• December 10, 2023

The Core of the Confusion

 The Core of the Confusion
Photo: Westock

The likely origins of the prevailing misperceptions about nicotine—and how that impacts tobacco harm reduction

By Sudhanshu Patwardhan

A widely prevalent misperception prevailing in society is that nicotine in tobacco products causes cancer. This myth and its widespread acceptance even among healthcare practitioners worldwide was recently highlighted by a survey among 15,000 doctors from 11 countries. Nicotine misperception may be the key reason preventing the world from becoming free from risky forms of smoked and smokeless tobacco products. The origins of this misperception may have something to do with south Asia and the nasty oral tobacco products sold there.

The Basis of Tobacco Addiction

To achieve a world free of risky tobacco product use, understanding nicotine’s role in tobacco addiction is crucial. Tobacco addiction—in lay terms, the harmful habit of consumers of risky forms of tobacco to continue consuming despite knowing the harms to themselves and society—is primarily driven by the psychoactive effects of nicotine. The hand-to-mouth action, the action of nicotine on brain receptors, the activation of reward pathways in the brain, the release of neurotransmitters during product use and their eventual depletion, the expectation of the kick of the drug on longer term use, the craving and withdrawal effects that are mitigated by further consumption (or dosing) of nicotine, the social and cultural cues—all these point to a complex interplay. Nicotine is central to this addiction. An addiction that kills over 8 million people worldwide every year, affecting millions more in bereaved friends and families, and sees another 1.3 billion people in the world struggling to quit.

It Is the Smoke, Stupid … or Is It Just?

Over nearly five decades of tobacco control, thought leaders in the West have been enamored by—and have generously quoted—Michael Russell’s statement, “People smoke for nicotine, but they die from the tar” (Russell, British Medical Journal, 1976). He was right in the context of smoked tobacco. Indeed, this insight underpinned the enlightening among some tobacco control researchers in the U.K. and across the Atlantic. That in turn manifested in ground-breaking publications, e.g., the 2001 National Academy of Sciences’ Clearing the Smoke report, the 2007 U.K. Royal College of Physicians’ report Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit and the 2014 U.K. Royal College of Physicians’ report Nicotine Without Smoke: Tobacco Harm Reduction.”

Indeed, the U.K. medicines agency’s authorization of an additional harm reduction indication for nicotine-replacement therapy (NRT) products from 2010 onward established the world’s first class of licensed tobacco harm reduction products. This is often forgotten by tobacco harm reduction advocates as well as tobacco control enthusiasts around the world, with even lesser understanding of how and why the U.K. arrived at this fork on its journey in addressing tobacco-related harms (Patwardhan, Drug Testing and Analysis, 2022).

Metaphorically separating nicotine from its toxic delivery system that burned tobacco allowed Russell and the subsequent generations of public health thought leaders to pave the way for nicotine in cleaner forms to be formulated in various delivery systems, starting with medically licensed nicotine gums, patches and lozenges and culminating in Hon Lik’s invention of the e-cigarette. Heated-tobacco products launched by large tobacco multinationals also entered the market, with companies keen to “unsmoke” the world and phase out combusted tobacco, just like electric batteries in place of combustion engines in automobiles. Or Coke Zero and Pepsi Max instead of Coke and Pepsi. Right? Wrong! This narrative ignores oral tobacco consumption by nearly 300 million tobacco users, living mostly in Asia and Africa, and the attending oral and pharyngeal cancer-related morbidity and mortality.

Smokeless Tobacco’s Harms: A Collective Blind Spot

One estimate suggests that nearly 10 percent of doctors in the U.K. are of Indian or Pakistani origin and a sizeable number from Africa and the rest of Asia as well. There is even a higher proportion of healthcare professionals from these continents in mental health settings. Training in south and southeast Asia or Africa inevitably exposes doctors to patients presenting with the harms of oral tobacco.

Current medical curricula in these countries (or in fact anywhere else in the world) do not go into any level of detail when it comes to treating smoked or smokeless tobacco addiction. During medical education, it is quite common to simply identify the myriad diseases that tobacco is responsible for and to require trainee doctors to advise patients to quit. Which nicotine-replacement therapy to prescribe, why, how to provide behavioral counselling for tobacco de-addiction, the need for follow-up and relapse prevention, the impact of smoking on specific drugs’ metabolism and reduced efficacy are skills and knowledge that are not imparted at any stage of clinical training to doctors, dentists or nurses anywhere in the world.

There are millions of healthcare professionals in Asia and Africa and hundreds of thousands of expatriate doctors and nurses from these continents in Europe, America and the Middle East who have seen oral cancer patients, most likely resulting from oral tobacco use. They have seen firsthand the harms from oral tobacco products.

Unsurprisingly, telling them that tobacco harm reduction can be achieved by going smoke-free or by switching to “smokeless tobacco products” or giving “safer” nicotine alternatives will be perceived as fake news at best, disingenuous and dishonest at worst. Even licensed NRTs are not spared in this misperception, with many clinicians worried about nicotine causing cancer and NRT addiction with longer term use. This may result in inadequate NRT being prescribed for not long enough, thus making relapse more likely.


