In 2021, I was asked, “If a patient is 200 pounds overweight and loses 100 pounds, would you tell them that’s not good enough?” It was a compelling question. In the words of my favorite surgical attending, we don’t let perfect be the enemy of good. We would celebrate that win, and keep going.
The next question stopped me: “Do you have strategies to help smokers make similar incremental change?”
I didn’t. In medical school, I learned that smoking is the most detrimental habit to long-term health. My role was clear: Advocate unequivocally for cessation. More than two decades later, that approach has not meaningfully evolved. We still talk about smoking, tobacco, and nicotine as if they are interchangeable. We still deliver a singular absolute message: Quit.
The person asking me the questions was a lobbyist I worked with on direct primary care legislation. He later asked if I would be willing to learn about a “heat-not-burn” nicotine delivery product called IQOS, tour the facility, meet the scientists, and, if I believed there were less harmful alternatives to cigarettes, say so. I agreed to the trip. And I didn’t forget his question.
We have to talk about nicotine.
In the years since, I’ve learned a lot about harm reduction. I’ve been deposed by a major tobacco company for writing about my father (a smoker), the IQOS and nicotine. And now, in clinical practice, I’m seeing a new layer of conversation emerging: patients and wellness communities discussing “microdosing nicotine.”
Nicotine acts on nicotinic acetylcholine receptors, triggering dopamine release and reinforcing reward pathways. It increases alertness, modulates mood, and can transiently improve attention and working memory. For many patients, it provides immediate relief in the context of chronic stress, fatigue, and overload.
It is not benign. But nicotine is not the primary driver of cancer and pulmonary disease. Those risks come from combustion. If we ignore that distinction, we limit both our credibility and our patients’ options.
The tobacco industry, for better or worse, is highly motivated to innovate. We do not need to partner with it, but we cannot afford to ignore it. In the U.S., nicotine delivery products are subject to FDA oversight, arguably more than many supplements, consumer devices, or “biohacking” products patients are already using.
Nicotine can be delivered in multiple ways: combustible cigarettes and cigars; heated tobacco products; e-cigarettes and vapes; smokeless tobacco like snus; and newer oral products such as nicotine pouches. Nicotine replacement therapies (patches, gums, lozenges, inhalers, and sprays) are FDA-approved medications.
These products are not equivalent. They vary substantially in toxic exposure and cancer risk. Traditional cigarettes remain, by far, the most harmful form of nicotine delivery.
Patients already understand something we often avoid acknowledging. A patient once told me, “My cigarettes have always been there for me.” Many patients report improved focus, reduced anxiety, and better emotional regulation with nicotine.
In the context of complex lives and competing stressors, patients don’t experience smoking as purely negative, even when they understand the risks. This is where harm reduction becomes clinically relevant.
Harm reduction does not abandon cessation. It recognizes that not all patients are ready, or able, to quit entirely. It aims to reduce overall risk by shifting behavior, not by abandoning it entirely.
We apply harm reduction principles everywhere else in medicine. Seatbelts. Narcan. Needle programs. Contraception. We meet patients where they are while working toward better outcomes. Nicotine should not be the exception.
Transitioning a patient from combustible cigarettes to a non-combustible nicotine source meaningfully reduces exposure to toxic chemicals, even if nicotine use continues. That is not failure. That is progress.
Changed care could start with a different question.
One challenge is that modern primary care is not built for this nuance. We have limited time, limited reimbursement, and competing priorities. Smoking is rarely a patient’s chief complaint. Counseling is compressed, often reduced to a checkbox or a script.
Outcomes reflect this reality. Quit rates hover around 5 percent without intervention and rise modestly, to 15 to 20 percent, even with intensive support. This is the ceiling of our current model.
Instead of defaulting to the 5A’s, we might ask: Have you ever tried a different form of nicotine? If not, would you consider it?
This is not an endorsement of smoking or nicotine use. It is an acknowledgment of behavior and the opening of a door to a conversation about choice, change, and risk.
This approach restores something else we risk losing: credibility. Patients know when we oversimplify. They know when our messaging doesn’t align with their lived experience. And they know when we are woefully out of touch with the marketplace.
We can hold two truths at once: Nicotine is addictive and not risk-free, and the way it is delivered matters. Cigarettes are the most dangerous form of nicotine delivery.
For decades, we have treated smoking cessation as a binary issue. Use or don’t use. Quit or fail. Principles of harm reduction acknowledge that there are more options for moving along a continuum of change now than ever before. Our clinical conversations and guidelines around cigarette smoking should reflect this and the advanced nicotine delivery options available.
We have spent years telling patients to quit with few mechanisms for robust success. It is time we start talking, honestly and thoughtfully, about nicotine.
Everybody else already is.
Julie K. Gunther is a family physician.
