Anyone who uses social media is likely to encounter messages about tobacco harm reduction. This information comes from multiple sources with varying and overlapping agendas. At one end of the spectrum, the World Health Organization and most public health authorities emphasize the risks associated with nicotine in all forms. Their primary concern is preventing nicotine initiation among adolescents and young adults, thereby reducing future tobacco-related disease. At the other end of the spectrum are groups of scholars and scientists with a deep understanding of nicotine dependence and public health. Their focus is on older smokers who have difficulty quitting and might benefit from interventions that reduce the health risks associated with continued smoking. Between these poles are advocacy organizations, clinicians, entrepreneurs, and manufacturers, each advancing their own perspectives and interests. Each group argues with a passionate intensity that can leave a reader wondering if they are getting the entire story.
Missing from the heavily polarized discourse are nuanced explanations of the actual choices that people need to make, medical risk, personal expenses, the availability of effective treatment, and a range of unintended consequences. Readers are regularly exposed to carefully curated selections from the medical literature that oversimplify the science, and either reinforce trust in, or skepticism toward, public health authorities.
The audiences for the current tobacco harm reduction debate are not limited to people who use nicotine, but also shape the public perception of scientific credibility, the effectiveness of tobacco treatment, public health communications, and government regulation.
False choices in harm reduction messaging
People who smoke cigarettes are faced with a wide variety of options in considering how to reduce the harm from tobacco smoke. Vaping or nicotine pouches are often positioned as the only choices and compared directly to continued smoking. Quitting completely, which is the best outcome, is rarely mentioned. Intentionally or not, this focus on nicotine reinforces the addiction narrative associated with nicotine use. Dependence on nicotine certainly makes stopping difficult, and repeated efforts are required for long-term success. Although medications can increase the likelihood of success during a quit attempt, most of the 56 million former smokers in the United States ultimately quit without using medications. Empowering information about how people actually stop smoking is rarely included.
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Medical risk
Current evidence clearly shows that exposure to toxic and carcinogenic compounds is substantially reduced if a cigarette smoker switches to vaping. Many of the cancer-causing chemicals generated by burning tobacco are absent or reduced. Some new compounds, caused by heating the nicotine, the chemicals used to dissolve nicotine, and flavoring compounds are generated. The CDC says that vaping is safer than smoking, but it is not completely safe.
Nicotine pouches are a more recent entrant to the marketplace. A fiber pouch contains nicotine that can be dissolved by saliva and absorbed through the mucous membranes in the mouth. The pouch contains nicotine, some flavoring, and small amounts of other chemicals. With even fewer toxic chemicals, pouches appear safer than vapes, but no nicotine-containing product is safe.
Most social media discussions promoting harm reduction devote little attention to the uncertainties surrounding the long-term health effects of vaping and nicotine pouches. Both pouches and new vaping products can deliver higher doses of nicotine than cigarettes, which increases the level of dependency and the direct toxic effects of nicotine. Twenty percent of people who use nicotine alternatives have dual use; they continue to use cigarettes and other nicotine products. Dual users have no reduction in risk of tobacco-related disease.
FDA authorization for sale of nicotine products can be confusing
The FDA has the authority to review all tobacco products available in the U.S., and only 20 percent of the vapes and pouches currently sold have been authorized for sale. FDA authorization should not be confused with FDA approval, a term reserved for medications shown to be safe and effective. The FDA does not say that these nicotine products are safe, but they are safer than cigarettes. FDA review includes chemical and toxicology data as well as evidence regarding the attractiveness of a product to young people and people who do not smoke. The full list of products authorized for sale by the FDA is available online. There are thousands of products on the market which were not authorized by the FDA and are therefore illegal. Some may be safer than cigarettes but fail to attain approval because of their attractiveness to young people. We are not told the reasons for rejection of nicotine products by the FDA, so they may contain or generate unknown chemicals with unknown effects.
How much will this cost?
Another important omission from discussion of tobacco harm reduction is cost. Many cigarette smokers spend thousands of dollars a year on their nicotine habits. In general, vape products and pouches cost less per day than cigarettes, so a switch to pouches or vapes might appear like savings. The current prices are set to help attract young people and may go up. Much of the price of cigarettes sold is driven by taxes. As state and federal revenue from cigarette taxes declines, some locales will seek to make up the loss by increasing taxes on other nicotine products.
