccocontrol 2018 054635
  3. -Tabuchi T, Gallus S, Shinozaki T, Nakaya T, Kunugita N, Colwell B. Heat not burn tobacco product use in Japan: its prevalence, predictors and perceived symptoms from exposure to secondhand heat not burn tobacco aerosol. Tob Control. 2018;27(e1):e25 e33. doi:10.1136/tobaccocontrol 2017 053947
  4. -Liu X, Lugo A, Spizzichino L, Tabuchi T, Pacifici R, Gallus S. Heat not burn tobacco products: concerns from the Italian experience. Tob Induc Dis. 2019;17:58. doi:10.18332/tid/110127
  5. -Czoli CD, White CM, Reid JL, O’Connor RJ, Hammond D. Awareness and interest in IQOS heated tobacco products among youth in Canada, England and the United States. Tob Control. 2020;29(1):89 95. doi:10.1136/tobaccocontrol 2018 054654
  6. -Philip Morris International. Scientific Assessment of IQOS. 2017. Disponible sur le site de PMI.
  7. - U.S. Food and Drug Administration. TPSAC Meeting : Modified Risk Tobacco Product Applications, January 24–25, 2018.
  8. -Nabavizadeh P, Liu J, Havel CM, et al. Vascular endothelial function is impaired by aerosol from a single IQOS HeatStick to the same extent as by cigarette smoke. Tob Control. 2018;27(Suppl 1):s13 s19. doi:10.1136/tobaccocontrol 2018 054325
  9. -Auer R, Concha Lozano N, Jacot Sadowski I, Cornuz J, Berthet A. Heat not burn tobacco cigarettes: Smoke by any other name. JAMA Intern Med. 2017;177(7):1050 1052. doi:10.1001/jamainternmed.2017.1419
  10. -Glantz SA, Bareham DW. E cigarettes: use, effects on smoking, risks, and policy implications. Annu Rev Public Health. 2018;39:215 235. doi:10.1146/annurev publhealth 040617 013757
  11. -Biondi Zoccai G, Sciarretta S, Bullen C, et al. Acute effects of heat not burn, electronic vaping, and traditional tobacco combustion cigarettes: The SUR VAPES 2 randomized trial. J Am Heart Assoc. 2019;8(6):e010455. doi:10.1161/JAHA.118.01045
  12. -Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9.
  13. -Ben Saad S et al. Effects of Heated Tobacco Products compared to Conventional Cigarettes on Cardiovascular System: Protocol for a Systematic Review. Tun Med 2025;....
  14. -Loakeimidis N, Emmanouil E, Terentes-Printzios D, Dima L, Aznaouridis K, Tousoulis D and al. Acute effect of heat-not-burn versus standard cigarette smoking on arterial stiffness and wave reflections in young smokers. Eur J Prev Cardiol 2021:20;28:e9-e11.
  15. -Ikonomidis I, Vlastos D, Kostelli G, Kourea K, Katogiannis K, Tsoumani M and al. Differential effects of heat-not-burn and conventional cigarettes on coronary flow, myocardial and vascular function. Sci Rep. 2021:3;11:11808.
  16. -Yaman B, Akpınar O, Kemal HS, Cerit L, Yüksek Ü, Söylemez N, Duygu H. Comparison of IQOS (heated tobacco) and cigarette smoking on cardiac functions by two-dimensional speckle tracking echocardiography. Toxicol Appl Pharmacol. 2021;423:115575.
  17. -Biondi-Zoccai G, Sciarretta S, Bullen C, Nocella C, Violi F, Loffredo L, Pignatelli P, Perri L, Peruzzi M, Marullo AGM, De Falco E, Chimenti I, Cammisotto V, Valenti V, Coluzzi F, Cavarretta E, Carrizzo A, Prati F, Carnevale R, Frati G. Acute Effects of Heat-Not-Burn, Electronic Vaping, and Traditional Tobacco Combustion Cigarettes: The Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking ( SUR - VAPES ) 2 Randomized Trial. J Am Heart Assoc. 2019;8(6):e010455.