The use and harm profile of south Asian and African smokeless tobacco products is often not mentioned when championing snus (and therefore smokeless tobacco) as harm reduction. This can only add to the distrust of the industry and tobacco harm reduction advocates by the public health community.

Nicotine Misperception: The Likely Origin Story

There is an unprocessed wrong belief that most health experts and lay people have come to harbor: tobacco = nicotine = cancer. Toxicants, including carcinogens, are delivered during consumption of most tobacco products: from the smoke due to combustion of tobacco in the case of cigarettes/cigars/cigarillos and bidis, or added/formed in the manufacturing and storage of Asian and African oral tobacco products, e.g., chemicals, slaked lime, areca nut-specific nitrosamines and tobacco-specific nitrosamines (TSNAs).

The exception to these is Swedish-style pouched smokeless tobacco (snus). Through decades of evolving manufacturing standards and innovation, concentrations of carcinogens such as TSNAs and other toxicants in Swedish-style snus have been engineered to be minimal. The population level effects of the “Swedish experience” with snus in enabling a transition to a smokefree nation with the attending lowest male lung cancer rates in the EU, are the darling of tobacco harm reduction advocates. However, the use and harm profile of south Asian and African smokeless tobacco products is often not mentioned when championing snus (and therefore smokeless tobacco) as harm reduction. This can only add to the distrust of the industry and tobacco harm reduction advocates by the public health community.

In the absence of a curriculum that does not specifically distinguish nicotine’s psychoactive properties and dependence-causing potential from the toxicants formed or present in smoked or most smokeless tobacco products, healthcare professionals may easily conflate the tobacco products’ harms with nicotine.

Furthermore, their experience with patients from south Asia and Africa makes it logical for them to unconsciously do so. There are already lazy parallels with other widely prevalent addictions afflicting the world: e.g., alcohol. The nuance, however, is lost, that unlike nicotine, ethanol is the psychoactive component as well as the chemical that harms the liver and brain cells.

Lay media add to the confusion. Globally, tobacco control slogans and campaigns have run for decades now, most often using simple one-liner messages against nicotine. There was no need or place for nuance for those wanting to rid the world of the indirect harms of nicotine. It could even be justifiable for some to do so to achieve their utopian prize of a tobacco-free society (not to be confused with a society free from the harms of tobacco, a worthy goal).

The problem arises when nicotine, the very chemical that is vilified in the prevalent anti-tobacco narrative, when delivered in clean systems is recognized as a key solution for the 1.3 billion users of risky smoked and smokeless tobacco products. E.g., the World Health Organization has NRT on its model essential medicines list for treating tobacco dependence.

Nicotine: An Orphan Drug

Eighty percent of the world’s users of risky tobacco products, nearly 900 million people, live in low-income and middle-income countries (LMICs). Most of them do not have access to affordable and appealing safer forms of nicotine-replacement products, including NRT. A majority of healthcare professionals in those countries wrongly believe that nicotine in tobacco products causes cancer. In these countries, tobacco cessation treatments are either unavailable or delivered by healthcare professionals who are not trained in the art and science of nicotine replacement and behavioral interventions.

For too long, pharma and tobacco companies have shied away from owning nicotine, with pharma perhaps worried about the optics of selling a psychoactive substance with such global harms, albeit due to the dirty delivery system it is currently sold in. Tobacco companies care about their own brand and product and may prioritize brand building over broader product-agnostic market conditioning about nicotine. The result is that a large swathe of countries that lack the sophistication or the academic rigor and experience of the U.K.’s tobacco control community or the U.S.’ Food and Drug Administration find themselves accepting hand-me-down anti-tobacco-harm-reduction rhetoric.

Light at the End of the Tunnel?

A rush to launch new nicotine products globally without adequate disentanglement between tobacco and nicotine education will only lead to more knee-jerk reactions and bans. That shall slow down any ambition to make the world smoke-free, or to be more precise, free from risky tobacco products. Achieving nicotine literacy through education and practice may be the much-needed game changer. In theory, most countries, including LMICs, have NRT on their national essential medicines list.

That does not necessarily translate into actual availability and affordability for cessation. Anyone truly invested in tobacco harm reduction should recognize that much groundwork needs to be laid first to get the new generation of healthcare students and future practitioners to be nicotine confident—starting with NRT. Tobacco cessation, underpinned by tobacco harm reduction principles, should be taught, practiced and experienced in LMICs through well-regulated healthcare ventures and partnerships.

Consumers, healthcare practitioners and governments first need to see the success with cessation using conventional NRTs but also recognize the need for a wider choice of safer nicotine alternatives to wean off the 1.3 billion current tobacco users. Only then will the conditions be ripe for companies to responsibly market their nicotine innovations to adult tobacco users in such markets.