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Behind the Smoke and Mirrors: the Continuing Challenge of Tobacco Harm Reduction
Harry Shapiro
Director of DrugWise, a UK online drug information NGO and lead author for the Global State of Tobacco Harm Reduction reports
I recently returned from the 12th annual Global Forum on Nicotine (GFN) conference in Warsaw. My first visit was 2015 when I had just entered the tobacco harm reduction (THR) space after over thirty years spent with UK NGOs advocating for drug and HIV harm reduction – a space I still inhabit.
I was invited by the conference founders Professor Gerry Stimson and Paddy Costall, colleagues from my previous world, who realised the principles underpinning drug, HIV and tobacco harm reduction were the same. These principles were implicit in the concept of a universal right to health as laid down (ironically as it turned out) by the WHO in its founding charter of 1948. In other words, it doesn’t matter if somebody is engaging in risky behaviour be it drug use, gay sex or smoking, nobody should be left behind in the public health imperative to both improve and save lives.
It would be hard to imagine a public policy issue more riven with controversy and polarisation than drugs and drug addiction. Turned out I was wrong: I quickly realised that when it came to THR, the world of international tobacco control was unbelievably febrile and toxic, driven by value-laden health zealots who demonised THR in a web of misinformation, propaganda and downright lies.
Worse still, over the past ten years, I have seen the careers of experienced and honest tobacco researchers, doctors and public health advocates threatened for supporting THR using safer nicotine products. I have witnessed these same people barred from speaking or even attending tobacco conferences, THR meetings cancelled or disrupted accompanied by well-orchestrated smear campaigns against individuals. I have no time for conspiracy theories, but trust me, this is cancel-culture red in tooth and claw.
At the same time, anti-THR papers continue to find their way into academic journals deeply flawed in their methodology and/or ending with policy conclusions utterly removed from the preceding research findings. It smacks of a peer review process broken or complicit or both. So what is going on? The key word in this global struggle for truth about the benefits of THR relative to smoking is disruption.
For decades, manufactured cigarettes sold by multi-national tobacco companies dominated global tobacco consumption. Then in the early 2000s came the first commercially viable e-cigarette, not from Big Tobacco but from a heavy smoking Chinese chemist whose dad died of lung cancer. Like any new technological development, small start-ups were ahead of the game leaving the incumbent industry to play catch-up. To a greater or lesser extent it has, through internal product development or mergers and acquisitions although it is still not the dominant force in vapes where some small start-ups are now anything but small.
However, the global disruption within academic, medical and public health communities caused by this seemingly inauspicious innovation has been seismic. Life used to be simple. In one corner, the good guys and girls in white coats and stethoscopes and in the other, those evil fellows in smart suits smoking fat cigars.
But very gradually from the 1970s, some tobacco researchers posited the view that the real damage to health from smoking was not the nicotine, but the smoke caused by burning tobacco. Their revolutionary view suggested if the nicotine could be divorced from the cigarette, you could have a much safer way of consuming nicotine. But there was no mass market safer product out there – until there was.
Once the major players in the industry took an interest, those individuals and agencies who had been fighting the tobacco wars of the 1980s and 1990s saw the opportunity to open a new front. After decades of egregious behaviour on the part of Big Tobacco, how on earth could we trust them again? Fair point, until a growing body of independent evidence from authoritative sources demonstrated the relative safety of these products.
The economist John Maynard Keynes was once criticised for changing his policy. His response was: “when the facts change, I change my views. What do you do?” The answer from the international tobacco research community was to double down on evidence denial and attack anybody who supported it.
The disruption within medical and public health circles is systemic. Tobacco researchers have built whole careers and acquired substantial funding tackling death and disease from smoking. The idea that there were safer ways to consume nicotine went against everything they had learned over decades. This created group think, a circling of the wagons to defend existed orthodoxies against new threats and challenges.
Public health has also been left standing uncomfortably in the wings. Smokers have been empowered to switch away from smoking simply by peer-to-peer information exchange and the availability of products. The introduction of a heated tobacco product has seen cigarette sales in Japan fall by 50% in the past five years – a feat unachievable by any public health intervention. The adoption of snus in Sweden has meant the country has the lowest lung male cancer rates in the whole European Union.
