Stimson, a public health social scientist and emeritus professor at Imperial College London, was speaking at the Global Forum on Nicotine (GFN) in Warsaw, Poland, in early June. He emphasized the extremely high prevalence of tobacco smoking, and related harms, among people who use banned drugs.

“Smoking rates amongst people who use drugs or people in drug treatment are two to four times higher than the general population,” Stimson said. Of 100,000 people who used heroin in the United Kingdom, according to research he cited, 63 percent were projected to die before the age of 70, compared with 16 percent of the general population. While 27.6 percent of the projected premature deaths were attributed to factors around banned drug use, 23.6 percent were attributed to smoking.

“We’re all aware of drug-related deaths,” said Stimson, who helped pioneer harm reduction approaches to drug use in the UK in the 1980s. “But the fact is, in this population, there are nearly equal numbers of deaths from smoking.”

Such figures are “stunning,” Stimson said, yet remain “invisible.”

“We can’t talk about harm reduction without tobacco harm reduction.”

The GFN panel, titled “Drugs and Tobacco Reduction: Shared Challenges, Shared Solutions,” highlighted how ignoring this intersection is one major way in which people who use drugs are denied the right to health. And the relationship is so obvious.

Nicotine use and use of other drugs go together so often that, “We can’t talk about harm reduction without tobacco harm reduction,” said panelist Magdalena Bartnik.

Bartnik is the founder and director of PREKURSOR, a Polish organization providing harm reduction services and advocacy for people who use drugs. She sees safer nicotine products as essential resources. “Cigarettes are an important part of people’s lives, a way of coping with stress,” she told the audience, “so tobacco harm reduction allows for the mitigation of health risks without the need to quit using nicotine.”

Marianna Iwulska, another of the panelists, has first-hand experience of that. She’s a drug-user activist who chairs the board of EuroNPUD, and a peer worker at PREKURSOR. She switched from cigarettes to vapes, and said her health has improved immeasurably as a result. But she did so without any encouragement from those who should be looking out for her health.

“When it comes to tobacco harm reduction, I have déjà vu. I am seeing the same arguments thrown about as with opiate substitution therapy.”

“No doctor ever asked me, even, if I am smoking, throughout my 26 years of [opioid] substitution treatment in Poland,” Iwulska told the audience. And that silence reflects what she described as a culture of hostility towards safer nicotine options, similar to that seen against medications for opioid use disorder.  

“When it comes to tobacco harm reduction, I have déjà vu,” she said. “I am seeing the same arguments thrown about as with opiate substitution therapy, when people were saying, ‘It’s the same, it’s like drug use, you are not recovering at all.’ But harm reduction is about meeting people where they are, not expecting miracles—not, ‘You have to stop first, then we treat you.’ I think it will be very, very beneficial to drug users to implement tobacco harm reduction to services.”

There have been some signs of momentum, with more groups concerned with drug-user rights and health recognizing the importance of tobacco harm reduction in recent years. In the United States, for instance, the National Harm Reduction Coalition has been working on it, as has the Urban Survivors Union, among others. Prominent supporters include Mark Tyndall, a Canadian physician with a long background in “drug” harm reduction.

A recent briefing paper from Global State of Tobacco Harm Reduction (GSTHR)—a project of Knowledge-Action-Change (KAC), which Stimson co-founded—highlights some of the reasons nicotine and other drugs often go together. 

“One of the problems is that drug services are often in a different silo, with different budgets from smoking cessation.”

Many people find nicotine relieves symptoms of withdrawal from other drugs, the paper notes. Smoking cigarettes before and after can be part of people’s ritual of drug use, “reinforcing both habits,” while nicotine may enhance people’s experiences of using drugs such as cocaine or opioids, as it “increases the body’s uptake of one or both substances.” Yet at the same time, data show that many people—including up to 80 percent of those in substance use treatment—do have a desire to quit smoking.

An accompanying GSTHR briefing paper offers ideas on how drug services could incorporate tobacco harm reduction to help people who smoke—by displaying information on safer nicotine options, for instance, and creating a smoking-cessation community that shares the same goals. 

This kind of integration would be fairly straightforward and wouldn’t cost much. “It’s a lot simpler than trying to persuade governments that you want to prescribe methadone, or persuading governments that you want to give out needles and syringes,” Stimson said. 

So why is tobacco harm reduction not already routinely included in most harm reduction and drug treatment services?

“One of the problems is that drug services are often in a different silo, with different budgets from smoking cessation, and people are focused on their own targets and priorities,” KAC Director David MacKintosh told Filter.

Harm reduction services are typically very stretched, dealing with acute crises such as overdose with scarce funding, he acknowledged, “so it’s understandable it’s not the priority, even though it will kill half of those who continue to use combustible nicotine.”

“I think the way to bring change is within community-based organizations upwards.”

Change requires support from leadership. MacKintosh moderated the GFN panel, where he said the idea of tobacco harm reduction remains “abstract” for many, and needs to be made more concrete in decision-makers’ minds.

“Whether you’re working with national politicians, public health people, whoever it is, they have their own interests,” he told the audience. Advocates, he said, need to appeal to those interests, to sell the idea of tobacco harm reduction and its benefits for individuals and local communities to the people who fund harm reduction services.

“We have to build from the ground up and help policymakers and public health leaders find their confidence to do what’s right around THR, rather than ignoring the potential, which can seem safer and easier,” MacKintosh told Filter after the event.

This grassroots approach is something Stimson agrees with. He told the GFN audience that getting THR into drug services can be a “bottom-up way to influence donors and international organizations.” 

“I think the way to bring change is within community-based organizations upwards,” he said. 

Photograph by Irina Iriser on Unsplash

The Influence Foundation, which operates Filter, has received donations and grants from KAC and from GFN Ltd. Filter‘s Editorial Independence Policy applies.

The post Growing Calls to Integrate Tobacco Harm Reduction Into Drug Services appeared first on Filter.

That included her doctor. She recalled going to see him when she came down with bronchitis one time. “The doctor said to me, in a really grumpy voice, ‘I told you a year ago that you’re going to keep getting sick if you don’t stop smoking.’” 

When Murray explained how many times she had tried to do just that, and how her most recent attempt had only lasted two days, the doctor just said, “I think you should try harder next time.”

“He did not offer me any medication or suggest nicotine replacement therapy,” Murray said. “If he’s not willing to offer tools to help me succeed, how am I supposed to believe I’m worth helping?”

The doctor’s “quit or die” attitude left her feeling a “failure,” and she never made another attempt to quit. After more than 50 years of smoking, she eventually stopped “accidentally,” after she started working at a vape shop and tried the products herself—a journey that led her to become a tobacco harm reduction advocate, who has written for Filter.  

“Urban smokers are nearly twice as likely to quit as rural smokers.”

Murray lives in a rural part of Minnesota, a few miles from a town called Brainerd. She’s far from alone among rural residents—who have higher smoking rates than their urban counterparts—in facing particularly high barriers to quitting. And while a lack of helpful smoking-cessation advice in rural medical settings is part of the story, there’s a lot more to it.

Smoking rates in the United States have taken a significant tumble in recent years, in large part due to uptake of safer nicotine products, like vapes and pouches. In 2024, the country achieved its lowest smoking rate up to that point, of 9.9 percent. But in some groups, smoking rates remain stubbornly high. Providing them with accurate information and effective options is vital, when an estimated 25-30 million US adults still smoke, and the country’s biggest cause of preventable death still claims close to 500,000 lives each year.

“Urban smokers are nearly twice as likely to quit as rural smokers,” noted a recent report, “The Forgotten Smoker,” published by the tobacco and nicotine products company Philip Morris International (PMI), which also focused on people with mental health conditions and veterans. 

