Putting Smoke Back at the Center of Tobacco Control

Beaglehole, Bonita, and Pang’s Comment in Nature Health seems to be about vapes, snus, and smoke-free nicotine products. It is really about what counts as success in tobacco control.

For decades, tobacco control was organized around an almost moral clarity. On one side stood a familiar horizon: quit smoking, give up nicotine, break the circuit of dependence. On the other stood everything that threatened that ideal. Abstinence remained close to virtue; nicotine, almost always, to suspicion. It was an architecture at once normative and symbolic: the field knew how to name the enemy with the same confidence with which it named salvation.

Robert Beaglehole, Ruth Bonita, and Tikki Pang, all with long experience inside the WHO, want to unsettle that arrangement. Their argument is simple enough to state and difficult enough to absorb: the real enemy is not nicotine, but smoke. Global policy, they suggest, should stop treating vapes, snus, heated tobacco, and nicotine pouches as morally equivalent extensions of the cigarette and begin to see them, at least in part, as tools for hastening its decline.

That, though, is only the surface of the argument. What is truly at stake is the power to redefine what the field recognizes as success. For years, success seemed to have a stable name: fewer smokers, less nicotine, less dependence, less tobacco in circulation. Beaglehole, Bonita, and Pang propose another hierarchy. The defeat of the cigarette, they suggest, may matter more—and more urgently—than the disappearance of every form of nicotine use. Their target is exact: adult daily smoking prevalence below five per cent by 2040. The price is more delicate: accepting that nicotine dependence may not disappear, but migrate into less lethal forms.

It is a technical proposal. It is also a manageable heresy.

There is hardly any dissent about the diagnosis. Tobacco remains one of the world’s leading preventable causes of death: more than seven million people die from it every year. The burden falls with particular brutality on low- and middle-income countries. Even where consumption has fallen, the costs remain: damaged bodies, strained health systems, entrenched inequalities. Among the various ways of consuming nicotine, the cigarette remains by far the most devastating. And one figure gives the impasse its geographic scale: China and India alone account for more than a third of the world’s adult smokers, a weight that makes any global strategy incomplete if it cannot reckon with those two giants.

None of this is new. What matters is what follows from it. The field has achieved a great deal and may, for precisely that reason, have reached a point of fatigue. Since entering into force in 2005, the Framework Convention on Tobacco Control has given the world the grammar of the fight: health warnings, advertising restrictions, smoke-free environments, taxation, and cessation support. It turned tobacco control into a recognizable international language. It gave method to what had once been scattered. It gave legitimacy to what had once been isolated resistance.

Beaglehole, Bonita, and Pang do not diminish that legacy. They depend on it. Their case begins by acknowledging that the FCTC was decisive. But the old repertoire, they argue, no longer delivers decline at the speed now required. Tobacco control has entered a harsher phase. Smoking is increasingly concentrated among poorer, older, more heavily dependent smokers, many of them marked by repeated and unsuccessful attempts to quit. In that view, the cigarette no longer looks simply like a widespread habit. It looks like a hard residue, lodged among the most vulnerable and the hardest to reach with conventional tools.

The slowdown is not just a mood. It shows up against international targets that, at the current pace, no longer look plausible. The WHO’s voluntary goal of reducing tobacco use by thirty per cent by 2025 has fallen short; SDG 3.4, which calls for reducing premature mortality from chronic disease, is also off track; and the UN, in its 2025 political declaration, fixed its ambition at fewer than a hundred and fifty million people using tobacco by 2030 a figure that, as the authors note, would do little to alter the scale of the global burden.

If combustion is the central problem, policy cannot go on treating all nicotine products as moral equivalents. The cigarette stops being merely one more product in the tobacco universe. It becomes, explicitly, the singularly most destructive one. Everything else has to be reorganized around that difference.

The shift can look small, almost semantic. It is not.

For a long time, much of tobacco control operated as if its regulatory ideal were the progressive elimination of nicotine. Beaglehole, Bonita, and Pang propose another horizon: not necessarily a world free of nicotine, but one in which the combustible cigarette has become residual. What changes is not just the instrument. It is what counts as success.

