This op-ed is by Harry Shapiro, author and tobacco harm reduction expert at the Global State of Tobacco Harm Reduction (GSTHR).
As the new Global State of Tobacco Harm Reduction report shows, THR inexorably marches on, but the spectre of denial is ever present.
“Time’s glory is to…unmask falsehood and bring truth to light”. Shakespeare
Despite temperatures soaring, wildfires destroying thousands of hectares across the globe and widespread drought damaging food security with increasing regularity – dare I say it – combustion is all the rage. Yet there are high profile (invariably) right wing politicians who publicly deny the whole idea of climate change or who deny we humans are to blame. Step up Trump, Putin, former Brazilian president Bolsonaro and the current Argentine incumbent Javier Milei.
By the same token, and despite the wealth of global independent scientific and clinical evidence, there are high profile public health and medical organisations and NGO activists who continue to deny that the deadly effects of smoking combustible tobacco can be significantly reduced by encouraging those who cannot (or don’t want to) quit smoking to switch to safer nicotine products (SNP). The danger of combustion has many faces.
The new report examines the current situation regarding role of SNP in continuing to combat global death and disease from smoking. Faced by over a century of cigarette domination, THR progress has been remarkable when you consider that twenty years ago (apart from snus) SNP were hardly known or hadn’t even been developed. But no longer marginal, SNP have become structurally embedded in the global nicotine market presenting a major opportunity to improve public health and crucially, without costing the taxpayer a penny.
The report’s key findings reveal that while millions of consumers are embracing the opportunities to switch away from smoking, politicians in many countries, encouraged by tobacco harm reduction deniers, are doing their utmost to restrict access. But first, the good news:
- The report analysis shows a pattern across 28 countries where the rise of SNP use has coincided with clear falls in smoking prevalence. In Sweden, Norway, Iceland, New Zealand and the UK, the use of SNP has already overtaken smoking. This is substitution at work – and it’s good news for individual and public health.
- Exclusive GSTHR estimates suggest that globally, 200 million people now use SNP;
- SNP use is equivalent to a fifth to a quarter of the global smoking population
Less welcome is that since 2025, the balance of global policy has moved further toward restrictive regulation and safer product bans, while cigarettes of course, remain universally legal. Incidentally the US Forest Service estimates that 1700 wildfires a year are caused by guess what?
Also concerning is that access to tobacco harm reduction is heavily skewed toward high-income countries (HIC): of the 28 nations with the clearest substitution trends, 27 are high-income and one is upper-middle-income. In HICs, price structures often facilitate switching away from cigarettes. In low- and middle-income countries (LMICs), by contrast, the price premium on most SNPs is a direct barrier to harm reduction. The report reveals that disposable vapes cost on average 2.5 times the price of the cheapest cigarette brand in LMICs. In most LMICs, home to 80% of those who smoke, cigarettes remain the cheapest nicotine option.
The ‘get out of jail free ‘card, often played by public health THR sceptics, is ‘the precautionary principle’, whereby caution is advised in the face of new scientific and clinical developments especially where new drugs are concerned. All perfectly reasonable, except the evidence in favour of the relative safety of SNP over smoking is not only well-researched but just plain common sense. Any nicotine product which does not involved combustion is by definition safer than lighting up a cigarette or cigar. And while we might not know absolutely everything about SNP safety and efficacy twenty years down the line, there is a mountain of literature which tells us we know enough.
In a 2025 update, the latest gold-standard Cochrane review found high-certainty evidence that vapes outperform NRT. Multiple switching studies show large reductions in toxicant exposure among people who switch from smoking to vaping, approaching levels seen in people who quit entirely.
Yet public misperception of relative risk is worsening, even in countries that have embraced elements of harm reduction.
By 2023, 57% of adult smokers in England incorrectly believed vapes were equally or more harmful than cigarettes.
This is entirely driven by the media’s love of bad news stories fuelled by disinformation from organisations supposedly existing to improve public wellbeing and by often grossly flawed ‘academic research.’
When it comes to excessive restrictions on commodities already adopted by millions of people, I don’t believe in ‘unintended’ consequences. It is obvious that organised crime will fill any universally popular commodity vacuum and it is particularly reprehensible when politicians set this up to tick the right boxes and, in the process, deny or restrict access to products with a proven health benefit.
Caps on nicotine liquid and flavour restrictions have intensified – equivalent to de facto bans. For example, Denmark’s 9mg pouch cap is projected to remove approximately 90% of products from the market; modelling suggests 35% of affected users will turn to the black market and 13% will revert to smoking. At least ten countries enacted new SNP prohibitions during the report period; by March 2026, one-third of the world’s population, in 109 countries, were living under a complete ban on all SNP. Inevitably, restrictive regimes are fuelling large illicit SNP markets, with criminal supply-chain involvement including cartel activity in Mexico and fatal firebombing incidents in Australia.
Institutional resistance to tobacco harm reduction remains strong. At the eleventh Conference of the Parties (COP) to the World Health Organization (WHO) Framework Convention on Tobacco Control, held in Geneva in 2025, the Convention Secretariat claimed that there is no legitimate role for tobacco harm reduction. WHO continues pushing for bans or cigarette-equivalent treatment of SNPs. However, in an unprecedented development, a small but growing group of countries, did raise harm reduction at the COP meeting, arguing for evidence-based, risk-proportionate policy.
We do need a reality check. Smoking has a very long history with deeply embedded investment in global finance, politics, culture and social engagement. So it will be a long goodbye to the cigarette. Even so, and despite political intransigence, millions of people are already making that transition themselves. For tobacco harm reduction to gain the ascendence over smoking, the report concludes, it is not a matter of if, but when.
Link to report: https://gsthr.org/resources/thr-reports/the-global-state-of-tobacco-harm-reduction-2026-a-situation-report/