There’s a temptation to assume rural areas’ higher average age might account for this. According to the last US Census, the median age in rural and small-town communities was 41.3, compared to 38.8 for the whole population. The 45-64 age group has the highest smoking rate in the US; and people aged 65-plus, though smoking at a lower rate, are the most vulnerable to smoking-related disease and death. The “forgotten smokers” among these older age groups were discussed at the Nicotine Summit in Washington, DC, in May. 

“Older age distribution in rural areas may play a role, but it is only likely one part of a much more complex picture.”

But according to Lorna Bittencourt of the University of Minnesota’s School of Public Health—lead author of a study titled, “Smoking Quit Attempts and Associated Factors Among Rural Adults Who Smoke Daily in the United States,” which was cited in the PMI report—taking this as the whole explanation for the rural-urban disparity would be reductive.    

“Older age distribution in rural areas may play a role,” Bittencourt told Filter, “but it is only likely one part of a much more complex picture involving socioeconomic conditions, health care access and longstanding tobacco-related disparities.”      

Rural communities, she continued, often face reduced access to healthcare and smoking cessation services, transportation barriers, economic stressors and fewer tobacco treatment resources.

Other researchers paint a similar picture. Dr. Ruoyan Sun is an assistant professor with the Department of Health Policy and Organization at the University of Alabama at Birmingham, whose work has also covered smoking behaviors by location. She was among the speakers at the recent Nicotine Summit, and like Bittencourt, she warns against oversimplified explanations. 

“One important lesson is that rurality is more nuanced than simply labeling areas as ‘urban’ or ‘rural,’” Sun told Filter. She said binary classifications risk masking important variations.      

“Higher smoking prevalence in rural areas is partly explained by socioeconomic and demographic factors,” she continued, “but these do not fully explain why adults in rural areas are less likely to quit.”

“I called this person when I was still smoking, requesting help. The best they could do was to tell somebody to drive up to 100 miles to pick up brochures.”

The point about lack of access to smoking-cessation resources rings true to Marc Slis, who lives in the small community of Hancock on Michigan’s Upper Peninsula. Trying to quit smoking there, with a health system ill-equipped to help him, was excruciatingly difficult, he told Filter. “What I found was that there were little or no smoking cessation resources available in the area.” 

Slis explained that the health department in question covers five counties of about 71,000 residents across roughly 14,000 square miles. Faced with extremely high smoking rates in such a thinly spread population, the health department designated one person, with no formal training or experience, to be the smoking-cessation coordinator. 

“I called this person when I was still smoking, requesting any help they could give me,” Slis said. “The best they could do was to tell somebody to drive up to 100 miles to pick up brochures.”  

“In other words, there is no smoking-cessation help available in the five-county area that I live in,” he continued. “It illustrates that the number one cause of preventable death is not only not a priority for a five-county health department, but also not even on their radar.”

Like Murray, Slis ran his own vape shop for years; discovering vapes had finally enabled him to quit smoking. But he’s still exasperated by the lack of help communities like his get from health authorities.

“If this is the state of things in other rural areas,” he concluded, “I think this alone may be responsible for much of the low quit rates and high smoking rates seen in rural areas.”

“Tobacco product regulation could be an opportunity to advance health equity in rural America, particularly if paired with efforts to improve access to support and health care.”

Another important issue Bittencourt pointed to is that tobacco-related inequities in rural communities are often overlooked in tobacco control conversations. 

“In a recent paper, we discussed how tobacco product regulation could be an opportunity to advance health equity in rural America, particularly if policies are paired with efforts to improve access to cessation support and health care infrastructure,” she said.

The internet is one obvious place to find tools and information, especially for people in remote areas, but here too there’s a disparity. According to the Federal Communications Commission, over 22 percent of people in rural areas of the US, and almost 28 percent living on Tribal lands, “lack coverage from fixed terrestrial 25/3 Mbps broadband.”  

One study tested three strategies to promote engagement with an online program to encourage rural adults to quit smoking. Printed materials; printed materials plus a loaned iPad with data plan coverage; or print materials, the iPad, plus up to six individualized coaching calls to support technology needs. It found that those who received the coaching support “had improved smoke-related outcomes.”

“Our study provides a better understanding of the resources needed to support digital access in rural populations,” the authors concluded, “and the results could be used to improve approaches to encourage people living in rural areas to stop smoking.”

“One important takeaway is that reducing rural smoking disparities will likely require more than individual-level interventions alone.”

Murray agrees. “So much of health care and cessation is now digitalized,” she said. “If a person doesn’t have good internet or cell service, it is next to impossible for them to have access to modern health care and cessation services. I am fortunate to have reliable internet access and can take advantage of telehealth, because I would not be able to drive for several hours just to attend an appointment.” 

But no single intervention is likely to end a rural smoking disparity that translates into a severe health disparity. Instead, it would take a range of far-reaching changes.

“I think one important takeaway is that reducing rural smoking disparities will likely require more than individual-level interventions alone,” Bittencourt said.

“Addressing these disparities will also require structural approaches,” she continued, “including improving access to evidence-based cessation treatment, expanding health care access in rural communities, and ensuring that tobacco regulatory policies consider the unique needs and contexts of rural populations.”

People’s desire to stop smoking is evident in all parts of the country: The PMI report cited CDC data showing that over 67 percent of US adults who smoke would like to quit. Rather than implying that people in rural areas—or anywhere else—just need to “try harder,” it’s imperative to make sure they have the right tools.

Photograph via PublicDomainPictures.net

The Influence Foundation, which operates Filter, has received unrestricted grants from PMI. Filter‘s Editorial Independence Policy applies.

The post Why Is It Harder for People in Rural Communities to Quit Smoking? appeared first on Filter.

Health Secretary Wes Streeting called the legislation “a turning point in the nation’s health.”

“By ending the cycle of tobacco addiction for future generations,” he continued, “we are taking one of the boldest steps in decades to prevent illness before it even begins.”

Some observers call the incremental prohibition “illiberal.” Tobacco harm reduction experts express concern that the law is mistargeted—and that it simultaneously paves the way for a clampdown on smoking-cessation tools.

The bill had cross-party support when it was first introduced by the then-Conservative government in 2023. A general election meant the bill was shelved, but it was reintroduced in 2024 by the current Labour government.

The law aims to break the cycle of smoking for the next generation and save National Health Service resources by reducing smoking-related illnesses. From January 1, 2027, the legal age for tobacco sales, currently 18, will increase by one year every year.

“The headline ‘smoke-free generation’ sales ban misses the critical smoking problem.”

But critics say the government is overestimating the scope of that measure to improve public health. 

“The headline ‘smoke-free generation’ sales ban misses the critical smoking problem,”  British tobacco harm reduction advocate Clive Bates, of Counterfactual Consulting, told Filter.

He explained that young adults in the UK are already smoking much less, with the help of  smoke-free nicotine alternatives. Those aged 18-24 have seen the biggest reduction in smoking prevalence since 2011. The people that need the most help in quitting, he said, are “older adults stuck on smoking.”

It should also be noted that for people born after 2008 who do choose to smoke, the fact they won’t be able to buy cigarettes legally doesn’t mean they won’t be able to buy them at all.

Before the gradual prohibition is enacted, close to 6 billion illegally purchased cigarettes are smoked in the UK each year—just over a quarter of the total market. This costs the government over £3 billion annually in lost tax revenues. Experiences with many other drugs have shown that bans don’t eradicate demand, and unregulated vendors have little incentive to ask for ID.

It seems strange that in pursuit of its “smoke-free” goal, the UK government doesn’t look more closely at the only country to have accomplished this. Sweden has driven smoking below the 5 percent threshold not by banning cigarettes, but by allowing the availability of attractive, flavored safer alternatives—snus and pouches, in that country’s case—and using taxation levels to incentivize switching. It’s the carrot rather than the stick.

“The bill does nothing for public health and is likely to cause more death and disease than it prevents.”

