A patient considering a nicotine patch asks, “Doesn’t nicotine cause lung cancer?” A reassuring answer should not minimize nicotine’s risks. It should explain why a nicotine patch and a cigarette are not medically equivalent.
Our survey in Ukraine suggests that this distinction warrants attention. Healthy Initiatives collected 1,538 responses to a questionnaire targeting health care professionals between October 2025 and September 2026. Asked to identify the most harmful components of smoking, 58.7 percent selected nicotine. Even more selected tar (81.5 percent) or toxic substances (68.4 percent); the question allowed multiple answers. In a separate question, 91.9 percent agreed that nicotine directly causes lung cancer, and 89.7 percent agreed that it directly causes chronic obstructive pulmonary disease (COPD).
These results come from a convenience sample of Ukrainian physicians. The respondents had varied professional backgrounds, and reported beliefs cannot establish how they counsel patients. Selecting nicotine as harmful is not inherently wrong: Dependence perpetuates smoking. Nevertheless, attributing these diseases directly to nicotine raises a clinically important issue about risk communication.
Nicotine sustains dependence; smoke drives most smoking-related disease
Nicotine activates pathways in the brain involved in reward and withdrawal. As a major review of nicotine addiction in the New England Journal of Medicine explains, cigarette design and rapid nicotine delivery reinforce repeated smoking.
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But addiction and the direct toxicity of smoke are different mechanisms. The U.S. Food and Drug Administration (FDA) attributes most serious smoking-related diseases to the complex mixture of toxic chemicals in tobacco and tobacco smoke, not to nicotine itself. Cancer Research UK likewise identifies carcinogens in smoke as the principal cause of smoking-related cancer.
Nicotine is not harmless. It can affect the cardiovascular system, creates dependence, and poses particular concerns for adolescent development and pregnancy. Recognizing these risks does not justify equating medicinal nicotine with inhaled cigarette smoke.
The Ukrainian responses are not isolated. In a randomized survey experiment involving 926 U.S. physicians, researchers also found substantial attribution of cancer and COPD to nicotine. Although survey responses do not establish clinical behavior, the findings suggest that understanding nicotine’s specific health effects is relevant to clinical education beyond Ukraine.
Why accurate risk communication matters for treatment
Confusing nicotine with cigarette smoke may affect decisions about smoking-cessation treatment. In a study of 900 smokers, researchers found that misconceptions about nicotine-replacement therapy (NRT) were common. Many respondents said accurate safety information would increase their willingness to consider NRT.
The effectiveness of NRT is well established. A Cochrane review found that it increases successful quitting by approximately 50 to 60 percent relative to placebo or no NRT. The World Health Organization recommends NRT and other evidence-based medicines alongside behavioral support. The U.S. Surgeon General’s 2020 report also supports combining cessation medication with counseling.
For patients concerned about nicotine patches, the explanation is straightforward: Medicinal nicotine can ease withdrawal without exposing users to the toxic mixture produced by burning tobacco.
What lower exposure does and does not mean
Patients also ask about e-cigarettes, heated tobacco, and nicotine pouches. The question is not whether these products are harmless. They are not. It is whether different nicotine-delivery methods produce different exposures and health outcomes.
In a study of 181 adults, researchers found substantially lower levels of selected carcinogen and toxicant biomarkers among former smokers using e-cigarettes exclusively or NRT exclusively than among cigarette smokers. Participants who continued smoking alongside either product did not show the same reductions. A comprehensive review by the National Academies of Sciences, Engineering, and Medicine reached a complementary conclusion: Completely substituting e-cigarettes for combustible cigarettes reduces exposure to numerous toxicants and carcinogens.
Effectiveness for smoking cessation is a separate question. The August 2026 Cochrane review found high-certainty evidence that nicotine-containing e-cigarettes increase smoking-cessation rates at six months or longer compared with NRT in the studied settings. The Royal College of Physicians’ 2024 evidence review similarly recognizes the potential role of e-cigarettes for adults who smoke while emphasizing the importance of discouraging uptake among young people and never-smokers.
A practical opportunity for clinical education
In our Ukrainian sample, 88.3 percent reported no previous cessation-support training, while 49.9 percent expressed interest in receiving such training. The survey cannot establish that education would change risk perceptions or patient outcomes. It does, however, identify an opportunity to strengthen practical clinical education. Training should prepare health care professionals to distinguish nicotine dependence from combustion-related harm, explain the evidence supporting approved cessation medicines, and discuss alternative products without overstating either their benefits or their uncertainties.
Patients who smoke need different guidance from people who have never used nicotine. Complete cessation remains the preferred objective, supported by evidence-based treatment. When smokers ask about alternatives, clinicians should explain what is known about relative risks and why completely replacing cigarettes matters more than adding another product while continuing to smoke.
Accurate risk communication does not mean describing nicotine as harmless. It means recognizing that the method of delivery matters, the strength of evidence differs between products, and patients deserve to understand those distinctions.
This study was funded through a grant from Global Action to End Smoking (formerly known as the Foundation for a Smoke-Free World), an independent U.S. nonprofit 501(c)(3) grantmaking organization. The funder had no role in the conception, design, implementation, data analysis, interpretation of the study results, or preparation of this article. At the time this research was conducted, the author had a service agreement with the Ukraine-based nonprofit organization Healthy Initiatives. In parallel, he has a service agreement with Knowledge-Action-Change (KAC), a U.K.-based organization focused on harm reduction as a public-health strategy.
Giorgi Mzhavanadze is a health economist, public health researcher, and PhD candidate in economics at Tbilisi State University in Georgia. His research focuses on health economics, tobacco control, tobacco harm reduction, and the economic and behavioral determinants of health.
His work combines applied econometrics, discrete choice experiments, and quantitative policy analysis to examine tobacco and nicotine use, risk perceptions, smoking cessation, taxation, and regulatory interventions. He has contributed to peer-reviewed scientific research and international policy reports, with a particular focus on Eastern Europe and Central Asia.
His research is listed on ORCID, and he has written about the implementation gap in smoking cessation for Healthcare Business Today.
