Proper regulations should be in place for heated tobacco products 

Located on the second floor of a shopping mall in Jakarta, the outlet and billboard of IQOS-HEETS look catchy with white neon lights. In its glass display case, the 4-square meter outlet sells IQOS, an oval-shaped tobacco heater, and HEETS, a refill tobacco that looks like a cigarette stick but smaller and is kept in a wooden box. This is one of several outlets that are located in Jakarta, Tangerang, Surabaya and Bali, since January last year.

Arjuna—not his real name—is one of the customers who visited the outlet on Wednesday afternoon, February 16, 2022. He admitted that it had been 6 months since he switched to the smoking tool made by PT HM Sampoerna. Compared to the conventional cigarette, this electronic cigarette that uses chopped tobacco does not produce coals and ash. The smoke was just a thin mist. “Once I used this product, the conventional cigarette didn’t taste good anymore in my mouth. Instead, it just felt like burning,” he told Jaring.id.

That day, Arjuna bought several packs of HEETS to fill his IQOS 3 Duos tool, which was worth Rp 1.3 million. “I can still use this while I am in a room. It only releases a mist. It doesn’t stink either, so the smell doesn’t stick to our body,” he said.

Another consumer of IQOS-HEETS, Ardi—as he is fondly called—admitted that he had smoked the heated tobacco product for the last two months. According to him, this product is almost similar to the conventional cigarette stick. Ardi can still feel and inhale the smell of tobacco when he turns on the heater. “I used to use vaping too, but then I turned to conventional cigarettes again. Now, I am trying IQOS. It’s only been two months. I knew about this from a friend who had used it first,” he said after buying HEETS on Wednesday, February 23, 2022.

IQOS-HEETS is a set of tobacco products that began to be sold on a limited basis in Indonesia in 2019. These smoking aids are priced from hundreds to millions of Rupiah. The IQOS 3 Multi product is priced at Rp 900,000, while the IQOS 3 Duos is more pricey, as it is worth Rp 1.3 million. Even though it is expensive, according to Rival, a vendor of IQOS-HEETS, the outlet where he sells the products is quite busy. “Every day, we always have buyers. Many public figures buy the products here, too,” said Rival when Jaring.id met him on Wednesday, February 16, 2022.

Not only selling, Sampoerna also makes it easier for smokers to try out heating equipment with a rental system. “If you are still hesitant to buy it, you can rent it first. If you are still not used to it for 14 days, it can be extended. Let consumers try it first by renting it,” he said. Customers, according to Rival, only need to buy 5 packs of HEETS for Rp 165 thousand or register through the IQOS.COM site to take the IQOS home. “Just buy the tobacco, the equipment is free,” he added. However, Rival reminded that IQOS and HEETS products can be accessed offline and online only by adults.

Tangkapan layar situs IQOS

Based on data from Philip Morris International (PMI), IQOS has been marketed in more than 64 markets worldwide. More than 17.6 percent of adult smokers are claimed to have switched to IQOS since December 2020. Meanwhile, in Indonesia, it is still marketed on a limited basis. This limited market test is also what consumers like Ardi have complained about. “Using this, indeed, gives you more hassle, because you have to go to the mall to buy the tobacco or buy it online. It’s not as easy as buying cigarette sticks,” he said.

Nevertheless, the wide sales of IQOS-HEETS is believed to be a matter of time. At the end of last year, the government inaugurated PT HM Sampoerna factory in Karawang, West Java. This tobacco company invested at least US$166.1 million. The factory is scheduled to operate in the fourth quarter of 2022. Meanwhile, heated tobacco production will be aimed at meeting domestic market demand and export markets in the Asia Pacific region.

During the limited market test in Indonesia, PT HM Sampoerna recorded an increase in the membership of IQOS users. From 6,000 members in 2019, to nearly 30,000 a year later. “This was achieved by utilizing the IQOS Expert virtual channel and platform and an e-commerce platform that had been perfected during the pandemic,” said a statement written in PT HM Sampoerna’s 2020 annual report.

