ONE: Develop an empathetic approach to people who smoke.

Most people who still smoke made a bad life choice when they were in their teens, before their brains were fully developed, thinking that they could quit smoking later. In middle age, they found that tobacco smoking had addicted them to nicotine, because tobacco companies were allowed to develop the most addictive cigarettes possible. They lacked the support, the strength, and the other sources of pleasure in their lives that would have made it easier to quit. The standard medically-recommended methods for quitting they thought would help them actually only have a success rate of 10% or less.

People who smoke are often poor, less well-educated, and suffering from physical or mental health problems. Many are from disadvantaged groups such as the indigenous and LGBTQ communities.

They do not deserve decades of disease and disability, painful, disfiguring and disabling surgery and toxic chemotherapy, and a premature death, just for making a stupid choice in their youth and being unable to recover from the resulting nicotine addiction.

TWO: Set a goal and make a plan

Health Canada has committed to a reasonable goal of a tobacco prevalence of under 5% by 2035. They have yet to publish a plan to achieve that goal.

Failing to plan is planning to fail.

THREE: Do not reinvent the wheel

The UK and New Zealand have made similar end-game goals and have developed plans. They have done the reading and the research. There is an excellent UK Evidence Review of the risks and benefits of vaping. The prestigious Cochrane Collaboration has stated that they are convinced that e-cigarettes help smokers to quit more effectively than traditional NRT.

FOUR: Remember that people smoke for the nicotine but die from the tar

We have known since 1976 that, while nicotine is the natural substance in cigarette smoke that causes pleasure and can lead to addiction to smoking, it is the carbon monoxide and tar in tobacco smoke that causes cancer and the other diseases that kill smokers. This is the science behind the nicotine patches and gum that have been used since 1984 to try to help smokers quit smoking. Medical nicotine replacement therapy (NRT) attempts to provide the nicotine that smokers crave without the harmful chemicals in cigarette smoke. Unfortunately, NRTs release too little nicotine, too slowly, which is why many smokers do not find them useful or effective. As a result, smoking is still a major medical problem 38 years after NRT was invented.

FIVE: Accept nicotine as a legal and legitimate recreational drug

Caffeine, alcohol and, recently, cannabis are all socially accepted. They are all unhealthy products that can be addictive, but they also give many people pleasure. Society accepts that adults have the right to make a choice to use these products if they so wish. Nicotine should join this group of substances.

Nicotine has similar effects to caffeine. It slightly increases heart rate and blood pressure and can help concentration. Unlike alcohol, it is not carcinogenic, and does not lead to violence, dangerous driving or promote sexual assaults. A teenager who vapes nicotine will be able to concentrate on schoolwork, while one who uses cannabis will not be able to do so.

SIX: Make reducing the use of combustible tobacco the #1 priority

The chemicals in burnt tobacco smoke kill about 1,000 Canadians every month. Globally tobacco kills 8 million people per year, many more than are killed by alcohol, violence, TB, AIDS, illicit drugs or malaria.

It is the inhalation of burnt tobacco that causes the problem. All three factors are needed. Remove either inhalation, combustion or tobacco, and the health risks diminish dramatically.

SEVEN: Recognize that one size does not fit all. People need multiple choices

Ideally, people who smoke should quit smoking and not use any form of tobacco or any nicotine product. If this were easy to achieve, the smoking problem would have already disappeared. Many smokers have become dependent on nicotine, and need to switch to a safer source of the chemical as a way of avoiding tobacco-induced diseases.

People who smoke should try to quit “cold turkey” because some people are not strongly addicted to nicotine and can quit without assistance.

They should also be encouraged to try medical nicotine replacement therapy, as some people find these products effective and they are very safe alternative sources of nicotine.

Smokers may even consider smoking cessation drugs such as bupropion, varenicline and cysteine if these are available to them. These products have significant side effects, and some people find them unpleasant, but they are effective for some people.

Other people may want to use commercially-available sources of nicotine such as vape, heat-not-burn, snus and oral nicotine pouches.

While in Canada vaping with e-cigarettes is the most common alternative commercial source of safer nicotine, there are many alternatives that have been used very successfully in other countries.

Vaping provides people who smoke with a very cigarette-like experience. Some people like the tobacco and menthol flavours, but most people prefer to switch away from the smell and taste of tobacco and go for a fruit or sweet dessert flavour. Vaping can provide the same amount of nicotine as cigarette smoke but is 20x safer.

Heat-not-burn devices use real tobacco in small sticks that are heated without burning. The tobacco flavour is much better than tobacco-flavoured vape. Sticks come in a package that looks, smells and feels like a mini cigarette. They are much safer than cigarettes but not as safe as vaping. They have become very popular in Japan, where they have reduced cigarette consumption by 74 billion units per year.

Snus are an oral tobacco product that is widely used in Sweden, where it contributes to a very low smoking rates and very low rates of tobacco-related diseases. Oral nicotine pouches are similar but tobacco-free. Although they are the safest commercial nicotine product, they are unauthorized for sale in Canada.

Adult nicotine consumers should be free to choose which nicotine source they prefer, based on accurate information about their relative risks.

EIGHT: Use language accurately. Stop lying about the risks of vaping

Vape is tobacco-free. “E-cigarettes” are not cigarettes and they are not a “tobacco product.”

You do NOT smoke an e-cigarette. Vaping produces a vapour, not smoke.

An epidemic refers to an outbreak of a disease. Vaping is NOT a disease, so there cannot be an “epidemic” of vaping.

Vaping does NOT cause popcorn lung. There have been no reports of popcorn lung being caused by vaping.

Nicotine vaping did NOT cause the 2019 outbreak of severe lung disease in young people. That disease, falsely called “EVALI,” was caused by illegal cannabis products contaminated with Vitamin E Acetate by criminals.

NINE: Protect youth by enforcing the existing age laws

Selling vaping products to minors is already an offence in Canada and many other countries. Enforce this law. Prosecute people buying vaping products for minors. People who repeatedly sell to minors should be imprisoned.

TEN: Follow the data and the science

Vaping is NOT leading to an increase in teen smoking, or rolling back years of progress in tobacco control. It is true that teens who experiment with vaping are more likely to experiment with smoking. This is called “common liability.” However, having tried both they either use neither or continue to use the much less harmful vape. Teen smoking rates have declined faster since vaping has become common.

It is 2023. It is time to move away from shaming and blaming smokers, and away from stigmatizing nicotine use.

It is time to recognize that nicotine plays a role in some people’s lives. If they cannot, or do not want to, quit using it, we should adopt a harm reduction approach and persuade them to switch to safer nicotine sources.