Key concepts

Tobacco harm reduction is a potentially life-saving intervention for millions of people across the world. To those who currently use high-risk tobacco products, like cigarettes and some oral tobaccos, it offers the chance to switch to a range of safer nicotine products (SNP) that pose fewer risks to their health. And, while it is a relatively new addition to the arsenal of global public health solutions, its effectiveness builds on decades of success with earlier harm reduction initiatives.

Everyone uses products or behaves in ways that pose risks to our health. Governments do not try to stop people from driving, for example. What they do instead is enact laws about seat belt use and issue safety standards for manufacturers. These things reduce – but do not eliminate – the risk of injury or death.

In public health, harm reduction reduces health risks by providing people with safer alternative products and/or encouraging less risky behaviours, rather than by banning those products or behaviours. It emerged in the fight against HIV/AIDS in the 1980s and has since developed into a range of evidence-based, humane and cost-effective practices that save countless lives worldwide.

Most people know that tobacco use is harmful to health and that people use tobacco to consume nicotine. It is less well known that nicotine itself does not cause the severe illnesses associated with high-risk tobacco products like cigarettes. Nicotine is a comparatively low-risk drug, but its effects encourage repeated use. This is one of the reasons people find it hard to stop smoking, even when they know it is bad for their health.

The most dangerous way of using nicotine is by burning a cigarette and inhaling the smoke. Burning tobacco releases tar and gases containing thousands of toxins, many of which pose a risk of severe illness, leading to premature death in half of all smokers. Some oral tobacco products also release dangerous toxins when consumed.

In contrast, safer nicotine products (SNP) are non-combustible: none of them burn tobacco and some of them do not contain any tobacco at all. They include nicotine vapes (e-cigarettes), tobacco-free nicotine pouches, Swedish-style snus (an oral tobacco), many US smokeless (chewing) tobaccos and heated tobacco products. Many of these products have only been developed in the last 10–15 years.

Safer nicotine products are non-combustible: none of them burn tobacco and some of them do not contain any tobacco at all.

Patches and gums represent another category of tobacco harm reduction product called nicotine replacement therapy (NRT). NRT and pharmaceutical products like varenicline (also called Champix) are effective for many people, while for others, they do not work. In many low and middle-income countries (LMIC), they are inaccessible or unaffordable.

SNP provide another option for people who want to reduce the harm connected to their use of nicotine. Many consumers report that they like vaping, using nicotine pouches, snus or heated tobacco products as they offer a more satisfying replacement for some of the habits and behaviours of smoking compared with other methods of quitting smoking.

Why is tobacco harm reduction needed?

Current efforts to curb smoking are not working quickly, equitably or effectively enough.

The number of smokers worldwide has remained the same for 20 years

In 2024, one in six people worldwide (16.7 per cent) were current tobacco smokers.1

Reductions in global smoking rates have largely stalled since 2010 and have been unevenly distributed across the world. Four in every five people who smoke live in low- and middle-income countries – the places least able to offer cessation support or healthcare for smoking-related illness.

There are still one billion people who smoke tobacco every day. The absolute number of people who smoke is set to rise in some regions as populations grow.2 And every year, smoking causes an estimated eight million preventable deaths, most of them in low- and middle-income countries.

Current tobacco control measures alone are failing to reduce smoking-related death and disease fast enough. New approaches are needed.

Harm reduction history

Rather than coming from experts, harm reduction is often initiated by people who are directly affected by, or engaging in, risky behaviours, as a means of supporting their peers. Its development can be an organic and dynamic process.

When harm reduction first took off in the 1980s, communities were responding to the emergence of HIV among men who have sex with men, sex workers and people who inject drugs. People distributed condoms, sterile injecting equipment and advice on how to reduce the risk of contracting the virus. Initially these groups received no government help. The reaction of politicians, the media, society at large and many in the health sector was often hostile.

But by the late 1980s, politicians and the medical community in the UK began to recognise the potential benefits and cost-effectiveness of a harm reduction approach. This resulted in the UK’s success in limiting the spread of HIV. Other countries also saw steep falls in infection rates once they adopted harm reduction measures. Harm reduction works.