In the Framework Convention on Tobacco Control (FCTC), harm reduction is mentioned but not defined alongside an obligation on the part of the Parties to consider future scientific and technological developments. This was built into the FCTC by WHO officials in recognition, way before e-cigarettes appeared, that the tobacco landscape might change and so the FCTC might need to adapt accordingly. And so it did, but in ways totally inimical to the best interests of public health.
Article 5.3 of the Convention reasonably urges Parties to be open and transparent in their dealings with industry. However, the subsequent Guidelines to 5.3 have been weaponised to bar any engagement with industry whatsoever. This is the beauty of GFN. It is a safe space where all interested parties are welcomed including industry with nobody excluded. THR opponents have an open invitation to attend but never do, instead hiding behind 5.3 to avoid having to justify their opposition. Unfortunately, over the years, tobacco researchers working in this field who used to attend have now been warned off by their institutions – a truly shocking state of affairs.
The story of THR is one of resistance, misinformation, competing interests, and the unique obstacles faced by those advocating for a pragmatic approach to one of the world’s deadliest habits. It’s also a story relevant to those within the nicotine industry, who, despite commercial interests, find themselves intersecting with a public health movement that is as controversial as it is urgent. Here are some expert views on the many faces of the challenge to THR.
The Science Is Not Enough
Many THR advocates come from scientific or medical backgrounds, motivated by the mounting body of evidence showing that safer nicotine products carry a fraction of the risk of combustible cigarettes. Yet in many circles, especially within mainstream public health, these experts often find their voices marginalised or ignored.
“Every time I present evidence on vaping as a harm reduction tool, I’m met with scepticism or outright hostility,” says Dr. Marewa Glover, a New Zealand-based tobacco researcher. “It’s as though harm reduction only counts when it’s done through pharmaceutical channels.”
Indeed, traditional nicotine replacement therapies (NRTs) such as gums, patches, and lozenges have enjoyed decades of institutional support. But newer consumer-led innovations like vapes and HTPs, which don’t come from the pharmaceutical world, face a tougher road—despite often being more effective in helping people quit smoking. A 2022 Cochrane review found that e-cigarettes are more effective than NRTs in helping people quit. Yet this message has struggled to penetrate the mainstream.
Entrenched Public Health Orthodoxy
One of the core challenges is the dominant narrative in public health, which still largely equates nicotine use with tobacco use—and both with harm. For example, many doctors still believe nicotine causes cancer; many health professionals and smokers believe vapes are as dangerous or even more dangerous than cigarettes.
“There’s an absolutism in public health that works well for infectious disease but poorly for chronic, behaviorally entrenched issues like smoking,” says Clive Bates, a long-time THR advocate and former director of Action on Smoking and Health (ASH UK). “If you can’t say ‘just quit,’ you’re treated like an enabler.”
This absolutism extends to policy. Countries like Australia and India have taken aggressive stances against vaping, often banning consumer nicotine products outright while still selling cigarettes.
Even in the UK, where public health bodies like Public Health England have openly supported vaping, confusion reigns at the local implementation level due to contradictory media messaging and evolving political climates. There is a swop to stop government-backed initiative providing free vapes, vapes are allowed in prisons but disposables, often an entry point for those wanting to switch, have been banned.
Media Misrepresentation and Moral Panic
Perhaps no challenge is more frustrating for THR advocates than the role of the media in shaping public perception. Headlines warning of “popcorn lung” or the infamous “EVALI” lung injury outbreak in the U.S.—which was later linked not to commercial nicotine vapes but to illicit THC products—have left lasting scars on the reputation of harm reduction products. People still come into vape shops asking if it’s going to rot their lungs. That narrative stuck because it confirmed what people already feared.
Even when corrections are issued, the damage is done. Sensationalism sells, and public understanding of relative risk suffers. For consumer advocates—often ex-smokers who turned to vaping after repeated failure with NRT—this media landscape can feel like a personal affront.
But it is easy to load blame on the media which only reports the information it is fed. Yes, it will try and find the vaper with popcorn lung or the tiny percentage of teenage vapers who vape daily. But much of the reported misinformation comes either from the flawed research mentioned above or from supposedly reputable medical and public health organisations, most notably the World Health Organization. For the past decade, the WHO have pumped out a constant stream of documented misinformation about THR hoping to encourage countries to adopt tough anti-THR legislation.
Regulatory Hostility
So in many countries, THR advocates must also contend with regulators who seem to view harm reduction as a threat rather than part of the solution. Strict advertising bans, flavour prohibitions, and excessive taxation create barriers to access, particularly for those who might benefit most: lower-income and marginalised populations who smoke at higher rates than the general adult smoking population.
