Until recently, smoking was seen as a disease, a medical problem needing a professional solution from a physician, nurse or pharmacist. People who smoke were diagnosed with “Tobacco Use Disorder”. They were labelled as addicts, patients who needed to be cured with drugs such as nicotine patches or gum from a pharmacy or a prescription for Champix or Bupropion. They were encouraged to seek medical attention, to go to a clinic, and to follow a medically-ordained procedure to quit.

This was remarkably ineffective. These treatments have an 80 – 90% failure rate, perhaps the highest failure rate of any medical intervention. This is why smoking is still the leading cause of preventable deaths in Canada (and in many other countries), why 3.8 million Canadians still smoke, and why over 100 Canadians die every single day from smoking-related illnesses.

What happens if, instead, we assume that people who smoke are rational and intelligent consumers who are merely misinformed about the wide range of nicotine products that are available to them?

Some people who eat make careful, informed and sophisticated choices. For religious or ethical reasons, some people only eat kosher, halal or vegan food. Others avoid lactose, nuts or MSG. Some people are comfortable with drinking cow’s milk but not with eating veal. Other people avoid cow’s milk and use soy, almond or oat milk instead. Restaurants and supermarkets are required to provide people who eat with detailed health information about what they are eating. This may include quite complicated and detailed data about calories, fats, proteins and vitamins. Major chain restaurants provide low-calorie options for people who want to lose weight, as well as options for vegetarians.

Maybe people who smoke are similar to people who eat cheeseburgers, fries and a milkshake at a fast food restaurant because they are unaware that healthier options are available?

What are the equivalent less harmful but still satisfying, tasty substitutes for a cigarette?

There are many safer alternatives to smoking. Which is best for a particular smoker depends on why they smoke and what they are looking for from a “smoke break.”

If they want something to do with their hands, something to put in their mouths, and the opportunity to blow a cloud into the air, then they could switch to vaping, which is about 20 times safer than smoking (despite all the media scare stories).

If they like the smell and taste of tobacco and want to use a small portion of tobacco that will last about five minutes, then they could use a heat-not-burn device such as IQOS. Because the tobacco is only heated and not burnt, this product is about 10 times safer than smoking.

However, if the main reason that they smoke is that they want the psychological effects of nicotine, then oral nicotine products such as snus (made with tobacco) or nicotine pouches (that are a tobacco-free source of nicotine) may be the best option. These products are placed under the gum, where they release nicotine over the course of about 30 minutes, reducing nicotine withdrawal symptoms and decreasing cravings for tobacco. They are about 100 times safer than smoking.

Instead of assuming that people who smoke are addicted, deranged and diseased, we should instead assume that they are rational consumers who are aware that smoking is dangerous and who, given the choice and the right information, may prefer to use a different source of nicotine, instead of smoking cigarettes.

How can we compare the different sources of nicotine?

There is now a wide range of nicotine-containing products available to consumers. Most people are aware of nicotine gum and vaping, but few people know about heat-not-burn devices and nicotine pouches. The table below should help to clarify their choices. Note that they all contain nicotine, a relatively harmless natural substance that makes cigarettes addictive. Nicotine is less addictive in other forms – almost no one gets addicted to nicotine patches or gum. Nicotine does not cause cancer or lung disease. It does slightly increase heart rate and blood pressure, but this effect is similar to caffeine or a brisk walk. For consumers who do not want to use nicotine that comes from tobacco, there is now a synthetic form of nicotine that is manufactured in a laboratory that has nothing to do with the tobacco plant.

The three things that make cigarettes so dangerous are tobacco, combustion and inhalation. Tobacco can be cleaned and purified (as is the case with snus, which are pasteurized), but it will always contain some harmful chemicals, such as tobacco-specific nitrosamines. When organic matter, such as tobacco leaves, is burnt, this combustion creates a wide array of poisonous and carcinogenic chemicals. The “sidestream” smoke produced by a lit cigarette sitting in an ashtray between puffs is actually even more dangerous than the smoke which is inhaled directly. Lungs are very delicate, and ideally, they should not be exposed to any chemicals except fresh air. Inhalation of a chemical is a very rapid way to get it into the body, but it risks causing lung damage.

Nicotine pouches and medical NRT do not involve tobacco, combustion or inhalation, so they are the safety options, but they may not meet the behavioural needs of people who have enjoyed the rituals of tobacco smoking for many years. If a product is not enjoyable, then consumers may be inclined to return to smoking.

How much safer are the alternatives to cigarettes?

This chart shows the relative risks of various nicotine products. Cigarettes are the most dangerous and are assigned a value of 100. Heat-not-burn, snus and vape all score less than 10, meaning they are at least 10 times safer than smoking. Nicotine pouches and medical nicotine replacement therapy have a risk level of under 1, meaning that they are over 100x safer than smoking. The exact figures are debatable. At one time, Health Canada suggested that vaping may “only” be 5x safer than smoking. However, no one who understands the science and has read the research disputes the idea that all the alternative nicotine products are many times safer than smoking.