Harm reduction is particularly relevant to the use of psychoactive substances (those substances that alter your mental state). The use of mood-affecting products is common to all cultures and parts of the world with examples including caffeine, tea, nicotine, alcohol, cannabis, opium, tranquillisers, and psychoactive plants. Some substances are risky in themselves. For others, much of the risk lies in the way the drug is administered. For nicotine, the route of administration is crucial to the level of risk.

Is continued use of nicotine a concern?

Nicotine is on the World Health Organization’s list of Essential Medicines in the form of Nicotine Replacement Therapy (NRT).3 For decades, medical practitioners have prescribed patches, gums and lozenges containing nicotine to help people trying to quit smoking.

Nicotine has a stimulant effect, triggering the release of neurotransmitters including dopamine, associated with pleasure and reward. This process can encourage regular consumption and may lead to dependence. Crucially, however, none of the significant health problems associated with smoking, such as cancer or COPD, are caused by nicotine.

In its 2024 evidence review of vaping and harm reduction, the Royal College of Physicians (UK) confirmed that “current evidence suggests nicotine itself confers little risk to health”, and that while “not harmless, [nicotine vapes] are demonstrably less harmful than smoked tobacco to user and bystander alike.”4

For people who are currently smoking and who either cannot, or do not want to, stop using nicotine, switching to safer products offers an opportunity to dramatically reduce the risks to their health.

Harm reduction and the right to health for all

Harm reduction is a political and social justice issue as well as a public health issue. International treaties make it clear that health is a universal right,5 and the UN has accepted that harm reduction for people who use drugs is part of the right to health.6 There are a billion people who smoke worldwide, and they have the same right to health as anyone else.7

A basic principle of public health endorsed by the World Health Organization is that people should be empowered to have control over their own health in order to live healthier lives.8 Tobacco harm reduction is a prime example of people being empowered to take charge of their health by choosing safer ways of using nicotine.

How did tobacco harm reduction develop?

The idea of tobacco harm reduction can be traced to the British tobacco researcher Michael Russell, writing in the British Medical Journal in 1976.9 He recognised that people “smoke for nicotine but die from the tar”.

Several influential reports followed, which explored the idea that so long as tobacco is not combusted, nicotine can be consumed at substantially reduced risk. These included the 2001 US Institute of Medicine report Clearing the smoke: assessing the science base for tobacco harm reduction,10 and the UK Royal College of Physicians’ 2007 report Harm reduction in nicotine addiction: helping people who can’t quit.11 These reports were written before most safer nicotine products were widely available, with the exception of snus and NRT.

The advent of nicotine vaping, from the mid-2000s onwards, was a significant step forward for tobacco harm reduction. Many people who wanted to quit smoking tried vaping and found it easy to switch. In 2015, Public Health England (PHE), an agency of the UK’s Department of Health, published a landmark review into the safety and harm reduction potential of vaping, concluding that “best estimates show e-cigarettes are 95 per cent less harmful to your health than normal cigarettes”.12 The UK National Health Service has supported vaping for smoking cessation since the mid-2010s.

Globally, tobacco harm reduction is being driven by people who want to switch away from smoking and improve their health. The increasing availability of safer nicotine products offers them this choice. In most countries, however, this is taking place without the support of – and sometimes despite opposition from – public health authorities and governments.

Tobacco harm reduction, the tobacco industry and international tobacco control

Tobacco harm reduction is one of the three pillars of tobacco control. The Framework Convention on Tobacco Control (FCTC)13 – the international treaty on tobacco – was enacted in 2005. Its aim was to challenge the increasingly international nature of tobacco companies by bringing nations together to develop measures to control tobacco production and use.14

The FCTC states that tobacco control means “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” [emphasis added].15

The FCTC does not define harm reduction, but officials drafting the Convention were aware that products might be developed to allow the consumption of nicotine at far less risk to consumers and bystanders. The FCTC also declares that tobacco control measures are dynamic and should be “based on current and relevant scientific, technical and economic considerations”.