They know how much resistance that shift will invite. So they make a shrewd political move. Harm reduction is not presented as something imported from outside tobacco control, but as something that has always been there, at least in latent form. The turn is anchored in the Convention itself. Article 1(d) of the FCTC, they remind the reader, includes harm reduction within the broad definition of tobacco control. The gesture matters. It lowers the charge of deviation and changes the terms of the argument. The question is no longer whether this belongs in the field, but why, if it does, it has remained at the margins for so long.

Under the heading “smoke-free nicotine products,” they draw together things regulatory practice often prefers to keep apart: nicotine-replacement therapy, snus, e-cigarettes, heated tobacco, and nicotine pouches. These are not the same thing. They have different histories, uneven evidentiary foundations, different risk profiles, distinct regulatory origins, and commercial interests that do not always converge. Even so, they are grouped for a strategic reason: all of them displace combustion from the center of the experience. From that framing comes a policy that is as simple to state as it is hard to ignore: regulate each product in proportion to its risk.

The idea can sound almost banal when put so plainly. In the abstract, it is hard to argue that the most lethal product should receive the same treatment as the least lethal one. And yet that is where the most uncomfortable accusation enters: in the name of prudence, tobacco control may have produced an incoherence. Cigarettes remain widely available, while potentially less harmful products face, in many settings, equivalent—or even greater—restrictions. The result, the authors suggest, is a policy that has treated unlike things as alike and, in doing so, helped shield the market for the most dangerous product.

What follows is a proposed regulatory order. Combustible cigarettes should bear the full weight of taxation and restriction. Smoke-free alternatives should indeed be regulated, but regulated to ensure safety, curb youth-oriented marketing, prevent uptake among non-smokers, and reduce environmental harms, not in ways that strip them of their capacity to compete with cigarettes. This is not a plea to liberate nicotine. It is a demand for a different hierarchy of severity.

That demand cannot survive without another struggle: the struggle over language. Public communication is central to the whole argument. Many adult smokers, Beaglehole, Bonita, and Pang suggest, remain trapped inside a flattened perception of risk. They do not clearly distinguish the harms of cigarettes from the harms of other nicotine products.

Part of that is the result of ambiguous messaging; part of it comes from alarmist media coverage; part of it reflects the difficulty, within public health itself, of sustaining a language of relative risk without seeming indulgent toward dependence. What they want, at bottom, is a new lexicon. Not an indulgent one, but a way of speaking that can say plainly that smoke kills more than nicotine, and say it clearly enough, including from the WHO.

Here, the dispute stops hiding behind products and data. It becomes a quarrel over what public health is willing to say aloud. Do more cautious messages protect adolescents? Or do they confuse adult smokers who might otherwise leave cigarettes behind? Do clearer messages about relative risk aid cessation? Or do they reopen a culture of nicotine normalization? Beaglehole, Bonita, and Pang take a side. Without more direct speech, harm reduction will remain confined to the policy footnotes.

Any argument that tries to displace doctrine needs territory. This one is no exception. The examples are already loaded with meaning in the international debate.

Sweden appears as the country in which cigarettes seem to have lost centrality while other forms of nicotine—above all snus—have gained ground. Japan emerges as the case in which the introduction of heated tobacco coincided with a sharp decline in cigarette sales. The United States enters as the setting in which the decline of adult smoking unfolded alongside the expansion of vaping. And New Zealand, more than any other example, is cast as a laboratory of the future.

New Zealand serves two purposes. The first is public-health related. It offers evidence that smoking declines can accelerate when regulated alternatives become more widely available, including among groups historically hit hardest, such as Māori and other disadvantaged populations.

The second is political. In 2022, the country approved an endgame package with hard measures: denicotinization of cigarettes, a drastic reduction in retail outlets, and a “smoke-free generation” law. After the change of government, much of that package was repealed before it could take effect. The episode is read as a lesson: perhaps more coercive strategies are too fragile to endure; perhaps a transition built on regulated substitution is less elegant, but more sustainable.