Quitting cigarettes completely is the best form of harm reduction
Very few voices on social media are talking about tobacco cessation. Complete cessation eliminates medical risk as well as future costs. Effective treatments are available and are fully covered by insurance. Treatment has two forms, counseling and medications, which work best when used together. Counseling is available from your state Quitline (1-800-QUIT-NOW), your physician, and your health plan. Several prescription medications are approved by the FDA for the treatment of tobacco. Nicotine gum and patches are also available over the counter. Several recent studies have shown that electronic cigarettes, when used with counseling, can be part of an effective treatment program for cigarette smokers. England’s National Health Service public guidance on quitting smoking states that “Nicotine vaping is less harmful than smoking and is one of the effective tools to help people stop smoking, though it is not risk-free.” It also notes that combining vaping with behavioral support increases quit success. The role of nicotine products in tobacco harm reduction is being debated worldwide.
Quitting cigarettes requires repeated efforts, sometimes over several years. The high relapse rate occurs because most people who try to quit don’t use counseling or don’t use their medications correctly. There are over 56 million people in the U.S. who have quit tobacco. Tobacco users are being told that they are addicted and are given an easy way to “lower their risk” without mention of evidence-based methods that are freely available.
Some long-term cigarette smokers use nicotine to self-medicate for underlying behavioral health problems. Examples include depression, schizophrenia, attention deficit disorder, and anxiety. Nicotine has effects that help these smokers manage their symptoms. When they stop smoking their underlying condition worsens. People who have difficulty quitting should consider evaluation and treatment at a center of excellence for smoking cessation. If these patients remain unable to stop smoking with optimal treatment, they would be ideal candidates for harm reduction.
Follow the money: Who is paying for this post?
Another omission in many messages around tobacco harm reduction is the ultimate funding source for the posting. The underlying financing of media campaigns may help explain some of the missing information. A wide variety of funding sources have been identified: tobacco companies, producers of alternative nicotine products, trade associations representing vape shops or producers, not-for-profit advocacy groups, research organizations, and independent consultants and advocates. The not-for-profit groups often obtain funding from major philanthropic organizations, such as Bloomberg, or other tobacco-related interests. The polarized discourse has led the World Health Organization to declare that “Tobacco and nicotine companies are misappropriating the public health concept of harm reduction while mass marketing harmful products like e-cigarettes and nicotine pouches to the public at large.”
It is important to understand the economic drivers and political forces behind all these messages. Although cigarette smoking by adults in the United States has declined substantially in the last decade, the number of people using tobacco products to obtain nicotine has remained somewhat constant at 50 million. Tobacco companies, which generate billions of dollars of revenue, have shifted their production from cigarettes to vapes and pouches to maintain their hold on consumers. For example, Juul is owned by Altria, and Zyn is owned by Philip Morris International. Tobacco harm reduction is the only major public health strategy in which the most enthusiastic corporate supporters have a direct financial interest in ensuring that the underlying behavior, nicotine use, continues indefinitely.
Unintended consequences
When experts debate, their overall credibility is diminished. With respect to tobacco harm reduction, there has been a continued erosion of authority in public health communications, adding a measure of doubt to any recommendation. The creation of doubt is a well-established public relations technique developed by the oil and gas industry to obscure the significance of global warming and perfected by the tobacco industry to delay public awareness and understanding of the harm of cigarettes. The main product of doubt in any debate is a paralysis that invariably serves the agenda of industry. Many tobacco users are in a state of denial regarding their risk of tobacco-related disease, and the public dispute reinforces their ambivalence.
In my opinion, tobacco harm reduction is unique among preventive interventions because it substitutes one ongoing consumer expense for another. Successful cessation eventually eliminates both the health risks and the consumer spending associated with nicotine use. There is sufficient information and resources available to allow every nicotine user to take proactive steps to improve their health. That decision should be based on careful exploration of the available information and discussions with knowledgeable clinicians.
Edward Anselm is a board-certified internist with a long-standing focus on public health, tobacco control, and preventive care. He earned his medical degree from the Chicago Medical School at Rosalind Franklin University and completed his internal medicine residency at Montefiore Medical Center in New York. Over the past three decades, Dr. Anselm has served in senior leadership roles across clinical, corporate, and managed-care settings, including chief medical officer positions at HIP Health Plan of New York, FidelisCare, and Health Republic Insurance of New York.
Recently retired from his role as medical director at Aetna, Dr. Anselm continues to teach at the Icahn School of Medicine at Mount Sinai as a clinical assistant professor. His current work focuses on strengthening reimbursement pathways for tobacco cessation and preventive services, helping clinicians integrate evidence-based care that improves patient outcomes while supporting practice sustainability. His research has been published in the American Journal of Accountable Care, the American Journal of Preventive Medicine, AJPM Focus, and Health Affairs Forefront, including articles on tobacco control in accountable care, underbilling of cessation services, and the financial and quality benefits of treating tobacco use as a clinical priority.
Dr. Anselm’s educational and policy work is shared through EdwardAnselmMD.com and The Anselm Nicotine Prescription, with professional updates available on LinkedIn.