The FCTC was enacted long before many of today’s safer nicotine products were widely available. The WHO endorses a harm reduction approach in many areas of public health, including drug use. But to date, despite being explicitly named in the FCTC, the WHO rejects harm reduction for tobacco and encourages bans or heavy restrictions on safer nicotine products.

The major tobacco companies have a long and egregious record of lies over the health risks of combustible cigarettes. Many people working in tobacco control have spent years fighting against the industry. Numerous tobacco companies are now producing safer nicotine products. The understandable lack of trust has led to a refusal to engage with harm reduction.

But nicotine vapes were first developed and marketed by independent companies in China. It was only once it became evident that consumers were switching to vaping at scale that some international tobacco companies began investing in the development, manufacture and sale of vapes and other safer products.

And independent evidence is mounting that safer nicotine products can both improve health and save lives. If tobacco harm reduction is to reach its potential, much rests on the global regulation of safer nicotine products. In March 2026, a third of the global population were living in countries that ban all safer nicotine products.16 Combustible cigarettes, meanwhile, remain legally available in every country on Earth. If safer products continue to be banned or heavily restricted, tobacco companies will stop producing them, while continuing to reap huge profits from cigarettes.

The evidence base

The evidence base for tobacco harm reduction

Reviews of the evidence from many internationally respected professional and medical bodies have definitively stated that safer nicotine products pose significantly fewer risks to health than any combustible, and many types of oral, tobacco products. The evidence shows they have an important role to play in helping people quit smoking and reducing smoking-related death and disease.

Independent Multi-Criteria Decision Analysis (MCDA): In 2014, the Independent Scientific Committee on Drugs convened an expert panel to assess the harms of nicotine-containing products. They developed a model using multi-criteria decision analysis, enabling them to rank products according to their harm to individuals and to others; 100 was the highest harm score, and zero represented no harm. Cigarettes emerged as the most harmful product, scoring 100. Snus scored 5 and nicotine vapes scored 4. The group concluded that “cigarettes are the nicotine product causing by far the most harm to users and others in the world today. Attempts to switch to non-combusted sources of nicotine should be encouraged as the harms from these products are much lower.”17

The Society for Research on Nicotine and Tobacco leaders: Fifteen past Presidents of the SRNT published a joint statement that “vaping can benefit public health, given substantial evidence supporting the potential of vaping to reduce smoking’s [death] toll. [...] Frequent vaping increases adult smoking cessation [and] completely substituting vaping for smoking likely reduces health risks, possibly substantially.”18

Office for Health Improvement and Disparities (OHID), formerly Public Health England (PHE): The organisation’s first review into vaping (when it was known as PHE) was in 2015 and concluded that “best estimates show e-cigarettes are 95 per cent less harmful to your health than normal cigarettes.”19 The eighth and final review into vaping concluded in 2022 that “in the short and medium term, vaping poses a small fraction of the risks of smoking”, and that there is “significantly lower exposure to harmful substances from vaping compared with smoking, as shown by biomarkers associated with the risk of cancer, respiratory and cardiovascular conditions.”20

UK Royal College of Physicians: “E-cigarettes should be promoted as an effective means of helping people who smoke to quit smoking tobacco. Campaigns recommending e-cigarettes for smoking cessation should include populations who are likely to experience the most benefit, including people with mental disorders, those who experience socio-economic disadvantage and people living in social housing.”21

UK National Health Service: “Nicotine vaping is less harmful than smoking. It’s also one of the most effective tools for quitting smoking.”22

New Zealand Ministry of Health: “The Ministry considers vaping products could disrupt inequities and contribute to a Smokefree 2025. The evidence on vaping products indicates they carry much less risk than smoking cigarettes but are not risk-free. Evidence is growing that vaping can help people to quit smoking. There is no international evidence that vaping products are undermining the long-term decline in cigarette smoking among adults and youth and may in fact be contributing to it.”23

