Are People Who Smoke Sick? Or Just Unaware of Better Options? 

    When the dangers of cigarette smoking were recognized in the 1950s and ‘60s, physicians assumed that tobacco would be treated like any other environmental toxin and gradually removed from the marketplace, as was done with substances such as lead or asbestos. It is no longer possible to buy lead pipes, leaded petrol, asbestos brake linings or asbestos insulation. However, cigarettes remain available at the local convenience store in every country.

    Despite decades of work on tobacco control, the World Health Organization reports that tobacco use causes over 8 million annual deaths. The number of tobacco users, most of whom smoke cigarettes, is only declining very slowly, from 1.36 billion in 2000 to 1.25 billion in 2022. 

    What is going wrong, and what could we do better?

    As a physician, I would suggest that the medicalization of smoking cessation therapy is one reason why so many people continue to smoke. Quitting smoking would be easier if it were principally regarded as a consumer choice, not a medical procedure.

    Physicians have created a clinical condition called “tobacco use disorder.” Its manifestations include: 

    *Persistent desire/unsuccessful efforts to stop using  

    *Failure to fulfill major role obligations due to use 

    * Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by tobacco


    This medicalization of tobacco use means that physicians can label people who consume combustible tobacco products as patients needing treatment for a medical problem, and may consider them to be irrational “addicts,” unable to control their own actions.

    These statements seem designed to reinforce a lack of autonomy and create a long-term reliance on medical care.

    Where I live in Toronto, the Centre for Addiction and Mental Health runs a Nicotine Dependence Clinic. The organization states that “Nicotine dependence (also called tobacco addiction) involves physical and psychological factors that make it difficult to stop using tobacco, even if the person wants to quit.” 

    “Medications and behavioral counseling are the two main types of tobacco cessation treatment,” it adds. “The more time a person spends in counseling, the more likely that they will succeed in quitting tobacco use.”

    These statements seem designed to reinforce a lack of autonomy and create a long-term reliance on medical care.

    One problem with medical smoking-cessation therapy is that it requires people who smoke to consider themselves as sick patients in need of advice from a trained medical professional. Many people who smoke do not consider that they have a disorder, and are uncomfortable around people in white coats. 

    Pharmaceutical companies play into this too, encouraging physicians to prescribe their medications by funding smoking-cessation conferences, for example. 

    This all creates employment for health care workers and profits for pharmaceutical companies, but therapy and medication have very limited effectiveness at helping people quit smoking.

    If 100 people try to quit smoking without using any kind of medication or nicotine, this is likely to work for just six of them, according to Cochrane.

    If they use drugs, the success rate is between 12-16 percent with varenicline (Champix); between 10-18 percent with cytisine; and about 9 percent with bupropion (Wellbutrin). At least two of the medications also have unwelcome side effects.

    For nicotine replacement therapies (including patches and gum), Cochrane reports a success rate of just 8-9 percent with a single form of NRT, which delivers too little nicotine, too slowly. 

    Vapes, like other harm reduction options, can be made available to all adults at retail outlets, allowing access on a vast scale. 

    Other research shows that “In addition to having slower delivery, NRT only offers 30% to 75% of the amount of nicotine that would be acquired from smoking.” However, the same authors state that “use of emerging nicotine delivery systems, such as e-cigarettes, should continue to be discouraged.”  

    This is curious, when Cochrane, in 2023, found “high certainty evidence that nicotine e-cigarettes are more effective than traditional [NRT] in helping people quit smoking.” Further research has found vapes to be almost twice as effective as NRT. 

    Assessing respective quit rates is often a minefield, when the duration of abstinence from cigarettes that’s measuredtogether with how this abstinence is verifiedvaries from study to study. The earlier Cochrane source I cited puts the success rate of nicotine vapes at 10-19 percent—a wide range but not, to be sure, dramatically better than some of the medications.

    In continuing to scrutinize such data, however, we must not lose sight of a critical distinction. 

    Vapes, like other harm reduction options that deliver nicotine more safely than cigarettes, can be made available to all adults at retail outlets, allowing access on a vast scale. 