In the UK, vapes are the dominant safer nicotine products. A 2024 national survey showed that just over half of British adults who managed to quit smoking in recent years used vapes to do so.

But far from embracing this, the new law restricts the promotion of vapes and “provides ministers with powers to regulate the flavors, packaging and display of all vapes and other nicotine products, as well as powers to amend and update product standards.”

Advocates say it’s nonsensical to strive for a smoke-free UK by clamping down on products that are helping people to quit cigarettes in large numbers.

Bates called the anti-vape measures “spiteful” and “petty,” saying they will “cause harm to the older adults who most need encouragement to switch from smoking to vaping.”

Altogether, “The bill does nothing for public health and is likely to cause more death and disease than it prevents,” he said.

“The real issue isn’t the bill itself, it’s the power it hands ministers.”

The extent to which new powers to make vapes less visible and attractive will be used has yet to be seen, however, noted Mark Oates, director of the consumer advocacy group We Vape, who also worries about the impact on smoking rates.

“The real issue isn’t the bill itself, it’s the power it hands ministers,” Oates told Filter. “Secondary legislation will decide whether vaping continues to displace smoking or is artificially constrained.”

Flavor bans and other excessive restrictions will not result in “abstinence,” Oates said, but will migrate people back to cigarettes, whether or not they can purchase them legally.

Equivalent behavior has already been evident following the ban on disposable vapes in June 2025; demand remained, and many consumers continued buying them illegally.

Though the UK established itself as a world leader in tobacco harm reduction with a landmark review on relative risk, the groundbreaking “swap to stop” scheme and sensible advice from health authorities, it’s been a different story in the most recent years, amid growing media and political pushback.

With details of new potential restrictions not yet known, Oates remains hopeful. “If regulation remains proportionate, the shift to lower-risk nicotine will continue,” he said.

However, “If it becomes overly restrictive, you don’t eliminate demand, you redirect it. The trajectory then depends less on consumer behavior and more on whether policy aligns with harm reduction or aligns against it.”

“The health effect of any policy is dominated by its impact on smoking. In this case, we have anti-smoking measures that will do little to reduce it and anti-vape measures that are likely to increase it.”

The new law really is a new frontier, and scientists will be monitoring any resulting trends.

“What is important now is that we track what actually happens once the measures are implemented, especially given that it remains unclear exactly which levers will be pulled through secondary legislation,” Dr. Harry Tattan-Birch, a researcher at University College London’s Department of Behavioural Science and Health, told Filter.

There will be a lot of interest, he said, in how a bill aimed at reducing smoke and youth uptake of nicotine products will affect patterns of smoking, vaping and other nicotine products in reality over time.

“Our team at UCL will be closely monitoring these changes using population data to understand what impact each specific policy has,” Tattan-Birch said.

Bates remains skeptical. “The health effect of any tobacco or nicotine policy is dominated by its impact on smoking,” he said.

“In this case, we have anti-smoking measures that will do little to reduce smoking and anti-vape measures that are likely to increase it,” Bates concluded. “I don’t understand why anyone is cheering.”

Photograph (cropped) by Global State of Tobacco Harm Reduction via Flickr/Public Domain

The post Banning Cigarettes, Threatening Vapes: A New UK Landscape appeared first on Filter.

The European Commission, the European Union’s executive branch, published the report on April 1, as an evaluation of EU tobacco control under the Tobacco Products Directive. It duly determined that EU rules had significantly contributed to a decline in smoking.

“Since 2012, smoking rates in the EU have fallen from 28% to 24% of the population, with an even sharper decline among young people,” stated a press release. “Tobacco-related deaths have also decreased substantially, reflecting the positive impact of stricter rules on product regulation, advertising bans and health warnings.”

“It trumpets a meager reduction in smoking prevalence as a triumph, and disingenuously claims that all the credit is due to traditional tobacco policies.”

Martin Cullip, a British tobacco harm reduction advocate, called the report “an embarrassing document for the EU.”

“It trumpets a meager reduction in smoking prevalence, from 28 percent to 24 percent since 2012, as a triumph, and disingenuously claims that all the credit is due to traditional tobacco policies,” he told Filter.

For comparison, Cullip pointed to the smoking rate in Britain: Over the same time period, it fell from 20 percent to 9 percent, as health authorities recognized nicotine vapes as a safer alternative and millions switched. In Sweden meanwhile, easy access to oral snus saw the smoking rate plummet from 12 percent to below the 5 percent “smoke-free” threshold.

“Considering there are tens of millions of users of vapes, heated tobacco and pouches in the EU, only a fool could deny that they have had an impact,” Cullip said—even if restrictions and bans, including the EU-wide snus ban, have blunted that impact.

The report raised the familiar specter of safer nicotine products being a “gateway to nicotine addiction” for youth—despite the mounting evidence against this.

Far from emphasizing the ability of safer nicotine products to reduce smoking, the report flagged them for introducing “new public health concerns” to which the EU’s regulatory framework must respond—presumably with more bans and restrictions.

And the report raised the familiar specter of safer nicotine products being a “gateway to nicotine addiction” for youth—despite the mounting evidence against this gateway theory, including the experiences of countries where youth vaping has dramatically declined even as vapes continue to drive down adult smoking rates and youth smoke less than ever.

Dr. Konstantinos Farsalinos, a cardiologist and research fellow at the Onassis Cardiac Surgery Center in Athens, Greece, noted that the report failed to acknowledge any of the benefits to people switching from cigarettes to safer nicotine products. The EU, he said, has been obstinate in treating tobacco harm reduction as a threat when it should view it as an “ally.” 

“Tobacco harm reduction is a valuable tool in reducing smoking, and I hope the EU will soon realize this and adjust its approach and regulatory framework,” he told Filter.

“The Commission had committed to basing its decisions on solid scientific evidence, yet its own report … appears to have been drafted while systematically ignoring that science.”

Dr. Fabio Beatrice, scientific director of the Italy-based Medical Observatory of Harm Reduction, criticized the report’s “fragile” and superficial methodology, which disregarded high-quality evidence like the latest Cochrane review that confirmed the effectiveness of vapes for smoking cessation.

“The Commission had committed to basing its decisions on solid scientific evidence, yet its own Evaluation Report … appears to have been drafted while systematically ignoring that science,” he told Brussels Signal.

The report’s apparent bias should be viewed in the context of its authorship. The European Commission awarded the €3 million evaluation contract to the sole bidder—a consortium of groups including, among others, the European Network on Smoking Prevention and Vital Strategies. The former has received funding from Bloomberg Philanthropies and the latter is entirely funded by Michael Bloomberg, the anti-vaping US billionaire. Bloomberg-funded groups like Vital Strategies have a history of opposing tobacco harm reduction and pushing for bans around the world. 

It would have been a big surprise if such authors had not attacked safer nicotine products in their report for the EU. Their conclusions could carry a heavy price for Europeans who smoke.

“As usual, the Commission is careless to the point of negligence with the health of more than 100 million Europeans.”

“The evaluation report doesn’t evaluate anything in a way that would be useful to policymakers in the member states and legislators in the European Parliament,” British tobacco harm reduction advocate Clive Bates, of Counterfactual Consulting, told Filter.

The report not only failed to admit the very slow decline in EU smoking rates, he said, but demonstrated no understanding of how safer nicotine products can rapidly replace cigarettes in a “massive market for nicotine that involves one in four European adults.”

“As usual, the Commission is careless to the point of negligence with the health of more than 100 million Europeans, thousands of small businesses, the rise of organized crime, and the credibility of the European Union,” Bates said. “A reckoning is inevitable.”

Photograph by Lindsay Fox via Flickr/Creative Commons 2.0

The post “Embarrassing”—Experts Slam EU’s Self-Congratulatory Smoking Report appeared first on Filter.

