Delivery is promised within two hours, by motorcycle, with no tax ID, no company registration, no receipt, and almost no paper trail.

“Don’t worry, it’s all original,” an automated message replies.

On apps, age restrictions often amount to little more than a click confirming that the buyer is over 18. Brazil’s National Health Surveillance Agency, Anvisa, prohibits the sale of these products. The market does not argue. It does not wait for authorization. It simply delivers.

In Brazil, vapes, pods, and other electronic nicotine devices cannot be sold legally. The country banned them in 2009 and reaffirmed the prohibition in 2024, after years of regulatory dispute and pressure from industry groups, medical organizations, consumer advocates, and harm-reduction specialists.

The ban is not symbolic. It covers almost the entire commercial life of the product: manufacture, importation, advertising, distribution, and sale. In 2024, Anvisa not only maintained the prohibition but also expanded the regulatory scope to include devices, refills, accessories, and online promotion. The result is a legal architecture that leaves little room for formal market entry and enormous room for informal circulation.

The issue, then, is not regulation versus no regulation. Total prohibition is itself a form of regulation — one that, in Brazil’s case, appears to shift much of the market’s practical control away from the state and toward informal sellers, digital platforms, and smuggling routes.

A harm-reduction approach would begin from a different premise: nicotine products should be regulated according to risk, use, age access, and enforceability, rather than treated as a single moral category.

The dispute is not only about whether vapes should be legal. It is about who controls the existing nicotine market. Brazil enters this new phase with two conflicting inheritances: a country long regarded as a global reference in tobacco control, and one of the largest illicit cigarette markets in the Americas.

But Brazil is no longer the only country confronting this contradiction. Across the Pacific, Australia chose a different restrictive architecture. Rather than allowing a consumer vape market, it channeled legal access into a therapeutic pharmacy model: nicotine vaping would be treated less as an ordinary consumer product than as a tool for smoking cessation or nicotine-dependence management.

On paper, the Australian system appears almost opposite to Brazil’s. Brazil pursued prohibition. Australia pursued medicalization.

Yet both countries are confronting similar pressures: informal supply chains, digital distribution networks, weakened practical oversight, and markets adapting faster than regulators can control them. The comparison matters because it shifts the question. The issue is not only what each country intended to regulate, but what their policies left outside the legal door.

Brazil: The Ban That Entered the App

With more than 213 million people, Brazil turns seemingly modest percentages into mass-market phenomena. What might remain a niche in smaller countries can quickly become a logistics chain, an informal resale network, a tax dispute, and a nationwide supply system.

In markets of this size, products used repeatedly rarely disappear simply because they have been banned. They leave the storefront. They enter the app.

Long before the vape boom, Brazil had already shown how difficult it was to control the traditional cigarette market. Electronic devices did not create nicotine informality in the country. They found an infrastructure already in place: smuggling routes, shadow distribution networks, established demand, and limited state capacity for enforcement.

In 2025, roughly one in every three cigarettes consumed in Brazil circulated outside formal tax, regulatory, and health-surveillance systems. Public authorities were competing not only with legal manufacturers but also with packs sold at improvised stands, small neighborhood markets, and kiosks supplied by routes that cross borders before reaching major cities.

Brazil shares nearly 16,900 kilometers of land borders with ten South American countries. Beyond the border line itself lies the country’s 150-kilometer Border Strip, where illegal cargo can be broken up, stored, transferred, and redirected toward urban markets.

A KPMG report commissioned by the tobacco industry has estimated that Brazil accounts for more than half of the illicit cigarette market among surveyed Latin American countries. Federal enforcement officials now describe electronic cigarettes as part of that same criminal opportunity.

The point is not that vapes and illicit cigarettes are identical markets. They are not. Their consumers, aesthetics, technologies, and channels of circulation differ. But they meet inside the same structural weakness: a large nicotine market where prohibition, price gaps, porous borders, digital platforms, and limited enforcement capacity can turn restricted products into ordinary commodities.