Like other cigarette promotions, in the report, Sampoerna stated that it had involved 12,000 adult consumers through direct introductions and at outlets spread across Jakarta, Bandung and South Tangerang. Starting from Pullman Central Park, Pasaraya Blok M, Pacific Place, MidPlaza, Mall of Indonesia, Gandaria City, Kota Kasablanka, and The Breeze. While overseas, IQOS has been marketed in 64 places with a reach of 17.6 million adult smokers across the country.

Director of PT HM Sampoerna Tbk, Elvira Lianita, has not been able to respond to Jaring.id’s questions, when confirmed regarding the marketing of IQOS-HEETS until 2022. Through an employee in Sampoerna’s communication team, Elvira suggested that the answers could be seen from the 2020 annual report. “With time considerations, we are unable to answer the questions for now,” said Muthiah, External Communications Manager of PT HM Sampoerna, on Wednesday, February 16, 2022.

Muthiah said that she had arranged the time for the interview. However, until this writing has been published, Jaring.id has not received any confirmation. “It seems difficult because we already have other agendas. We are quite busy in the next few weeks,” said Muthiah again via Whatsapp message on Monday, February 21, 2022.

To date, quoted from the IQOS website, at least this company has conducted 18 non-clinical studies and 10 clinical studies involving thousands of participants. Based on these studies, Sampoerna admitted that IQOS-HEETS is not risk free. However, this PMI-affiliated company claims that heated tobacco can reduce exposure to harmful or potentially harmful substances by an average of 90% – 95% compared to cigarette smoke.

This cigarette manufacturer also mentions that hot tobacco still contains nicotine, so it can lead to dependence. However, a recurring claim on the IQOS.COM website says, “IQOS is a better choice than continuing to smoke.”

Even so, the administrator of the Indonesian Consumers Foundation (YLKI), Agus Suyanto, stated that IQOS-HEETS is just the same as cigarettes. Instead of encouraging active smokers to switch, this new heated cigarette product is predicted to increase the number of smokers, which is now estimated to be more than 65 million people. According to him, the jargon saying IQOS and HEETS are heated-not-burned tobacco is simply ‘a trick of cigarette manufacturers to distort facts’. “This product is addictive and not suitable for consumption,” he told Jaring.id on Tuesday, February 15, 2022.

Salah satu cafe di Jakarta yang menampilkan iklan IQOS. Foto: Erna

He considered the distribution of heated tobacco products ignore a number of regulations, including Government Regulation Number 109 of 2012 concerning Safety of Materials Containing Addictive Substances in the Form of Tobacco Products for Health and Ministry of Health Regulation Number 28 of 2013 concerning the Inclusion of Health Warnings and Health Information on Tobacco Product Packaging. The regulation requires tobacco products to include health warnings in the form of images and writing.

Meanwhile, on the HEETS packaging, no pictorial warnings were found. The packaging only says that the product is not risk free and causes dependence. Meanwhile, the IQOS packaging is more like a cellphone packaging than a cigarette heating device. The heated tobacco smoking device is sold without a health warning. That is why, YLKI urges the government to immediately withdraw the product from the market. “Even though it has a permit, it gives more harm than benefits,” he said.

According to Agus, the products should be withdrawn until the Government Regulations Number 109 of 2012 is revised. This is because the circulation of electronic cigarettes and other tobacco products in Indonesia has not been regulated in detail until now. IQOS has not been included as one of the products prohibited in Government Regulations Number 109 of 2012. “There is no comprehensive regulation and control of distribution. If it has an impact on health, there should be regulations to control it,” he said.

Meanwhile, Chairman of the TAR-Free Indonesia Coalition, Ariyo Bimmo, shared his views that the sale of electronic cigarettes which have lower health risks does not need to wait for the revision of Government Regulation Number 109 of 2012. According to him, access for smokers to switch to lower-risk products should be  opened widely. “The regulations set for this product should be different from the regulations for cigarettes that have existed previously, and the regulatory points for alternative tobacco products will have to take into account these different risk profiles,” said Ariyo on Sunday, February 22, 2022.

He hoped that the government would participate in conducting scientific studies on various new tobacco products and methods of using them. This should be done to enable the public to get accurate and neutral information about electronic cigarettes. “Clinical research, population studies and systematic reviews are needed to get more convincing study results. Of course, it will take a long time,” he said.

