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IQOS isn't yet widely sold in the United States -- only in a few test markets, including Atlanta -- but its U.S. marketer, Altria, plans a nationwide rollout during 2020. In countries such as Russia and Romania, a five-year-long marketing campaign linking it with youthful allure has fueled its use according to a new white paper published by Robert Jackler, MD, director of Stanford Research into the Impact of Tobacco Advertising. The marketing efforts are far-reaching: "Coaches" and celebrities promote the products on social media. And some restaurants in countries including Ukraine and Japan are identifying as "IQOS friendly" even when smoking is not allowed. As a Reuters article outlines, it's being associated with luxury brands such as Mercedes-Benz.

"As conventional cigarettes are becoming less and less popular, the tobacco industry is seeking ways to recapture the marketplace," Jackler said. "They're trying to make smoking glamorous again. We have not seen the type of marketing Philip Morris is employing for IQOS since the mid-20th century." Something of a cross between a vaping device and a cigarette, IQOS kits come in a variety of shiny colors and cost about $100. They consist of a charger, about the size of a mobile phone, and a tobacco-stick holder. An IQOS user inserts a stick, containing shredded tobacco and glycerin, into the holder, which heats the tobacco to 350 C. The user inhales the emissions, a combination of smoke and vapor.

Philip Morris International first introduced IQOS to Japan in 2014. Since then, it has aggressively marketed the product in 52 countries, mostly to people ages 30 to 60. The company denies that IQOS is an acronym, but Jackler said many people believe it stands for "I quit ordinary smoking." Jackler said that one benefit of using heated tobacco is that it produces less smoke than traditional cigarettes, minimizing odor. He added that its advantage over vaping is that it's not -- at least not yet -- associated with lung disease caused by vaping.

The U.S. Food & Drug Administration approved IQOS for sale last year, but only as a cigarette equivalent. As a result, Altria may not make any claims that IQOS is safer than cigarettes, may not advertise on radio or television, and may add only menthol -- rather than the variety of flavors sold in other countries -- as flavoring. Jackler said that he hopes the paper will convince U.S. regulators and lawmakers to keep a close eye on Altria's attempts to sell IQOS. "Our hope is that the FDA recognizes what Philip Morris has done around the globe and will put stringent controls on its marketing," he said.

Because heated tobacco products are relatively new and little research has been conducted, it's not clear how harmful they are. "They may in fact be less risky than cigarettes," Jackler said. "But as cigarettes kill a half million Americans every year, that is indeed a very low bar."

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