Cochrane Review: Cochrane is a global, independent, non-profit network of health researchers and professionals working to produce high-quality health information and improve healthcare worldwide. Their systematic reviews of randomised controlled trials are considered gold standard. In 2025, Cochrane’s latest review of vaping for smoking cessation concluded that “nicotine e-cigarettes can help people to stop smoking for at least six months. Evidence shows they work better than nicotine replacement therapy.”24

US Federal Drug Administration: The FDA holds responsibility for regulating tobacco and nicotine products in the US. Recognising that some nicotine products pose less risk than combustible tobacco, a new legal category, Modified Risk Tobacco Products (MRTP), was created under the Family Smoking Prevention and Tobacco Control Act in 2009. Some Premarket Tobacco Product Applications (PMTAs) have been granted to individual safer nicotine products enabling manufacturers to sell the products, and a small number have also received Modified Risk Granted Orders (MRGO), meaning manufacturers can market them to consumers as lower risk compared to smoking.25 General Snus from Swedish Match became the first authorised MRTP in October 2019.

Tobacco harm reduction in action

Research carried out by the Global State of Tobacco Harm Reduction suggests that more than 200 million people are using safer nicotine products around the world.

Our peer-reviewed estimates indicate that, in 2024, 78 million people used heated tobacco products, and in 2025, 129 million people vaped. These figures do not include the tens of millions of people who use snus or nicotine pouches.26,27

Both market data and prevalence data provide convincing evidence of substitution effects from multiple countries across a number of regions.

  • Sweden and Norway: High levels of snus use are associated with very low levels of smoking in both countries. In 2024, 5.4% of the Swedish population aged 16–84 smoked daily, while 15.7% used snus daily. Among people aged 16–29, smoking has fallen to just 2%.28 In 2005, 5% of Norwegians aged between 16 and 74 used snus daily, while 25% smoked daily; by 2023, 16% were using snus and the daily smoking rate had fallen to 7%. Smoking among people aged 16–24 had fallen to around 3%.29
  • Japan: GSTHR research shows that after HTP were introduced to the Japanese market in 2014, cigarette sales halved in under ten years.30 Smoking rates had been falling for years in Japan, but the decline accelerated after HTP arrived; the reduction in cigarette sales between 2016–2019 was five times greater than the drop between 2011–2015.31 Smoking rates have continued to drop, and there are indicators that people who smoke are using HTP to reduce the number of cigarettes they smoke. There are early indications of improved health outcomes among younger cohorts.32
  • United Kingdom: As vaping has increased, there has been a rapid decline in smoking, with vapes becoming the most popular smoking cessation tool. In 2024, vaping prevalence overtook smoking for the first time; 9.1% of adults were current smokers, compared to 10.0% who were current vapers.33
  • New Zealand: A rapid rise in vaping (from 0.9% of adults in 2015/16 to 11.7% in 2024/25) has coincided with a substantial decline in smoking (from 16.4% in 2011/12 to 6.8% in 2024/25). Recent data indicate that vaping prevalence has stabilised at a level higher than smoking, with daily vaping continuing to exceed daily smoking among adults.34

CHANGES IN SMOKING AND VAPING PREVALENCE IN NEW ZEALAND

What should happen next?

Tobacco harm reduction has a key role to play in the future of tobacco control by reducing global consumption of cigarettes and risky oral tobaccos. It offers new choices to millions of people who want to switch away from smoking and other risky tobacco products. For people who can’t or don’t want to quit nicotine, switching to safer nicotine products offers huge potential benefits.

Governments should facilitate tobacco harm reduction, removing obstacles to the use of safer nicotine products by people who want to quit risky tobacco. Effective and appropriate product regulation is needed both to protect consumers and avoid youth uptake. However, policies and tax frameworks should be carefully designed to avoid unintentionally favouring risky products.

Millions of people are already benefiting after having switched from smoking to safer nicotine products. Many have done this despite opposition or indifference from their governments, and mixed messaging from health authorities. In the coming decades, many millions more could live longer, healthier lives if safer nicotine products are substituted for combustible cigarettes. Tobacco harm reduction could deliver one of the greatest public health gains of the 21st century – but only if its potential is fully realised.