“Flavour bans kill conversion,” says Dr. Konstantinos Farsalinos, a cardiologist and THR researcher. “Adults like flavours. Take them away, and you remove the appeal that makes vaping an attractive alternative to smoking.”
This sentiment is echoed by consumer groups who argue that such policies are not only ineffective but actively harmful. In the U.S., for example, the Food and Drug Administration (FDA) has authorised only a handful of vaping products, leaving a vast unregulated grey market where unsafe products can proliferate which in turn can confirm belief in the dangers of the products.
The Elephant in the Room
Even within the harm reduction movement, there’s a line many are reluctant to cross: support from or collaboration with the tobacco industry. This presents a unique challenge for THR advocates whose positions may align with, but are not beholden to, industry players.
“For some, the mere fact that a tobacco company makes a reduced-risk product is reason enough to reject it,” says David Sweanor, a veteran public health lawyer and chair of the Centre for Health Law, Policy and Ethics at the University of Ottawa. “But if we say we care about reducing harm, we have to look at outcomes, not origins.”
This tension creates a difficult tightrope. On one hand, the industry has the scale and infrastructure to deliver safer alternatives worldwide. On the other, decades of deceit and manipulation have left deep scars. For advocates working independently, engaging with the industry—even to share data or policy insights—can be reputationally risky.
The Unheard Consumer Voice
Perhaps the most overlooked stakeholders in this debate are the consumers themselves. Ex-smokers who credit safer products with saving their lives often find themselves shut out of public discourse.
“In most public health spaces, we’re seen as either dupes or shills,” says Nancy Loucas, a consumer advocate associated with The Coalition of Asia Pacific Tobacco Harm Reduction Advocates (CAPHRA). “We have lived experience, but they treat us like we’re unqualified.”
This marginalisation is not just disempowering—it’s counterproductive. Consumer insights can offer real-world perspectives on what policies work and what don’t. Ignoring these voices reinforces a top-down approach to public health that fails to engage the very people it claims to serve.
Keep on keeping on
Over the past hundred years, a global superstructure of financial, political, cultural, social and scientific vested interest has grown up around a humble product comprising a few tobacco leaves wrapped in paper. Set against this is a THR movement hardly more than a decade old.
At this years’ GFN, I heard further reiteration of the key challenges to THR. But there is a noticeable fork in the road now between legislative obstacles and realities on the ground. Many of the good THR metrics are on the increase; the numbers of global consumers, the range of products, overall market value and the weight of evidence of improved lives. Bad metrics are on the decline; falling cigarette sales in poster countries like Japan, Norway and Sweden. Not only is teen smoking at a historic low in the USA, but teen vaping has slumped there since 2018-19, despite continued unfounded claims by the WHO in its most recent report on global smoking that vaping will normalise smoking. By contrast, several countries are tightening regulations with bans or proposed bans on flavours, disposable vapes and nicotine pouches.
But I am reminded by a line in Jurassic Park. A scientist is trying to convince the Jeff Goldblum character that because they have ensured all the dinosaurs are female, they cannot reproduce. Jeff replies, “Nature will find a way”. Which of course it did.
So despite all the challenges and obstacles, tobacco harm reduction using safer nicotine products is here to stay. Over the years, consumer numbers will rise and product innovation will continue, hopefully able to market products – whether vapes, HTPs, pouches or other forms of safer oral products - that are affordable, acceptable, appropriate and accessible to the widest number of people especially those in the developing world bearing the brunt of death and disease from smoking.
So where now?
Tobacco harm reduction is one of the most contentious yet vital frontiers in modern public health. For the advocates pushing against the tide of misinformation, stigma, and institutional inertia, the work is often thankless. But it is work that matters—measurably, demonstrably, and urgently.
For those in the nicotine industry reading this, the takeaway is simple: support these advocates. Listen to them. Learn from them. Because while the future of your industry may lie in innovation, the future of global health depends on whether we make harm reduction a principle—not just a product.
Harry Shapiro is the director of DrugWise, a UK online drug information NGO and lead author for the Global State of Tobacco Harm Reduction reports.
·Official website: www.drugwise.org.uk
· Global State of Tobacco Harm Reduction: www.gsthr.org.uk
·To find out what you missed at this year’s GFN? Visit: GFN 2025 videos on YouTube
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