He started smoking at the age of 13—and continued for 30 years. During that time, he repeatedly tried to quit, using nicotine patches, gum and vapes.

“They didn’t really do anything for me,” he told Filter. “I didn’t care for vaping at all.”

Luckily, there was another option available. And this one helped him to stay off cigarettes long-term.

“As heated tobacco products can somewhat replicate the smoking experience, I found it much more suitable,” Sweeney said. “HTP is much closer to smoking, and I found it much more satisfying than the other products.”

Sweeney isn’t alone in that preference, or that experience. Although only 1.2 percent of Ireland’s adult population currently use HTP (compared to 11.2 percent using vapes), that still equates to almost 50,000 people who could otherwise be smoking.

“They felt closer to my usual habits, so for me, the switch was easier and more natural.”

Felisia Porcaro, who lives in Italy, quit smoking the same way. “I had looked at other alternatives, but HTPs worked best for me,” she told Filter. Just like Sweeney, she cited the products’ ability to mimic smoking as the key factor.

“They felt closer to my usual habits, so for me, the switch was easier and more natural,” she said.

Unlike vapes or nicotine pouches, heated tobacco products actually involve tobacco. You insert a stick of tobacco into an electronic device, which heats it up. Critically, the tobacco is not burned—the devices have also been known as “heat not burn” products—just heated enough to emit an aerosol containing nicotine, which is then inhaled. The absence of combustion is why HTP use is harm reduction.

Other consumers find further advantages. “For me, it wasn’t so much the familiarity of a tobacco stick,” Lindsay Reese, who lives in Switzerland and quit cigarettes with HTP, told Filter. “It was the finite experience.”

“Vapes keep going and going,” she explained, “but when the consumable is a stick it is more like… Ok, I’m going to take these five minutes to relax, as opposed to hitting a vape every 10 minutes.”

Despite their obvious appeal to some and their availability in an estimated 69 countries, it can feel to people in the Western world that HTP have not matched the popularity of vapes and pouches. In truth, there is a clear global divide: HTP have taken off in parts of East Asia, but much less so in Europe and North America.

“This creates an information gap. Adults should have access to clear, balanced and evidence-based information on all alternatives to combustible cigarettes.”

Francesco Luongo is the president of Heated Community Hub, a consumer advocacy group. He thinks one big reason for the global mismatch is a question of public consciousness in the West.

Vapes “have been more visible in the media, in public policy debates and in broader consumer awareness,” he told Filter. “Heated tobacco products, by contrast, have often remained in the background, even though they are part of the wider tobacco harm reduction discussion.”

Another factor, Luongo continued, is that the products tend to be viewed through an industry lens. The high costs and logistics of production, including the required research, mean that the HTP market is completely dominated by tobacco companies with deep enough pockets. While that doesn’t reduce the inherent validity of HTP as a harm reduction option, it does mean bad PR.

“From our perspective, this creates an information gap,” Luongo explained. “Adults should have access to clear, balanced and evidence-based information on all alternatives to combustible cigarettes, including HTPs.”

Another drawback of the current HTP landscape is that each brand has its own tobacco sticks, which aren’t compatible with other brands’ devices. This helps keep costs for consumers higher.

Though Sweeney is continuing to use the product that enabled him to quit cigarettes, he does consider this a major negative. “The main problem I have with them is the cost of replacement sticks,” he said. “More people would probably use them as a replacement for smoking if the cost was lower.”

“Many people still do not know the difference between cigarettes and heated tobacco products, and this creates confusion and prejudice.”

In Italy, 4.5 percent of the adult population use HTP—making it a rare European country where they’ve achieved that kind of popularity. But even there, Porcaro said, public information about the products “is still quite limited.”

She credited the internet, retailers and the tobacco harm reduction community for giving her the knowledge to try replacing cigarettes with HTP. But too many remain unaware of this method of reducing their exposure to health risks.

“I think many people still do not know the difference between cigarettes and heated tobacco products, and this creates confusion and prejudice,” Porcaro said.

On top of the general climate of misinformation around tobacco harm reduction, the fact that many studies on the efficacy of HTP are industry-led may add to public skepticism. However, since 2024, over 400 independent studies that “support their use as a safer alternative to smoking” have been published, according to a briefing paper by the Global State of Tobacco Harm Reduction.

Such assessments are complex, and experts are often reluctant to put a simple figure on relative risk, given toxic politics and many unknowns. But there is a consensus that HTP use is substantially safer than smoking. One widely cited 2022 study indicates that it’s about 20 times less risky.

Among those calling for more independent research is Dr. Harry Tattan-Birch, a researcher at University College London’s Department of Behavioural Science and Health. He has been involved in studies looking at the effects of HTP use.

“Heated tobacco products are likely to be a lot less harmful than cigarettes, but probably more harmful than vaping.”

“Based on a selection of randomized controlled trials, we found moderate-certainty evidence that people using heated tobacco products had lower exposure to many toxicants and carcinogens than cigarette smokers,” he told Filter.

Tattan-Birch added that this was “unsurprising,” since the products don’t burn tobacco. “Combustion is the main source of many harmful chemicals in cigarette smoke.”

Burning at 800 degrees Celsius, cigarettes produce over 4,000 chemicals in the smoke, including at least 70 known carcinogens. HTP devices heat tobacco to around 350 °C, producing fewer harmful chemicals—though not none.

Tattan-Birch said exposure from HTP use was higher than when people stop using tobacco altogether, and generally higher than levels seen with vaping.

“Taken together,” he said, the evidence “suggests heated tobacco products are likely to be a lot less harmful than cigarettes, but probably more harmful than vaping, and of course more harmful than not using nicotine or tobacco at all.”

People deserve to know all that as they weigh their choices. But as well as the relative risks of use, another factor is how effectively a tobacco harm reduction product can shift people away from the most dangerous option—cigarettes—at a population level.

Researchers found that from 2016-2019, immediately after HTP were first marketed in Japan, the decline in cigarette sales was five times faster.

One country above all is the leading example to show that HTP can be very effective indeed.

Japan, where the smoking rate among men aged 20-29 once stood at 79 percent in groups of men aged between 20-29, has halved its smoking rate in just a decade—a globally unprecedented achievement.

This has largely been attributed to the soaring popularity of HTP. While Japan’s smoking rate was already falling, researchers found that from 2016-2019, immediately after HTP were first marketed in the country, the decline in cigarette sales was five times faster than in the previous few years.

Other countries have also recognized the potential. Even the United States Food and Drug Administration, not known as a tobacco harm reduction champion, first authorized some HTP to be marketed as “modified risk” back in 2020. In 2023, the FDA authorized three new HTP, reasoning that, “the net population-level benefits to adult smokers outweigh the risks to youth.” 

In 2024, New Zealand decided to halve its tax on HTP in a bid to encourage more people to quit smoking. The country had already accelerated smoking cessation by embracing vaping as harm reduction, and now has one of the world’s lowest smoking rates. But as a health minister said at the time, “Vaping does not work for everyone,” so they also wanted to make alternatives more accessible.

“If they help some smokers move away from combustible cigarettes, they deserve to be part of the conversation.”

There’s always a backlash somewhere, and the United Kingdom is currently looking to limit HTP use by banning it from various public spaces. Outside hospitals, vaping will be permitted but HTP use will not—indicating a dismissal of the latter’s harm reduction role.

Dr. Riccardo Polosa, a professor of internal medicine at the University of Catania, Italy, said the proposed ban “muddled the message” that HTP are smoking cessation tools, not cigarettes.

“Quite frankly, I don’t see the urgency here as heated tobacco use in the UK is well under 1 percent of adults,” he told Filter. “Use is largely concentrated among people who already smoke or smoked in the recent past, so the ban looks like a solution in search of a problem.”

“It is also worth mentioning that, although not risk-free, HTPs expose users and bystanders to much lower levels of harmful compounds than cigarette smoke,” Polosa continued. “So banning them in open-air spaces around hospitals is unlikely to deliver any meaningful health gain.”