There is real-world population-level proof of the concept that smokers switching to less harmful sources of nicotine reduces smoking and saves lives. In Sweden, widespread use of snus is associated with the lowest smoking rate and the lowest rate of smoking-related diseases in Europe. In Japan, many smokers have switched to IQOS, decreasing cigarette sales by 74 billion units per year, which is now leading to a decrease in smoking-related diseases.

Should people who smoke switch to vaping?

There is very clear scientific evidence that switching from smoking to vaping is a significant benefit to health and an effective way to quit smoking.

The highly-respected Cochrane Collaboration has determined that “e-cigarettes, also known as ‘vapes,’ help people to quit smoking better than traditional nicotine replacement therapies, such as patches and chewing gums“.

Health Canada states that “If you’ve tried approved methods to quit and are still smoking, switching completely to vaping nicotine is less harmful than continuing to smoke.”

The Centre for Addiction and Mental Health recommends “Switching completely to e-cigarettes will significantly reduce the harms associated with combusted tobacco. Continued use of e-cigarettes may reduce risk of relapse to combustible tobacco.“

The Honourable Carolyn Bennett, Minister of Mental Health and Addiction and Associate Minister of Health, said:

“Vaping products offer the 3.8 million Canadians who smoke a less harmful source of nicotine than tobacco products, and do help people to stop smoking.”

However, Health Canada’s own research shows that neither smokers nor their medical professionals are aware of this vital information. In part, this is because Section 30.43 of the Tobacco and Vaping Products Act (TVPA) actually forbids people who are selling vaping products from saying that they are safer than smoking. This gag law is unjust and causes deaths. It needs to be repealed.

The manufacturers of Sesh, a brand of nicotine gum, specifically say that their product is not a smoking cessation tool, even though it is a safe and reliable alternative source of nicotine for smokers. It seems that the medical model for smoking as a disease is so strong that suggesting consumers pick a safer nicotine product could count as offering medical advice without a medical licence.

How do Canada’s policies compare to other countries?

Around the world, the laws and policies on nicotine products vary widely and irrationally. They owe much more to politics than they do to science. In many cases, they permit the tobacco industry to continue to sell its highly lethal products while preventing the sale of cheaper (but not completely harmless) competitors. For example, Japan forbids the sale of vape but permits the sale of more dangerous heat-not-burn devices. In the USA, the FDA states that “Using General Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis”, but snus is completely banned in the UK and in most of the European Union. India was praised by the WHO for banning vaping, but it still allows the sale of cigarettes, including cheap and dangerous “bidis”.

In Canada, we are lucky that the full range of nicotine alternatives is legally available to adult Canadians who smoke. However, the majority of alternative sources of nicotine are controlled by the tobacco industry. The only heat-not-burn product on the market is IQOS, made by Philip Morris International (PMI), a tobacco company. PMI has also bought up Swedish Match, the company that makes General Snus. The only nicotine pouch available is Zonnic, from Imperial Tobacco Canada, a branch of British American Tobacco. This monopoly creates a very dangerous situation. Tobacco companies make vast profits from producing cigarettes, a product that has changed very little over the years and a market in which they are unlikely to face competition from new companies. Although some tobacco companies claim that they are transforming or “unsmoking” the vast majority of their profits continue to come from selling combustible tobacco. Every time someone switches from cigarettes to vaping, snus or nicotine pouches, they lose money. The only way that a tobacco company profits from newer nicotine products is when they sell them to people who do not already smoke. This is why products like Zonnic have been deliberately marketed as lifestyle products for trendy young people rather than as smoking cessation aids. A company that produces a heat-not-burn device or an oral nicotine product but does not market cigarettes can sell it to the world’s one billion smokers without worrying that these sales will cut into its cigarette profits.

Unfortunately, although major cigarette manufacturers claim that they are transitioning away from selling cigarettes, no vaping device has been approved for smoking cessation in Canada, as none of the vaping manufacturers or tobacco companies have done the necessary paperwork. As a result, healthcare professionals are unwilling to suggest an unapproved but effective product to their patients who smoke.

Conclusions

We should consider that continuing to smoke is an unhealthy choice rather than an illness that requires a medical or pharmaceutical solution. Consumers who want or need to use nicotine to prevent cravings for cigarettes and nicotine withdrawal symptoms should know about all the other safer sources of nicotine. If nicotine consumers were properly informed about the full range of alternative safer (and cheaper) sources of nicotine that are available to them, many of them would act in a rational manner. and switch away from smoking and save their own lives. No medical intervention is necessary.

Health Canada should launch a massive public awareness campaign to ensure that people who smoke and healthcare workers are properly informed about all their options. The TVPA should be revised so that the sellers of vaping products can make truthful statements about the merits of their products.

Tobacco companies must not be allowed to develop a monopoly on the sale of all forms of nicotine. Ways should be found to encourage companies that are unrelated to “big tobacco” to sell nicotine products. Vaping products that can be prescribed by physicians, sold in pharmacies, and covered by provincial or private health insurance policies should also be developed.

Vaping products, heat-not-burn devices, snus and nicotine pouches should all be available wherever people can buy cigarettes. They should have the same age limit. Like nicotine gum, they should come in a range of enjoyable flavours. If they are taxed at all, they should be taxed at a much lower rate than combustible cigarettes. They should be labelled and sold as safer alternatives to combustible cigarettes.