  18. -Lüdicke F, Picavet P, Baker G, Haziza C, Poux V, Lama N, Weitkunat R. Effects of Switching to the Menthol Tobacco Heating System 2.2, Smoking Abstinence, or Continued Cigarette Smoking on Clinically Relevant Risk Markers: A Randomized, Controlled, Open-Label, Multicenter Study in Sequential Confinement and Ambulatory Settings (Part 2). Nicotine Tob Res. 2018;20(2):173-182.
  19. - Akiyama Y, Sherwood N. Systematic review of biomarker findings from clinical studies of electronic cigarettes and heated tobacco products. Toxicol Rep. 2021;8:282–94.
  20. -European Heart Network | Heated Tobacco Products and cardiovascular disease [Internet]. Available from: https://ehnheart.org/library/responses/heated-tobacco-products-and-cardiovascular-disease/
  21. -Glantz SA, Bareham DW. E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications. Annu Rev Public Health. 2018;39:215–35.
  22. -D’Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117(6):743–53.
  23. -Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease. JAMA. 2019;322(7):642–50.
  24. - Omland T, de Lemos JA, Sabatine MS, Christophi CA, Rice MM, Jablonski KA, et al. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med. 2009 Dec 24;361(26):2538–47.
  25. - Felker GM, Hasselblad V, Tang WHW, Hernandez AF, Armstrong PW, Fonarow GC, et al. Troponin I in acute decompensated heart failure: insights from the ASCEND-HF study. Eur J Heart Fail. 2012;14(11):1257–64.
  26. - Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness: a systematic review and meta-analysis. Circulation. 2007;115(4):459–67.
  27. - Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, et al. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J. 2006;27(21):2588–605.
  28. - Ferreira VM, Schulz-Menger J, Holmvang G, Kramer CM, Carbone I, Sechtem U, et al. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations. J Am Coll Cardiol. 2018;72(24):3158–76.
  29. - Moon JCC, Reed E, Sheppard MN, Elkington AG, Ho SY, Burke M, et al. The histologic basis of late gadolinium enhancement cardiovascular magnetic resonance in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2004;43(12):2260–4.
  30. - Puntmann VO, Voigt T, Chen Z, Mayr M, Karim R, Rhode K, et al. Native T1 mapping in differentiation of normal myocardium from diffuse disease in hypertrophic and dilated cardiomyopathy. JACC Cardiovasc Imaging. 2013;6(4):475–84.
  31. - Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731–7.
  32. - Messner B, Bernhard D. Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arterioscler Thromb Vasc Biol. 2014;34(3):509–15.
  33. - Heitzer T, Schlinzig T, Krohn K, Meinertz T, Münzel T. Endothelial dysfunction, oxidative stress, and risk of cardiovascular events in patients with coronary artery disease. Circulation. 2001;104(22):2673–8.
  34. - Lassègue B, Griendling KK. NADPH Oxidases: Functions and Pathologies in the Vasculature. Arterioscler Thromb Vasc Biol. 2010;30(4):653–61.
  35. - Violi F, Pignatelli P. Platelet oxidative stress and thrombosis. Thromb Res. 2012;129(3):378–81.
  36. -Dai Y, Yang W, Song H, He X, Guan R, Wu Z, et al. Long-term effects of chronic exposure to electronic cigarette aerosol on the cardiovascular and pulmonary system in mice: A comparative study to cigarette smoke. Environ Int. 2024;185:108521.
  37. - Patel U, Patel N, Khurana M, Parulekar A, Patel A, Ortiz JF, et al. Effect Comparison of E-Cigarette and Traditional Smoking and Association with Stroke-A Cross-Sectional Study of NHANES. Neurol Int. 2022;14(2):441–52.
  38. - Rose JJ, Krishnan-Sarin S, Exil VJ, Hamburg NM, Fetterman JL, Ichinose F, et al. Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association. Circulation. 2023;148(8):703–28.