Helping people quit smoking, however, is about the most meaningful health gain imaginable. And when HTP work for many and are much safer than cigarettes, they fully merit being on a menu varied enough to save as many lives as possible.

“The key point is adult smokers should have access to different alternatives and to correct information, so they can find the option that works best for them,” Luongo said. “If HTPs help some smokers move away from combustible cigarettes, they deserve to be part of the conversation.”

Correction, March 25: The original version of this article misspelled Felisia Porcaro’s name.

Photograph by the Global State of Tobacco Harm Reduction, via Flickr/Creative Commons 2.0

The Influence Foundation, which operates Filter, has received grants and donations from Knowledge-Action-Change, which publishes the Global State of Tobacco Harm Reduction. Both The Influence Foundation and the Center of Excellence for the Acceleration of Harm Reduction at the University of Catania, founded by Dr. Polosa, received grants from Global Action to End Smoking. Filter’s Editorial Independence Policy applies.

The post Heated Tobacco Products Shouldn’t Be a Harm Reduction Afterthought appeared first on Filter.

The latest example is from the annual National Youth Tobacco Survey (NYTS) in the United States. The 2025 results, released on March 4, show that youth use of tobacco and nicotine products continues to decline.

Overall tobacco use among middle and high school students fell again in 2025, dropping from 8.1 percent in 2024 to 7.5 percent. Youth vaping declined for the third consecutive year, plummeting to 5.2 percent, the lowest level in a decade. Other nicotine products show similar trends; nicotine pouch use edged down slightly from 1.8 percent to 1.7 percent. Cigarette smoking remained extremely low and unchanged, at just 1.4 percent.

If we look beyond experimentation and focus on regular use, the numbers become even more striking. Daily or near-daily use is rare across all products. Among high school students, only 2.09 percent report regular nicotine vaping, 0.39 percent report regular nicotine pouch use, and just 0.23 percent report smoking cigarettes regularly. Across middle and high school students combined, daily smoking sits at 0.22 percent.

In other words, cigarette smoking among young people in the United States has all but disappeared.

Despite the encouraging data, there was no major press release. Compare that lack of fanfare to the years when youth vaping was on the rise.

Despite the encouraging data, there was no major press release highlighting the findings from the Food and Drug Administration or the Centers for Disease Control and Prevention (CDC), the agencies that produce the NYTS.

Compare that lack of fanfare to the years when US youth vaping, which peaked in 2019, was on the rise. The outcry then was relentless—even though youth smoking, the real health threat, not only continued to decline during this period but was found by some researchers to be declining faster than before.

Despite what’s happening in the real world, influential public health bodies continue to repeat claims about a “gateway” from vaping into smoking.

The World Health Organization still warns of “children and adolescents going on to use smoked products following experimentation with [vapes].” The CDC’s website continues to tell the public that “youth who vape may also be more likely to smoke cigarettes in the future,” as do other public health organizations.

These statements are presented as though they reflect established causal evidence. But they do not.

Most research cited in support of the gateway theory relies on observational studies showing that young people who try vaping are statistically more likely to report later smoking. This is a classic example of correlation being mistaken for causation.

If vaping were a “gateway” into smoking, we would expect youth smoking to rise as vaping becomes more common. The opposite has happened.

Young people who experiment with one risky behavior are often more likely to experiment with others. The concept is known as “common liability,” whether it’s a purely a social phenomenon or has a genetic component. A teenager predisposed toward risk-taking might well try alcohol, cannabis, vaping and cigarettes at different times. Observational studies can document this, but cannot easily disentangle the reasons.

What matters most is the population-level trend. If vaping were truly acting as a gateway into smoking, we would expect youth smoking rates to rise as vaping becomes more common. Instead, the opposite has happened almost everywhere.

In the United States, youth smoking has fallen to historically unprecedented levels during the same period that vaping emerged. The latest NYTS data simply extend a pattern that has been visible for more than a decade: Experimentation with new nicotine products may occur, but smoking continues to collapse.

That pattern is difficult to reconcile with the gateway narrative. Indeed, if anything, the data are more consistent with a theory that alternative nicotine products may be diverting young experimenters away from cigarettes.

Yet instead of acknowledging this, many public health authorities continue to frame vaping as a threat to youth smoking prevention, thereby misleading the public.

Recognizing this success requires a willingness to look at the data as they are, rather than as some might wish them to be.

Good public health policy depends on honest communication about evidence. When institutions continue to repeat claims that are not supported by real-world population data, they risk undermining their own credibility.

The latest NYTS results should be cause for cautious optimism, even celebration. Youth smoking is now extraordinarily rare. Regular nicotine use among adolescents is limited. And across most categories, usage is declining.

This represents one of the most significant public health successes of recent decades. But recognizing that success requires a willingness to look at the data as they are, rather than as some might wish them to be.

If public health authorities want to maintain public trust, it is long past time that they updated their messaging. The facts are increasingly clear. Youth smoking is collapsing and the long-predicted vaping “gateway” into smoking remains nowhere to be seen.

Photograph by Matthew MacQuarrie via Unsplash

The post The Youth-Smoking Collapse Nobody Wants to Talk About appeared first on Filter.

The American Lung Association (ALA) recently published its 2026 State of Tobacco Control report, which awards Wisconsin a series of failing grades. These include “F” grades for tobacco prevention funding, access to cessation services and “Ending the Sale of All Flavored Tobacco Products”—plus a “D” for “Level of State Tobacco Taxes.”

The ALA’s main recommendations for the state include: “Raise Wisconsin’s legal age of sale for tobacco products to 21” and “Create tax parity between e-cigarettes and cigarettes.”

Molly Collins, the ALA’s Wisconsin advocacy director, told Wisconsin Public Radio that the grades are based on whether states are implementing policies “proven to prevent or reduce tobacco use and save lives.”

She went on to name counseling and nicotine replacement therapy (NRT) as things that aid smoking cessation. These options are offered by the Wisconsin Tobacco Quit Line, funded by the Wisconsin Department of Health Services.

What Collins didn’t mention—and what the Quit Line doesn’t offer—are other safer nicotine products that have been proven more effective at helping people quit smoking.

Why are the ALA and Wisconsin’s health department promoting one type of safer nicotine product—NRT—while seeking to reduce access to others that do a better job?

The prestigious Cochrane review, for instance, found “high certainty” evidence that “quit rates were higher in people randomized to nicotine [vapes] than in those randomized to nicotine replacement therapy.”

Real-world experiences match that. Vapes are the most popular and effective smoking-cessation method in the United States and the United Kingdom. The contrast in smoking-cessation trajectories between New Zealand, where vapes are widely available, and Australia, where they are heavily restricted, tells the same story.

Many people who smoked find vapes work for them as substitutes because the inhalation and hand-to-mouth action mimic smoking, while the flavors are enjoyable.

Meanwhile, widespread uptake of nicotine pouches and snus, also available in a range of flavors, has enabled Sweden to achieve the world’s lowest smoking rate.

So why are the ALA and Wisconsin’s health department promoting one type of safer nicotine product—NRT—while seeking to reduce access to others that do a better job?

“We know that preventing kids from trying these products has a significant impact on how many go on to develop a lifelong addiction,” Collins told Filter.

The health department did not respond to Filter’s request for comment. But when Filter put it to Collins, she replied that, “vapes and nicotine pouches are engineered to be highly addictive, easy to start and difficult to quit.”

“We know that preventing kids from trying these products has a significant impact on how many go on to develop a lifelong addiction,” she added.

This implies preventing “addiction”—a dubious concept when applied to activities without severe harms—is important enough to weigh against the priority of saving lives.

Many public health bodies, in the US and globally, have increasingly emphasized youth and addiction—rather than their original missions of reducing smoking-related disease and death—to justify portraying safer nicotine options as public health threats.