Brazil’s informal nicotine market is no longer peripheral.
It has become part of the system.

Australia: The Pharmacy Door and the Market Outside

Australia increasingly faces its own version of that contradiction. The Australian government attempted to address vaping not through outright prohibition, but through therapeutic gatekeeping. Vapes would be treated as medical products rather than consumer products. Pharmacies would replace vape shops. Doctors and pharmacists would become the new access points.

But the real market evolved differently.

Consumers did not stop wanting convenience, flavor variety, familiar products, immediate access, or social accessibility simply because the state reclassified vaping as therapeutic.

The result has been the emergence of two systems side by side: a tightly regulated, pharmacy-centered legal pathway and an unofficial market of tobacconists, imported disposables, Telegram groups, under-the-counter retail, social media promotion, and organized criminal supply networks.

Australia, therefore, produced a contradiction remarkably similar to Brazil’s:
a formal regulatory system existing beside a rapidly adapting informal market.

The pharmacy-only model also faces a quieter problem: legal access can exist on paper while remaining narrow, inconsistent, or inconvenient in practice.

Many pharmacies do not stock nicotine vaping products at all. Others stock only a limited range of devices, nicotine strengths, or products. Some pharmacists remain reluctant to participate because of uncertainty, reputational concerns, lack of commercial incentive, or personal opposition to vaping itself.

For many smokers, the legal pathway exists technically, but not practically.

Obtaining products may mean finding a participating pharmacy, navigating consultations or prescriptions, locating available stock, accepting limited product options, and repeatedly dealing with supply inconsistency.

A smoker attempting to move away from cigarettes does not experience regulation as an abstract public-health framework. They experience it behaviorally: Can I reliably obtain a product that works for me?

When the answer becomes uncertain, consumers often move toward the parallel market. That is one of the strongest comparative insights between Brazil and Australia. Brazil may show the limits of prohibition. Australia may show the limits of medicalization when the legal pathway narrows relative to demand.

The Smuggling of Words

The new clandestine market is not built only on routes, warehouses, and border crossings. It is also built on words.

To evade platform filters and enforcement, pods and electronic cigarettes often appear under other names. On digital marketplaces, they have been advertised as “air fresheners,” “essential oils,” “diffusers,” “essences,” and even “kitchen items.” On delivery apps, some sellers list devices under categories such as “natural supplements.”

The logic is simple: change the language to keep the market moving.

What once depended mainly on border routes and informal retail now also moves through search terms, closed profiles, temporary posts, messaging apps, and delivery systems.

The market no longer behaves like a traditional black market. Increasingly, it behaves like platform commerce.

This is what makes the modern nicotine debate so difficult for governments: the market is no longer only geographic. It is algorithmic.

The same digital infrastructure used for food delivery, social media advertising, and online retail can also be used to distribute restricted nicotine products.

In both Brazil and Australia, regulators are attempting to control these markets with twentieth-century enforcement structures, even as the markets themselves evolve through twenty-first-century digital systems.

The result is constant adaptation. Each new restriction generates new workarounds. Each enforcement action produces new distribution methods.
The market mutates faster than regulation itself.

The Two Bodies in the Room

That redistribution of control has become most politically charged when it comes to adolescents.

Among Brazilian students aged 13 to 17, the share who had tried e-cigarettes rose sharply between 2019 and 2024. Similar fears now shape Australian policy debates around youth vaping, disposable devices, flavors, and social-media visibility.

For public-health authorities, the concern is not simply nicotine itself, but renormalization: the possibility that a generation raised after decades of anti-smoking campaigns could once again be drawn into nicotine use.

Yet adolescents are not the only bodies in the room.

Brazil still has millions of adult smokers already exposed to the cumulative harms of combustible cigarettes. Australia does too.

A policy built only around preventing youth initiation risks leaves adult smokers in the most harmful form of nicotine use. A policy built only around harm reduction risks normalizes a new nicotine market among adolescents.

Neither problem disappears through moral certainty alone.