 

The Indonesian Lung Doctors Association (PDPI) has stated that all tobacco products, both conventional and heated, contain  ingredients that are harmful for health. According to doctor Feni Fitriani Taufik, the use of IQOS-HEETS can cause long-term lung cancer and addiction. “Even if it’s small, the content is dangerous because it still bring the harmful substances into the respiratory tract,” she explained to Jaring.id on Friday, February 18, 2022.

The reason, according to Feni, is that the respiratory tract is not supposed to receive harmful substances. Smokers can have coughs, get infected easily, and develop respiratory tract disorders. In fact, the use of electronic cigarettes can reduce the immunity, so that germs, bacteria, and viruses can easily enter the body. “The respiratory tract was created not to receive harmful products. Scientifically and healthily, there are potential dangers from these products,” said doctor Feni.

She added that the new electronic-based tobacco products contain carcinogens or substances that could cause cancer. The material was found in devices that were directly contaminated with inhaled fumes or vapors. “There are heavy metals in e-cigarette products. There are other products that are also harmful for health. Many people are ignorant about this. Once the disorders have developed into cancer, then they will only realize it,” she said.

Referring to the statement of the Tobacco Control Support Center (TCSC) of the Indonesian Public Health Experts Association (IAKMI) in April 2021, IQOS-HEETS emissions are considered to produce toxic substances that are not on the list of the United States Food and Drug Administration (FDA) and have higher levels than in conventional cigarettes.

Research conducted by Farzad Moazed, et al from the Department of Medicine, University of California San Francisco, also suggested the same results. They found no difference in the impact of conventional smoking and IQOS.

The conclusion came after reviewing pulmonary and immune toxicity data from modified tobacco products (MRTP). The researchers also compared the modified risk tobacco product (MRTP) data that PIM provided to the FDA. In April 2019, IQOS received approval from the FDA for marketing.

The IQOS product tested in this research, namely tobacco heated systems (THS) V.2.2. The research used mice as the media. The mice were given an aerosol that was diluted with filtered air to obtain a nicotine concentration of 15-50 micrograms per liter of aerosol. Then it is placed in the inhalation chamber with administration for 6 hours per day. “Toxins were measured in the respiratory zone of mice in the inhalation chamber and reported in ppm (carbon monoxide) or g/liter (acetaldehyde, acrolein, and formaldehyde),” said Farzad in his research released on August 29, 2018.

After that, conventional cigarette smoke and IQOS cigarette smoke were administered. IQOS emissions were found to contain significant levels of volatile organic compounds. “This includes known toxins such as acrolein, acetaldehyde, and formaldehyde,” the study said.

Mice exposed to IQOS also experienced impaired weight gain during the 90-day exposure compared to other mice not exposed. Mice exposed to IQOS also tended to increase the number of inflammatory cells in bronchoalveolar lavage (BAL)—a diagnostic method of the respiratory system. From this research, it was found that IQOS causes hyperplasia and metaplasia. “Taken together, these data suggest that IQOS induces significant, but less severe, inflammatory injury than that observed with intense cigarette smoke exposure. This finding raises the alarm that IQOS may increase the risk of infection in users,” said Farzad.

Therefore, PDPI urges the government to immediately formulate regulations that can prevent, control, and protect the public from the dangers of cigarette smoke, especially now that IQOS-HEETS products are easy to find, either through outlets in shopping centers or online markets. “In terms of public affordability, e-cigarettes and IQOS can be purchased online. Access is unlimited. It is easier for everyone to reach. Therefore, regulations must be in place and the public should also be educated,” said doctor Feni.

Until this news was published, we still have not been able to get confirmation from the Ministry of Health on the circulation of IQOS-HEETS since last week. The Minister of Health, Budi Gunadi Sadikin, did not answer the phone calls or messages sent by Jaring.id. However, on January 15, the Minister of Health, Budi, stated that IQOS is no different from cigarettes. Meanwhile, the Director General of Disease Prevention and Control, Maxi Rein Rondonuwu, could not provide information because he was still out of town. “I’m still out of town. Just send me a Whatsapp message,” he said on Wednesday, February 23, 2022. However, he no longer provides answers to our questions then. (Abdus Somad & Erna Martiyanti)

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