“They are profoundly challenged by safer products,” advocate Clive Bates recently commented; “after all, what is the point of tobacco control if there is no harm, and therefore no reason to control things? It would be like coffee control. So they are determined to find harm wherever they look.”

In line with its priorities, the ALA is urging Wisconsin to tax vapes as heavily as it taxes cigarettes. Harm reductionists and researchers have condemned such measures for discouraging people from switching to safer options.

“Wisconsin should use taxation as a way to incentivize smokers to use e-cigarettes rather than real ones.”

“Wisconsin should use taxation as a way to incentivize smokers to use e-cigarettes rather than real ones,” Michael Siegel, a professor of public health and community medicine at the Tufts University School of Medicine, told Filter. Siegel fears people who vape will return to smoking if Wisconsin follows the ALA’s advice.

Neighboring Minnesota provides a grim template. In 2010, it became the first state in the country to tax vapes. Research suggests that from 2013-2015, the tax dissuaded over 32,000 Minnesotans who smoke from quitting.

“If ALA truly means what it says when it argues that Wisconsin should invest in strategies that work to help smokers quit, then it should actually be promotion of e-cigarettes in addition to nicotine replacement therapy,” Siegel said. “If Wisconsin invests in anything, it should be programs that encourage smokers to quit by any means they can, including by switching to vaping.”

Other tobacco harm reduction proponents note that just allowing adults to make their own decisions, without trying to restrict and discourage certain choices, would be a big improvement on Wisconsin’s status quo.

“The fastest way to accelerate progress would be to simply allow responsibly marketed, lower-risk alternatives to remain available to adults,” Gregory Conley, a longtime THR advocate, told Filter.

“Instead,” he continued, “the state moved in the opposite direction by passing a PMTA registry that threatens retailers with $1,000 per-day fines for selling popular safer nicotine products.”

A bill implemented in Wisconsin in 2025 banned sales of vapes that are not FDA-authorized. Like other PMTA registry bills around the US,  this greatly minimized the range of legally available flavors, which are key to helping people quit cigarettes.

One of the ALA’s grading measures, of course, is “Ending the Sale of All Flavored Tobacco Products,” which in this parlance includes vapes.

“In recent years,” Conley said, the ALA “has focused less on helping smokers switch to lower-risk options and more on taxing and restricting those alternatives.”

Another of the ALA’s recommendations for Wisconsin is making 21 the legal minimum age for all “tobacco products” sales. State law currently has it at 18, but this is superseded by the federal minimum age of 21.

“Tobacco use almost always begins during adolescence and young adulthood. About 95 percent of adult smokers began smoking before they turned 21,” Collins told Filter, saying that raising Wisconsin’s legal age would “curb tobacco use.”

She acknowledged that the federal minimum age, established by a bill President Donald Trump signed in 2019, means it’s “already illegal” to “sell or distribute tobacco products to people under the age of 21 in Wisconsin.”

“However, aligning the state’s sales age for tobacco products, including e-cigarettes, to 21 to match federal law would be beneficial and allow our local law enforcement to address problem retailers who are selling to underage people,” Collins said.

Conley sees this as a red herring; while Wisconsin has a high rate of high schoolers using tobacco, recent data show a reduction in sales. He said compliance data suggest the vast majority of Wisconsin retailers are following federal law. “In other words, access restrictions are not the main issue.”

The American Lung Association has a record of opposing safer nicotine products and spreading misinformation about them, so its anti-vape recommendations for Wisconsin are unsurprising. That doesn’t mean they should be normalized.

Conley commented that the ALA’s annual grades “function more as advocacy tools than neutral analysis.”

“In recent years,” he said, “the organization has focused less on helping smokers switch to lower-risk options and more on taxing and restricting those alternatives.”

Photograph by Vaping360 via Wikimedia Commons/Creative Commons 2.0

The post Wisconsin Urged to Make Smoking-Cessation Tools Less Accessible appeared first on Filter.

But amid this toxicity, the THR movement can count Clive Bates among its ranks. A kind of battle-hardened rock star of the field, the British advocate is a formidable operator; without representing any major organization, his no-nonsense attitude, fierce intelligence and wealth of knowledge translate to serious clout.

It’s his energy, too. If you follow THR advocacy, you soon become aware that Bates is everywhere. He’s emailing groups of scientists, consumers and policy wonks to scrutinize the latest studies and global developments. He’s writing policy papers. He’s delivering pithy lines to hapless media interviewers and distilling arguments around the world, debating in Europe or roasting FDA officials in DC.

“I am driven by deep despair and intense frustration that the opportunity to avoid millions of premature deaths is being squandered by a kind of purity cult.”

His allies—and probably also his enemies, if they admitted it—see his impact as remarkable.

“Clive is, without doubt, one of the most important voices in THR,” Dr. Arielle Selya, a behavioral scientist who collaborates with Bates in critiquing new studies, told Filter. “He is truly visionary, with a unique ability to see straight to the heart of complex topics and accurately predict—sometimes decades into the future!—how THR debates and dialogues evolve. Not only that, but Clive has an unparalleled ability to communicate complex ideas into clear and persuasive arguments that THR is plain common sense.”

David Sweanor, who chairs the advisory board of the University of Ottawa’s Centre for Health Law, Policy and Ethics, believes that this “key leader” should take significant credit for the fact that the move from cigarettes to safer alternatives is global and unstoppable, despite all the well-funded opposition.

“His marshalling of data, building of coalitions, critiques of studies and proposed policies, and extraordinary productive capacity have been critically important,” Sweanor told Filter.

Bates has for years run the influential Counterfactual blog about THR, and recently ventured onto Substack. He’s not one to suffer fools gladly, but I wanted to find out more about who he is and what drives him, so I took the plunge. Filter’s interview has been lightly edited for length and clarity.  

Kiran Sidhu: How would you describe your current role in THR?

Clive Bates: To be honest, I wish I had no role at all. Tobacco policy is really a simple issue: We have much safer products that will remove most or all of the harms arising from nicotine use, which are mostly caused by smoking tobacco. That’s basically it. It’s over. It’s just a matter of what barriers are placed in the way of a wholesale migration from high-risk to low-risk nicotine use.

So I am driven by deep despair and intense frustration that the opportunity to avoid millions of premature deaths and tens of millions of years of human suffering is being squandered by a kind of weird ideology or purity cult that is obstructing this migration.

The resistance to the simple, obvious idea that much safer products are much better is truly extraordinary. The breadth, depth and ruthless arrogance of the opposition can be overwhelming. So I try to be a beacon for sound science and rational policymaking in the public interest.

I stand for the pragmatism of the problem-solvers and the people who approach this issue with empathy and humility (even if I can sometimes fall short on that myself). I try to present credible policy analysis and engage with the science in the way a policymaker should, grappling with risks, trade-offs, competing goals and unintended consequences.

I coordinate a few networks based on Google Groups listservs. I use conferences to draw my views together into a narrative that informs and inspires others to the best of my abilities. I try to speak to everyone involved and understand their worldview, and that includes tobacco and nicotine companies, but it has become almost impossible to engage the ideologues as they pursue their nicotine-free utopia. 

KS: How and why did you get involved in THR?

CB: I became involved soon after I started as director of Action on Smoking Health [ASH-UK] in 1997, having previously worked in the environmental movement for Greenpeace and others. At the time, we didn’t have the amazing range of consumer-friendly smoke-free products we have now, but we did have the basic idea: changing the way nicotine is consumed. We were thinking about possible harm reduction options with NRT and even snus. 

[Professor] Mike Russell was still very influential at the time, and all the academics who had studied under him were rising through the universities, several of whom were ASH board members. I felt it was an essential strategy and that we needed to recognise the Swedish experience and adopt a more subtle approach to smokeless tobacco, though snus was already banned in the EU by then.

