Recent analysis published in The Lancet Public Health reinforces a long-standing but often overlooked reality in tobacco control: nicotine use is not a monolith, and public-health outcomes depend critically on how nicotine is delivered. Policies that fail to distinguish between combustible and non-combustible products risk undermining smoking reduction goals, particularly among adults who continue to smoke despite decades of conventional interventions.
The study examines population-level patterns of nicotine use and health outcomes, highlighting how regulatory environments shape behaviour, exposure, and disease burden. Its findings carry important implications for governments grappling with how to regulate newer nicotine products while remaining credible in their stated ambition to reduce smoking-related harm.
Combustion, Not Nicotine, Drives the Burden of Disease
The evidence reviewed in The Lancet Public Health is consistent with a large and growing body of scientific literature showing that the primary driver of smoking-related mortality is combustion, not nicotine itself. Cigarette smoke exposes users to thousands of toxic compounds, including carbon monoxide, fine particulates, oxidants, and carcinogens that collectively drive cardiovascular disease, cancer, and respiratory illness.
By contrast, non-combustible nicotine products substantially reduce exposure to these toxicants. While they are not risk-free and nicotine remains addictive, the absence of combustion fundamentally alters the risk profile. Treating all nicotine products as equivalent therefore obscures the central mechanism of harm and weakens the analytical foundation of tobacco regulation.
When Policy Ignores the Continuum of Risk
The Lancet analysis highlights a persistent policy tension: governments increasingly acknowledge the continuum of risk in scientific forums, yet regulatory frameworks often continue to group cigarettes and smoke-free nicotine products together. This approach can blur risk distinctions for consumers and clinicians alike, making it harder for adult smokers to identify lower-risk alternatives.
From a public-health perspective, this matters because behavioural substitution is one of the most powerful tools available to reduce harm at scale. When regulation, taxation, and public communication fail to reflect relative risk, they may unintentionally discourage smokers from switching away from the most dangerous products.
Implications for Smoking Reduction Strategies
The findings underscore that progress in reducing smoking prevalence depends not only on discouraging initiation, particularly among young people, but also on supporting cessation and substitution among adults who already smoke. In populations with entrenched smoking patterns, especially those facing socioeconomic disadvantage, rigid or non-differentiated regulation may have diminishing returns.
A risk-proportionate framework does not require endorsing nicotine use. Rather, it requires acknowledging that policies designed to minimise total population harm must prioritise moving people away from combustion. This includes ensuring that regulatory barriers, fiscal measures, and public messaging do not inadvertently preserve cigarettes as the default or most accessible option.
Regulation That Aligns with Evidence
The Lancet Public Health article reinforces the need for regulatory coherence. Evidence-aligned policy would continue to apply the strongest restrictions to combustible tobacco, while calibrating controls on non-combustible products according to their lower, though non-zero, risk. This includes strict age restrictions, product standards, transparency requirements, and ongoing surveillance, without collapsing all nicotine products into a single regulatory category.
Crucially, such an approach supports informed decision-making by adults who smoke, without weakening youth protections or overstating the safety of any nicotine product.
Conclusion
The public-health challenge posed by smoking is not solved by denying scientific nuance. As The Lancet Public Health analysis illustrates, credible tobacco control depends on aligning regulation with the mechanisms of harm, not with nicotine per se. Recognising the continuum of risk is not a concession to industry or a departure from prevention goals; it is a prerequisite for reducing smoking-related disease at population scale.
For policymakers committed to evidence-based regulation, the message is clear: progress depends on proportionate frameworks that discourage smoking, protect youth, and enable meaningful harm reduction for adults who would otherwise continue to smoke.
Source: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(25)00296-8/fulltext
