Key points:
·Tobacco harm reduction aims to reduce harm—not necessarily consumption, according to Dr. Alex Wodak. This contrasts with traditional public health approaches that aim to reduce or eliminate tobacco use entirely.
·Nicotine is addictive but not the primary cause of smoking-related diseases. Instead, it's the combustion of tobacco that produces over 7,000 harmful chemicals leading to diseases like cancer and COPD. Non-combustible alternatives like e-cigarettes and oral products dramatically reduce these risks.
·Asia bears the highest burden of tobacco-related harm—and has the most to gain from THR.
·According to some estimates, THR could save 1.5 million lives in five years, and up to 30 million lives over 30 years if widely adopted throughout Asia Pacific.
·Despite strong evidence, THR faces opposition from major global health entities. Organizations like the World Health Organization remain resistant to THR, partly due to influence from philanthropic anti-tobacco advocates like Michael Bloomberg and Bill Gates.
·Safer nicotine products now make up 10% of the global market, and companies like Philip Morris International are shifting toward smoke-free products. Wodak argues the combination of consumer demand, scientific backing and commercial interest makes THR’s continued growth inevitable.
2Firsts, September 9, 2025-Dr. Rohan Sequeira and Dr. Alex Wodak made a powerful case for tobacco harm reduction (THR) during the inaugural Asia Forum on Nicotine (AFN) on Aug. 27. Based in India, Sequeira is a consultant cardio-metabolic physician specializing in non-invasive cardiology, diabetes, endocrinology and obesity management. A retired physician from Australia, Wodak has extensive experience in harm reduction, including efforts to control HIV among people who inject drugs.
While there is no universally agreed definition of harm reduction, Wodak defines the concept as “policies and programs that aim to reduce the health, social and economic costs of legal and illegal drugs without necessarily reducing consumption.”
The consumption aspect, he told the AFN audience, is what sets harm reduction apart from approaches that focus on controlling supply and demand. “You can have reduced consumption as a side effect of harm reduction intervention but that shouldn’t be the driving force,” he said. “The driving force should be an attempt to reduce harm.”
Nicotine Without Combustion
While nicotine and tobacco are often lumped together in public health conversations, Sequeira believes it’s important to separate them. Nicotine may be addictive, but it doesn’t cause smoking-related diseases. The real danger comes from combustion—burning tobacco releases over 7,000 toxic chemicals, including tar, nitrosamines and carbon monoxide. These, Sequeira said, are the culprits behind lung cancer, heart disease, and COPD—not nicotine.
The advent of smoking alternatives such as e-cigarettes, tobacco-heating products and modern oral products has made it possible to deliver nicotine without the byproducts of combustion. While not risk-free, these products allow people to consume nicotine at a fraction of the risk of smoking. Leading public health bodies, including Public Health England, affirm that e-cigarettes are at least 95% less harmful than traditional cigarettes, according to Sequeira. “Even if they were only 50% safer, the reduction in harm would still be monumental,” he said.
Staggering Potential
The argument for THR is particularly compelling in Asia, which has more than half of the world’s smokers and 90 percent of its smokeless tobacco users. Of the 8.7 million tobacco-related deaths annually, 4 million occur in Asia, according to Sequeira. Despite decades of tobacco control, smoking prevalence remains stubbornly high throughout the region, especially in countries like Indonesia, where 64.7% of men smoke.
Asia, Sequeira said, could benefit especially from modern oral products, given the “uniquely deadly” characteristics of the smokeless tobacco products used throughout the continent. Unlike Swedish snus, which has a famously low risk profile, the smokeless products consumed in Asia are unpasteurized and often mixed with ingredients such as areca nut, slaked lime and sometimes additional flavoring agents. The addition of areca nut (which itself is a carcinogen) significantly increases the health risks associated with these products. Traditional smokeless tobaccos are blamed for the Indian subcontinent’s disproportionate share of oral cancers.
To estimate THR’s potential to save lives in Asia Pacific, Sequeira ran the numbers through a model typically used to calculate the risk stratification ratio of pharmaceuticals. The exercise revealed that, within five years of implementation, THR would have saved 1.5 million lives throughout the region. After three decades, that figure would be up to 30 million. Countries that have implemented THR strategies, Sequeira said, are already seeing the benefits. Japan’s accommodation of tobacco-heating products, for example, has contributed to a 30 percent reduction in cigarette sales over five years, Sequeira noted.
Opposing Forces
Despite its promise, THR continues to face stiff opposition in many quarters, including in Asia. Wodak considers this odd, given the pervasiveness of harm reduction in public policy. When introduced for other aims, such as road safety—think seatbelts, motorcycle helmets or airbags—the concept faces minimal resistance,” Wodak noted. By contrast, when introduced for sex (condoms, for example) or psychoactive drugs, harm reduction efforts tend to encounter ferocious resistance, Wodak said, reminding his audience of the World Health Organization’s hesitance to embrace needle-exchange programs for intravenous drug users during the early years of the HIV/AIDS epidemic.
Such resistance, he lamented, often lasts long beyond the emergence of evidence supporting the intervention. The WHO eventually changed its position on needle-exchange programs but remains strongly opposed to harm reduction in the tobacco context. Wodak attributes the enduring hostility in part to the influence of billionaire philanthropists such as Michael Bloomberg and Bill Gates, who have promoted and generously funded the anti-THR camp.
A Problem that Will Resolve Itself
At the same time, there are plenty of stakeholders supporting THR, according to Wodak. Among smokers, he noted, support depends on whether the alternative is attractive, affordable and available. “Our opponents strive to make alternatives unattractive, unaffordable and—best of all—unavailable,” he said.
“This is true of drugs in general. When people who use drugs hear that their drugs of choice is much more dangerous than they thought, most will continue to use that drug provided that the alternatives don’t become available. When alternatives become available, they will start switching as soon as they can.”
Tobacco manufacturers, too, have become supporters of THR, according to Wodak. While the state companies that prevail in low- and middle-income countries have yet to buy into the concept, many of the traded tobacco companies are vocal THR advocates today. Wodak cited Philip Morris International as an example. In the early 2000s, the company directed its research and development away from traditional cigarettes and into next-generation products. By the second quarter of 2025, the smoke-free business accounted for 41 percent of PMI’s total net revenues and more than 42 percent of its gross profits, according to the company’s earnings statement.
Investors too are keen on THR, judging by the company valuations. “Because rapidly transforming companies have a higher share price than slowly transforming companies, it’s acceptable to assume that investors put a premium on rapidly transforming tobacco companies,” said Wodak. “They are prepared to pay more because they expect faster growth in value.”
Wodak suggested the forces favoring THR will eventually overcome those resisting it. Safer nicotine products, he noted, captured 10 percent of the global market in 15 years. “The next 10 percent will come event faster.” This, Wodak explained, was due to the combination of consumer power plus the commercial capability of the tobacco industry plus the scientific evidence supporting such products. “We are looking at a problem that will resolve itself.”
Cover image generated by ChatGPT