In 2003, I went off to work for [Prime Minister] Tony Blair’s Strategy Unit and then a procession of senior civil service roles, but returned to tobacco harm reduction in 2013, as the mother of all battles was getting underway over the EU Tobacco Products Directive.

The picture [above] is me celebrating an epic victory for consumers on October 8, 2013, when the European Parliament rejected medical regulation for vapes.

“There are so many lessons to learn from this miserable episode, yet lessons have not been learned, and failures are being aggressively repeated for pouches.”

KS: What was the rationale behind the European Union’s 1992 ban on snus?

CB: The snus ban emerged from a moral panic about Skoal Bandits, a form of oral tobacco that arrived in the UK in the mid-1980s. The arguments would sound very familiar today: the threat to children, nicotine addiction, the industry, high risks and gateway effects.

Tobacco control activists managed to have this banned in the UK, and then the ban was adopted in the EU in 1992. Sweden did not join the EU until 1994, and one condition of its accession was that the snus ban would not apply.

Recent analysis suggests that snus results in about 3,000 avoided smoking-related deaths annually in Sweden. But since 1992, over 20 million EU citizens have died from smoking-related disease.

Suppose we had gone the opposite way and encouraged people who smoke to give it a try, instead of banning it? It is difficult to pin any serious health effects on snus; suppose we’d given people good risk information? Instead of cheering the fake success of a ban, what if tobacco control activists had pressed companies and regulators to introduce more snus brands?

Nicotine pouches could have been invented 20 years ago if the market for them had been shaped by proactive regulators and public health. There are so many lessons to learn from this miserable episode, yet lessons have not been learned, and failures are being aggressively repeated for pouches.

KS: Do your thoughts on THR still align with those of ASH-UK?

CB: ASH has devoted its energies to pressing home the UK government’s Tobacco and Vapes Bill and cheering on other anti-vaping measures, like taxes and the disposables ban. The bill imposes pointless age restrictions on adults, does nothing for the people most at risk, and promotes anti-vaping measures that will protect the cigarette trade.

It’s an incoherent mess driven by poor analysis and political posturing, and, in my opinion, likely to do more harm than good. So we probably don’t see eye-to-eye on that. I don’t see how age restrictions on people born after 2009 once they become adults while cheering on anti-vaping measures and taxes will achieve much for health.

“Bloomberg will reach the end of his days responsible for thousands, maybe millions, of deaths and untold misery.”

KS: Even though vapes have been around for 20 years or so, the disinformation surrounding them has only grown louder. Why do you think this is?

CB: The abstinence-only opponents of realistic nicotine policy need a narrative to defend their stance and to restore their own standing. They are profoundly challenged by safer products—after all, what is the point of tobacco control if there is no harm, and therefore no reason to control things? It would be like coffee control. So they are determined to find harm wherever they look.

The process is self-reinforcing. Most people like to position themselves comfortably in the middle of a consensus among their peers. But since about 2016, a range of wildly inaccurate claims has been introduced by fringe pseudo-scientists and then repeated with less and less hesitation until the wild idea becomes the norm.

The most extreme example of this would be the claim that smoke-free products are as risky or more risky than cigarettes, which now seems to be the position of the European Commission. It is now common to read scientific papers in which the comparable risk claim is taken as given, and the idea of reduced risk is dismissed as tobacco industry marketing.

KS: What is the greatest threat to the success of THR?

CB: Michael Bloomberg and his highly-funded complex of activist-academics, aggressive campaigners, fake civil society organizations and PR hacks—I refuse to call them journalists. Bloomberg will reach the end of his days responsible for thousands, maybe millions, of deaths and untold misery.

A close second would be the politicians. bureaucrats, media, and health organizations that have been so comprehensively played by the rhetoric and money of this overconfident, out-of-touch, elitist New York financial services billionaire.

“We need to get away from THR as a kind of pimped-up smoking cessation treatment, and into the idea that there is going to be a persistent market for nicotine.”

KS: How do you see the future of THR? 

CB: One word: inevitable. It is a process of innovation and creative destruction in which the cigarette will become obsolete or a niche product in a diverse market of low-risk nicotine products. It is inevitable because that is what consumers want, it’s better for health and welfare, and a large economic opportunity.

The main questions are the extent to which tobacco control and public health activism slow down this migration, and whether they introduce prohibitions, restrictions and taxes that mean these products are supplied through illicit trade.

We need to get away from THR as a kind of pimped-up smoking cessation treatment, and into the idea that there is going to be a persistent market for the psychoactive substance nicotine. The job of public health regulation is to ensure that demand is met with high-quality, reliable and acceptably safe products in a lawful regulated market.  

Photograph courtesy of Clive Bates

The Influence Foundation, which operates Filter, received an unrestricted grant from the Sweanor Family Fund at the Ottawa Community Foundation in 2025. Dr. Selya is an employee of Pinney Associates, Inc. which consults to Juul Labs and Philip Morris International (PMI) on non-combustible nicotine products. She also individually provides consulting services on behavioral science to the Center of Excellence for the Acceleration of Harm Reduction (CoEHAR) through ECLAT Srl, which received funding from the Foundation for a Smoke-Free World (now Global Action to End Smoking). Her commentary in this article is her own and these funders had no involvement. The Influence Foundation has received unrestricted grants from Juul Labs and PMI, as well as grants from Global Action to End Smoking. Joe Gitchell, the CEO of Pinney Associates, has made personal donations to The Influence Foundation. Filter’s Editorial Independence Policy applies.

The post “One Word: Inevitable”—Tobacco Harm Reduction’s Heavy Hitter appeared first on Filter.

Most of those people in my life smoked—a significant risk factor for many cancers besides the most obvious ones. Only a couple of them survived cancer, which means I’ve become familiar with premature death and the long-term emotional and financial strains families are left with.

So when World Cancer Day takes place on February 4 each year, it isn’t a meaningless awareness campaign to me. It’s personal. 

As I watch entities like the World Health Organization (WHO) mark World Cancer Day, despite willfully spreading misinformation about things that can reduce cancer risk, I find myself lost in dark anger. I know that more people will die because they don’t know the truth.

Public health organizations’ messaging should make it easier, not harder, for people to reduce their risk of early death.

People need to know that it is the smoke from combustible tobacco, not the nicotine, that greatly increases cancer risk. People need to know that quitting smoking at any age, by any means, has health benefits. 

Public health organizations’ messaging and policy recommendations should make it easier, not harder, for people to reduce their risk of early death. The WHO’s constant blurring of a crucial distinction—between deadly combustible tobacco and the safer nicotine products that have helped millions quit smoking—does the opposite. 

A recent example comes from the WHO’s International Agency for Research on Cancer (IARC) and the fifth edition of its European Code Against Cancer. Released to the medical community in late 2025, it’s due to be presented to the public this World Cancer Day. It contains drastic changes in its messaging about smoking and nicotine. 

In the European Code’s 2014 fourth edition, the tobacco guidance included the basic recommendation of “Do not smoke. Do not use any form of tobacco.” But what made it extra helpful was that it anticipated questions people might have and answered them in plain language. It accurately explained that it’s not nicotine that causes cancer, but exposure to carcinogens in combustible tobacco.

The fourth edition also addressed nicotine vaping with a degree of nuance. While stating that “Long term safety is unknown at present” and raising concerns about potential youth use, it said that vaping “is expected to have a lower risk of disease and death than tobacco smoking,” due to the absence of combustion. If people switch to vapes, it added, that has “the potential to reduce the enormous burden of disease and death caused by tobacco smoking.”

This is not some minor editorial adjustment. It fundamentally changes what the public will understand.

Compare that with what the European Code’s fifth edition emphasizes. Its headline guidance on smoking is short and misleading: “Do not smoke. Do not use any form of tobacco or vaping products. If you smoke, you should quit.” 