    Prescribed medications, requiring doctors and appointments, will never be available at a comparable scale. This dramatically curtails their population-level effectiveness, even if they do demonstrate comparable quit rates among study participants.

    Instead of treating people who smoke as patients, how about considering them as rational and intelligent consumers?

    To take a real-world example, look at the United Kingdom, where, by 2023, 2.7 million people had switched entirely from cigarettes to vapes, which they can buy anywhere from gas stations to supermarkets. 

    No smoking-cessation medication has ever had a remotely comparable impact.

    Instead of treating people who smoke as patients, how about considering them as rational and intelligent consumers, who are merely confused and misinformed about the available consumer nicotine options?  

    That’s the opposite of what the World Health Organization wants us to do. In the runup to its COP10 global tobacco control meeting, currently taking place in Panama, the agency urged governments to ban vapes or to treat them purely as medical devices, as in Australia.

    We should ignore the WHO. There are many safer alternatives to smoking which, instead of being delivered through a pathologizing system, can be satisfying, enjoyable and widely available for people to choose for themselves, without medical supervision. 

    Which is best for a particular person depends on why they smoke and what they are looking for from a “smoke break.”  

    If they want something to do with their hands, something to put in their mouths, and the opportunity to inhale, then they could switch to vaping, which is about 20 times safer than smoking (despite all the media scare stories).

    If they like the smell and taste of tobacco, and want a small portion that will last about five minutes, then they could use a heat-not-burn device. As the tobacco is heated to produce vapor without combustion, these products are about 10 times safer than smoking.

    However, if the main reason they smoke is that they want the psychological effects of nicotine, then oral nicotine products such as snus (made with tobacco) or nicotine pouches (with no tobacco) may be the best option. These products are placed under the gum, where they release nicotine over the course of about 30 minutes. They are about 100 times safer than smoking.

    Physicians seem to have an irrational objection to safer nicotine products, perhaps because they compete with medical programs, or because of a sense that non-medical use is immoral.

    Different nations have permitted widespread adoption of vapes, heated tobacco products or oral products—resulting in dramatic population-level declines in cigarette smoking in each case. 

    Yet physicians and health care workers seem to have an irrational objection to safer nicotine products, perhaps because they compete with medical smoking-cessation programs, or because of a sense that any non-medical use of nicotine is dangerous and immoral.

    They’re far from alone in this opposition. In 2023, when Zonnic became the first nicotine pouch authorized for sale in Canada, tobacco control lobby groups focused on an unfortunate legal loophole that allowed it to be purchased by minors. They made no mention of the health benefits for people who switch from combustible tobacco. 

    It is ironic that the Canadian Cancer Society is one of the ring-leaders, when smoking causes about 30 percent of all cancer deaths. No reliable evidence links pouches and vapes, which replace cigarettes, to cancer in humans.

    Current regulation of safer nicotine products is based on politics, not science. Different countries authorize, tolerate or outright ban different options. 

    In a rational world, vapes, heated tobacco devices and oral products would all be available—and sold wherever people can buy cigarettes. They should come in a range of enjoyable flavors, with tax rates set to incentivize switching. Then you just need to ensure that consumers are honestly informed, and let them judge each nicotine product on its merits. 

    Sadly, that scenario has yet to be fully realized anywhere in the world.

    In Canada, for example, the Tobacco and Vaping Products Act specifically forbids people who are selling vaping equipment from saying that vaping is safer than smoking. It is a senseless suppression of the truth, and costs lives.

    With accurate information, the 1.25 billion people who currently smoke could take control of their own health by switching to far less harmful nicotine products. This would ultimately prevent hundreds of millions of deaths.  

    Quitting should primarily be a matter of consumer choice, not medical intervention.



    Photograph by Kiwiev via Wikimedia Commons/Public Domain

    • Dr. John Oyston is a retired anesthesiologist. Working in the operating room, he saw the damage that combustible tobacco does to the human body. He has been involved in many efforts to reduce smoking, including Stop Smoking for Safer Surgery. He currently advocates for safer sources of nicotine for adults who smoke. He lives in Toronto.

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