References

  1. WHO. (2024). WHO global report on trends in prevalence of tobacco use 2000–2030. World Health Organization. https://www.who.int/publications/i/item/9789240088283.
  2. WHO, 2024.
  3. WHO. (2026). eEML - Electronic Essential Medicines List—Nicotine Replacement Therapy. World Health Organization. https://list.essentialmeds.org/?query=nicotine+replacement+therapy.
  4. E-cigarettes and harm reduction: An evidence review. (2024). The Royal College of Physicians (RCP). https://www.rcp.ac.uk/policy-and-campaigns/policy-documents/e-cigarettes-and-harm-reduction-an-evidence-review/.
  5. Office of the United Nations High Commissioner for Human Rights. (2008). The Right to Health (No. 1014–5567; Fact Sheet No. 31). United Nations. https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf.
  6. United Nations. (1948, December 10). Universal Declaration of Human Rights. United Nations. United Nations General Assembly. https://www.un.org/en/about-us/universal-declaration-of-human-rights.
  7. WHO, 2024.
  8. World Health Organization. (2017, December 29). Human rights and health. WHO. https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health.
  9. Russell, M. A. (1976). Low-tar medium-nicotine cigarettes: A new approach to safer smoking. British Medical Journal, 1(6023), 1430–1433. https://doi.org/10.1136/bmj.1.6023.1430.
  10. Institute of Medicine (US) Committee to Assess the Science Base for Tobacco Harm Reduction. (2001). Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction (K. Stratton, P. Shetty, R. Wallace, & S. Bondurant, Eds). National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK222375/.
  11. Tobacco Advisory Group of the Royal College of Physicians. (2007). Harm reduction in nicotine addiction: Helping people who can’t quit. Royal College of Physicians. https://shop.rcplondon.ac.uk/products/harm-reduction-in-nicotine-addiction-helping-people-who-cant-quit.
  12. McNeill A, Brose LS, Calder R, Hitchman SC, & McNeill A, Brose LS, Calder R, Hitchman SC. (2015). E-cigarettes: An evidence update: A report commissioned by Public Health England. Public Health England. https://www.gov.uk/government/publications/e-cigarettes-an-evidence-update.
  13. World Health Organization. (2003). WHO Framework Convention on Tobacco Control, updated reprint 2004, 2005 (full text). World Health Organisation. https://iris.who.int/bitstream/handle/10665/42811/9241591013.pdf.
  14. Shapiro, H. (2020). Burning Issues: Global State of Tobacco Harm Reduction 2020 (GSTHR Major Reports). Knowledge- Action-Change. https://gsthr.org/resources/item/burning-issues-global-state-tobacco-harm-reduction-2020.
  15. World Health Organization, 2003. Article 1 paragraph (d), page 11
  16. Shapiro, H., Jerzyński, T., Mzhavanadze, G., & Porritt, O. (2024). The Global State of Tobacco Harm Reduction 2024: A Situation Report (No. 4; GSTHR Major Reports). Global State of Tobacco Harm Reduction (GSTHR). https://gsthr.org/resources/thr-reports/the-global-state-of-tobacco-harm-reduction-2024-a-situation-report/.
  17. Nutt, D. J., Phillips, L. D., Balfour, D., Curran, H. V., Dockrell, M., Foulds, J., Fagerstrom, K., Letlape, K., Milton, A., Polosa, R., Ramsey, J., & Sweanor, D. (2014). Estimating the harms of nicotine-containing products using the MCDA approach. European Addiction Research, 20(5), 218–225. https://doi.org/10.1159/000360220.
  18. Balfour, D. J. K., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R. (2021). Balancing Consideration of the Risks and Benefits of E-Cigarettes. American Journal of Public Health, 111(9), 1661–1672. https://doi.org/10.2105/AJPH.2021.306416.
  19. McNeill A, Brose LS, Calder R, Hitchman SC, & McNeill A, Brose LS, Calder R, Hitchman SC, 2015.