This is where both countries become accidental laboratories. One pursued prohibition; the other pursued therapeutic containment. Both reveal the same underlying tension: when legal systems disconnect from demand, markets reorganize outside them.

This does not mean nicotine products should circulate without restriction. Nor does it mean regulation cannot fail. It can be captured by commercial interests, weakened by bureaucracy, hollowed out by poor enforcement, or designed in ways that exclude the smokers it claims to help.

But the alternative to regulation is not necessarily control.

In both Brazil and Australia, the alternative increasingly appears to be the informal market: less traceability, less accountability, weaker age verification, less transparency, and weaker public oversight.

The deeper question is no longer only whether governments oppose nicotine use. It is whether they can still govern markets that emerge online, spread socially, adapt algorithmically, and only later appear in the physical world.

Brazil banned vaping. Australia medicalized it.

Both may now be revealing the same uncomfortable truth: when law becomes narrower than demand, markets do not disappear.

They mutate.

Comparative Fact Sheet: Brazil and Australia

Population

Brazil: 213 million people in 2025.

Australia: roughly 27 million people in 2025.

Why it matters: Brazil’s scale turns even modest prevalence rates into mass-market phenomena. Australia, by contrast, shows that a smaller population and stronger border controls do not necessarily insulate a country from illicit-market pressure.

Youth Vaping

Brazil: according to official data, 29.6 percent of adolescents aged 13–17 had tried electronic cigarettes in 2024.

Australia: national surveys have also shown substantial experimentation among adolescents and young adults, especially during the disposable-vape era, despite tighter restrictions and import controls.

Why it matters: Both countries reveal the same political paradox: restrictive policy frameworks have not prevented significant experimentation among youth.

Adult Use

Brazil: estimated daily adult e-cigarette use reached 2.6 percent in 2024, measured in state capitals only, roughly 4 million people.

Australia: adult vaping prevalence is substantially higher than Brazil’s, especially among younger adults and former smokers. Despite Australia’s pharmacy-only therapeutic framework, nicotine vaping had already become widely embedded among consumers before and during the current restrictions.

Why it matters: this creates a contradiction inside the Australian model: a formally therapeutic product now functioning socially as a mass consumer product.

Illicit Cigarette Trade

Brazil: 41.8 billion illicit cigarettes were consumed in 2025, representing an estimated illegal market share of 35.6 percent.

Australia: Australia is facing a rapidly expanding illicit tobacco market, driven in large part by high tobacco excise taxes and growing organized crime involvement. Illegal tobacco retailing has become increasingly visible, with illicit tobacconists operating openly in several cities. Fire bombings, extortion, and turf conflicts linked to the tobacco trade have also become recurring national news stories.

Why it matters: Brazil’s illicit market is older and structurally embedded. Australia’s is newer, but expanding quickly and becoming politically destabilizing. Both point to the same underlying principle: when price, restriction, and demand diverge too sharply, parallel markets emerge.

Geography and Borders

Brazil: 16,900 kilometers of land borders with ten South American countries.

Australia: an island nation with a far more controlled border environment.

Why it matters: This is perhaps the most politically revealing comparison. Brazil’s illicit nicotine market is often explained through porous borders, continental geography, and limited enforcement capacity. Australia lacks those structural vulnerabilities. Yet despite geographic isolation and heavy border policing, it has still developed a large illicit vape and tobacco market.

Australia, therefore, complicates the easy explanation that Brazil’s problem is only porous borders or weak state capacity. In both countries, illicit markets also reflect consumer demand, digital commerce, taxation pressures, and regulatory mismatch.

Enforcement

Brazil: 550,000 electronic cigarettes were seized in 2024.

Australia: authorities have expanded seizure operations against illicit vaping and tobacco imports, while state governments have carried out repeated raids on tobacconists and informal retailers.

Why it matters: In both countries, stronger enforcement has coincided with the continued expansion of illicit supply. High seizure numbers may signal state action, but they also reveal the scale and persistence of the market itself.