That reading is intelligent because it turns repeal into argument. What might have looked like the defeat of a harder-line project becomes indirect proof that another path is needed.

Of course, the resistance is easy to predict. Youth, long-term uncertainty, dual use: these are the gates that mark the frontier of what remains acceptable in the field.

On youth, the aim is to weaken the harder versions of the gateway hypothesis by insisting that many observational studies confuse correlation with a shared predisposition to risk.

On long-term effects, the authors concede uncertainty, but insist that the absence of combustion already changes the equation.

They make another defensive move as well: the review literature, they note, places nicotine e-cigarettes among the most effective cessation tools available, and, in countries such as the United Kingdom, their possible net population benefit is already under continuous scrutiny.

On dual use, they reject the idea of automatic failure. For some smokers, it may represent a transitional stage, not a destination. Here, the argument becomes more specific: biomarker studies suggest that dual users show lower exposure to toxicants than exclusive smokers. Even so, that reduction does not place them on the same footing as exclusive e-cigarette users.

The rhetorical strategy is consistent throughout. The concerns are not denied. They are stripped of veto power. The reader is asked to see an error of proportion: the new risk is feared too much, while the old one is tolerated out of habit.

The most politically effective part of the argument may lie elsewhere, in its distributive force. Harm reduction is not presented merely as an expedient for adult smokers who cannot quit. It is given a role in reducing inequality. That gives the proposal an added moral gravity. It would not simply accelerate average declines; it would help dislodge the cigarette precisely where it remains most deeply entrenched: among the poor, the vulnerable, the dependent, those most left behind by the field’s earlier successes.

This is the ground on which the clearest banner is raised: smoke-free 2040.
Less than 5% adult daily smoking prevalence by 2040.

Policy likes a slogan when it can condense a worldview. This one can. Its force lies not only in being measurable. It lies in establishing a new criterion of success. Not necessarily a world without nicotine. A world in which the cigarette no longer occupies the center. And the slogan comes with hard numbers: in 2024, global smoking prevalence among people aged fifteen and older stood at sixteen per cent to twenty-eight per cent among men and five per cent among women. If current trends persist, the world will fall to around ten per cent by 2040. Their target—below five per cent—would require more than doubling the current rate of decline.

The agenda is meant to travel beyond high-income settings. Low- and middle-income countries face a different reality: cigarettes are relatively more affordable, cessation services are scarce, regulation is uneven, markets are more opaque, and state capacity is weaker. Even so, the proposal is framed on a global scale. Its instruments are differential taxation, context-specific research, regulatory strengthening, and institutional innovation elements that the authors see as indispensable to adapting harm reduction to local conditions, especially where the state is weaker and the informal market more powerful.

There is also a note of state realism here that is hard to miss. A regulated transition affects revenue, health-care costs, and illicit trade, and those effects, the authors argue, will have to be actively managed, especially in countries where tobacco still carries fiscal weight. At that point, the debate stops being merely clinical or cultural. It becomes a matter of statecraft.

This is why the WHO ends up as the argument’s true addressee. The piece begins to read almost like an open letter. It asks for more than tolerance. It asks for legitimation. It wants harm reduction to stop occupying a gray zone and to be recognized as an explicit component of comprehensive tobacco control. It wants, in other words, to move the center of authority in the conversation.

That may be the fairest and most exact way to read Beaglehole, Bonita, and Pang: not as mounting a side defense of a set of products, but as trying to rewrite the code of an entire field. For a long time, tobacco control knew how to say clearly what it condemned. What is being asked now is whether the field is prepared to say, without embarrassment, what it would be willing to tolerate to defeat the cigarette.

Because, in the end, this is not only a request to revise the instruments. It is a request to revise the scruples. And it leaves hanging the question the field may be most reluctant to answer: what should count as success, the disappearance of nicotine, or the defeat of combustible tobacco’s relentless machinery of disease and death?

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Beaglehole, R., Bonita, R. & Pang, T. Smoke-free nicotine products can accelerate the end of the smoking epidemic. Nat. Health (2026). https://doi.org/10.1038/s44360-026-00121-1