  20. Office for Health Improvement and Disparities (OHID). (2022, September 29). Nicotine vaping in England: 2022 evidence update main findings. GOV.UK. https://www.gov.uk/government/publications/nicotine-vaping-in-england- 2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-main-findings.
  21. Royal College of Physicians. (2016). Nicotine without smoke: Tobacco harm reduction (RCP Policy: Public Health and Health Inequality). Royal College of Physicians. https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction.
  22. Vaping to quit smoking—Better Health. (2022, September 20). NHS.UK. https://www.nhs.uk/better-health/quit-smoking/vaping-to-quit-smoking/.
  23. New Zealand government. (2020, September 3). Position statement on vaping. Ministry of Health NZ. https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/vaping-smokefree-environments-and-regulated-products/position-statement-vaping.
  24. Lindson, N., Butler, A. R., McRobbie, H., Bullen, C., Hajek, P., Wu, A. D., Begh, R., Theodoulou, A., Notley, C., Rigotti, N. A., Turner, T., Livingstone-Banks, J., Morris, T., & Hartmann-Boyce, J. (2025). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, 1. https://doi.org/10.1002/14651858.CD010216.pub9.
  25. U.S. Food and Drug Administration, Center for Tobacco Products. (2022). Modified Risk Granted Orders. FDA. https://www.fda.gov/tobacco-products/advertising-and-promotion/modified-risk-granted-orders. General Snus from Swedish Match became the first authorised MRTP in October 2019.
  26. Mzhavanadze, G., Stimson, G. V., & Jerzyński, T. (2026). Global Heated Tobacco Product User Estimates, 2014-2024: Descriptive Surveillance Study Using Manufacturer Disclosures. JMIR Public Health and Surveillance, 12(1), e88761. https://doi.org/10.2196/88761.
  27. Jerzyński, T., Mzhavanadze, G., & Stimson, G. V. (2026). Estimation of the global number of nicotine vapers in 2025. Global Epidemiology, 11, 100257. https://doi.org/10.1016/j.gloepi.2026.100257.
  28. Folkhalsomyndigheten. (2024, December 12). Use of tobacco and nicotine products. The Public Health Agency of Sweden; folkhalsomyndigheten.se. https://www.folkhalsomyndigheten.se/the-public-health-agency-of-sweden/living-conditions-and-lifestyle/andtg/tobacco/use-of-tobacco-and-nicotine-products/.
  29. Tobacco, alcohol and other drugs. (2024, January 18). Statistisk Sentralbyrå (Statistics Norway, SSB). https://www.ssb.no/en/helse/helseforhold-og-levevaner/statistikk/royk-alkohol-og-andre-rusmidler.
  30. Cigarette sales halved: Heated tobacco products and the Japanese experience (Briefing Papers). (2024). Global State of Tobacco Harm Reduction (GSTHR). https://gsthr.org/resources/briefing-papers/cigarette-sales-halved-heated-tobacco-products-and-the-japanese-experience/cigarette-sales-halved-heated-tobacco-products-and-the-japanese-experience/.
  31. Cummings, K. M., Nahhas, G. J., & Sweanor, D. T. (2020). What Is Accounting for the Rapid Decline in Cigarette Sales in Japan? International Journal of Environmental Research and Public Health, 17(10), 3570. https://doi.org/10.3390/ijerph17103570.
  32. Iwanaga, Y., Nakai, M., Miyamoto, Y., Hirano, T., & Fujiwara, H. (2025). Heated Tobacco Product Spread and Hospitalizations for Acute Coronary Syndrome in Japan. JAMA Network Open, 8(10), e2537334. https://doi.org/10.1001/jamanetworkopen.2025.37334.
  33. Adult smoking habits in the UK: 2024. (2025, November 4). Office for National Statistics. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/ adultsmokinghabitsingreatbritain/2024.
  34. Trends in smoking and vaping: New Zealand Health Survey 2024/25. (2025, November 19). Ministry of Health - Manatu Hauora NZ. https://www.health.govt.nz/monitoring-statistics/surveys/new-zealand-health-survey/ publications/202425-survey-publications/trends-in-smoking-and-vaping.