Smoke and vapor are now treated as if they belong under the same warning label, without the explanatory details previously provided. 

This is not some minor editorial adjustment. It fundamentally changes what the public will understand. When you remove the nuance and the “why,” and keep only the “don’t,” people will be led to believe that vaping and smoking are equally harmful, which is unequivocally false.

It doesn’t stop at individual advice. The fifth edition policy brief calls for measures such as heavy taxation—”All tobacco products should be taxed in a comparable way as appropriate, in particular where the risk of substitution exists.”—and steps to “restrict the availability and accessibility of tobacco products.” And it explicitly says that policymakers should “Extend such regulations to apply to all tobacco products, electronic cigarettes and all novel tobacco and nicotine-containing products.” 

The document states that products like vapes and pouches are “relatively new,” and that “further research is needed to understand their potential links to cancer.” Yet it doesn’t mention that no cancer link has been proven to date, despite the best efforts of some researchers. It completely ignores these products’ role in smoking cessation. It just goes ahead and includes them in its blanket policy recommendations.   

When institutions conflate nicotine and smoking, they harden confusion into common knowledge; myths become facts. One of the most damaging misperceptions I’ve seen, widespread among the public and among clinicians, is the belief that nicotine causes cancer. The consequence is that some people will continue to smoke instead of trying a much safer alternative.

If the WHO were to include people who use nicotine in the conversation, it would find it harder to ignore our experiences and our needs.

The WHO’s framing of harm reduction communication adds another layer of confusion by arguing that nicotine companies “cloak” their marketing in “the public health language of harm reduction.”

Regardless of what companies do, harm reduction is not a tobacco-industry invention. It’s a longstanding public health framework that the WHO supports in other areas of drug use. This framework acknowledges that drug use will happen, but that public health efforts can still reduce death and disease by making it safer. The public deserves balance: skepticism about marketing claims, paired with truthful risk communication that keeps the focus on whatever helps save the lives of people who smoke.

Harm reduction is also a movement—led by and centered on the agency of directly impacted people. If the WHO were to include people who use nicotine in the conversation, it would find it harder to ignore our experiences and our needs. 

The WHO is already aware, but chooses to obscure, that modern vapor products were invented in 2003 by Hon Lik—a pharmacist who was seeking to quit smoking after his father, who also smoked, was diagnosed with lung cancer. Legacy tobacco companies did not enter the vapor market until years later, long after people who smoke had been taking matters into their own hands, building and improving vaping devices, and spreading the word in an inspired grassroots effort. To equate tobacco harm reduction with Big Tobacco is no more valid than equating opioid harm reduction with the Pharma companies that make opioids and medications for opioid use disorder.

The goal should not be a moralistic crusade to make people do what the WHO wants. The goal should be fewer funerals of the kind I’ve attended far too often.

Unfortunately, the perversion of harm reduction messaging and the truth is a pattern the WHO has repeated, growing more brazen over the years. 

World Cancer Day is not the time to hide the truth behind a mask of moral outrage. It’s time to communicate risk precisely. That means naming the core cancer hazard clearly: smoking. It means being clear that nicotine is associated with dependency, but not with cancer. And it means recognizing and learning from the lived experience of people whose health and lives have been transformed by switching to safer nicotine.

The goal should not be a moralistic crusade to make people do what the WHO wants. The goal should be fewer funerals of the kind I’ve attended far too often.

Photograph (adapted) by Klaus Nielsen via Pexels

The post Shameful Changes in the WHO’s European Code Against Cancer appeared first on Filter.

Advocates in Canada—who successfully fought to push back a prospective federal flavor ban in 2025—have a compelling new resource of their own, after the November publication of a study concerning Canadian jurisdictions that have imposed bans.

“This is the first study outside the US to show that banning vape flavors causes a direct, casual increase in cigarette sales,” Michael Pesko, one of its authors, told Filter.

A health economist and professor of economics at the University of Missouri, Pesko said the study is critical because it shows that even in countries with very strict tobacco laws, flavor bans backfire.

Canada enforces a raft of tobacco control measures including a plain-packaging mandate and prohibiting most forms of tobacco advertising and promotion. But these efforts to make smoking less attractive failed to prevent a surge in cigarette sales once vaping was made less attractive.

“By banning vape flavors, we saw cigarette sales jump by nearly 10 percent.”

The researchers analyzed 2018-2023 sales data, mostly from gas stations and convenience stores. They used a stacked DID model (difference-in-differences) to compare outcomes in provinces with vape-flavor restrictions versus those without.

Provinces and territories that have imposed near-total flavor bans in the name of preventing youth use include New Brunswick, Northwest Territories, Nova Scotia, Nunavut, Prince Edward Island and Quebec.

“Our data shows vapes and cigarettes are two sides of the same coin: When one becomes harder to get, people flip to the other,” Pesko said.”By banning vape flavors, we saw cigarette sales jump by nearly 10 percent.”

These findings are to be expected, said David Sweanor, an industry expert who chairs the advisory board of the Centre for Health Law, Policy and Ethics at the University of Ottawa.

Evidence of a substitution effect has long been established, he noted—even though it’s significant to demonstrate, as the researchers put it, that “patterns of substitution between e-cigarettes and cigarettes are generalizable across countries with different tobacco regulatory strengths.”

“This should be no more surprising than the substitution effects seen with caffeine, fruit or any other consumer products,” Sweanor told Filter. The difference is that this particular substitution can be a life-or-death matter. “The evidence is clear: Keeping cigarettes a better consumer option than massively less toxic products kills people.”

“Supposed health authorities are destroying that trust and putting our overall public health establishment into the hands of populists, conspiracy theorists and grifters.”

The 9.6-percent increase in cigarette sales under vape flavor bans that the researchers estimated is likely to represent many people who had been able to quit a deadly habit, but were then pushed back to it by provincial policies.

Maria Pappioannoy of Rights4Vapers, a consumer advocacy group in Canada, blames a group of tobacco control campaigners for using their longstanding relationships with provincial governments to lobby for flavor bans.

“We are deeply disappointed that these self-proclaimed leaders remain anchored to outdated thinking and chose fear over facts to get their bans,” she told Filter. “Their campaigns have not protected Canadians; it has failed them, and helped tobacco companies increase their revenues.”

Sweanor said he finds it “disturbing” that public health advocates have pursued policies so detrimental to the very thing they should stand for. “What is even more disturbing is how predictable it is that they will continue supporting and pursuing such policies and refuse to engage in any open discussion about what they are doing and how they can justify it.”

When decision-makers are persuaded by these arguments, it increases both stigma against people who use nicotine and distrust in public health, he added.

“Governments need to stop regulating in a vacuum and realize that ‘public health wins’ on vaping can be ‘public health disasters’ for smoking.”

“Supposed health authorities are destroying that trust and putting our overall public health establishment into the hands of populists, conspiracy theorists and grifters.”

Getting policymakers to embrace the evidence that is so routinely ignored seems like a herculean task, but Rights4Vapers, Pappioannoy said, “will continue to do what we have always done”—educate, advocate and “push for a modern, science-based framework that protects access to safer nicotine alternatives.”

Pesko would agree with that. Even though his latest study adds to a growing body of evidence pointing in the same direction, he’s seeing yet more jurisdictions considering flavor bans.

“Governments need to stop regulating in a vacuum and realize that ‘public health wins’ on vaping can be ‘public health disasters’ for smoking,” he said. They should not, he emphasized, be “accidentally incentivizing cigarettes by stripping away features like flavors that make less-harmful alternatives attractive.”

Photograph by Lindsay Fox via Flickr/Creative Commons 2.0

The Influence Foundation, which operates Filter, received an unrestricted grant from the the Sweanor Family Fund at the Ottawa Community Foundation in 2025. Filter’s Editorial Independence Policy applies.

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