Public Opinion and Regulatory Legitimacy

Brazil: 58.8 percent of submissions to Anvisa’s public consultation opposed continuing the vape ban.

Australia: the policy debate has become increasingly polarised among public-health authorities, harm-reduction advocates, pharmacists, smokers, consumer groups, and enforcement agencies.

Australia has not held an equivalent public consultation producing a directly comparable figure. Still, dissatisfaction with the pharmacy-only framework has increasingly centered on limited access, uneven pharmacy participation, inconsistent supply, high prices, consumer inconvenience, and the growth of the illicit market.

Why it matters: both countries now face a growing legitimacy problem: a widening gap between official nicotine policy and actual market behavior.

What the Comparison Reveals

Brazil and Australia chose radically different nicotine strategies. Brazil pursued prohibition. Australia pursued medicalization.

Yet the numbers point toward a similar structural outcome: persistent consumer demand moving into informal, digitally adaptive, and increasingly difficult-to-control supply systems.

Brazil’s scale makes the phenomenon massive. Australia’s smaller size makes it politically embarrassing and revealing. If even a wealthy island nation with centralized border controls and a pharmacy-only framework cannot contain informal nicotine markets, the problem cannot be explained by porous borders or weak state capacity alone.

The comparison raises a broader question about suppression-based policy itself: what happens when the legal pathway becomes narrower than demand?

The WHO’s nicotine pouch report is somewhat right about the marketing problem but uneasy about the harm-reduction problem.

It highlights a typical commercial style: playful, vibrant packaging; influencer marketing; sports sponsorships; aspirational branding; and trendy language. It also features flavors, discreet formats, and tobacco-free language. These strategies can lower the symbolic barrier to nicotine use, especially for adolescents and young never-smokers.

But the report struggles with the harder ambiguity: the same attributes that may attract never-users can also help adult smokers move away from cigarettes.

That is the fault line. Nicotine pouches are not harmless. But they are also not combustible cigarettes. Public health can readily recognize the first fact. It still hesitates before the second.

Why It Matters

For decades, tobacco control was organized around a clear enemy: the cigarette. It joined nicotine, combustion, addiction, disease, death, and industry manipulation in a single object.

Nicotine pouches disrupt that clarity. They deliver nicotine without tobacco leaf, without smoke, without smell, and without combustion, the mechanism responsible for most smoking-related harm.

The WHO report responds mainly through the grammar of precaution. That is understandable. Youth uptake matters. Marketing matters. Dependence matters.

But precaution becomes incomplete when it cannot accommodate relative risk.

If public health treats all nicotine products as extensions of the cigarette, it may protect the moral clarity of tobacco control while weakening its capacity to reduce harm among smokers who have not quit.

Evidence at a Glance

• The WHO report warns that nicotine pouch marketing is expanding faster than regulation.

• Its central concern is commercial capture: flavors, packaging, digital influence, sports sponsorships, and “tobacco-free” branding.

• In Great Britain, nicotine pouch use among 16-to-24-year-olds rose from 0.7% in January 2022 to 4.0% in March 2025; among young men, it reached 7.5%.

• The same data show overlap with smoking and vaping, making it difficult to reduce the trend to simple initiation.

• In the United States, youth pouch use among 10th- and 12th-grade students increased from 2023 to 2024, alongside dual use with e-cigarettes.

• The unresolved question is whether growth reflects initiation, experimentation, dual use, substitution, cessation attempts, or all of these at once.

Why This Matters for Policy

Scientific

• The key question is not whether nicotine pouches are safe. They are not risk-free. Nothing is.

• The key question is: safe compared with what?

• Compared with abstinence, pouches carry risk. Compared with combustible cigarettes, the toxicological distance is substantial. The main devastation caused by smoking comes from combustion: tar, carbon monoxide, ultrafine particles, and thousands of toxic compounds generated by burning tobacco.

• The WHO report sees absolute risk clearly. It is less comfortable with relative risk.

Regulatory

• The report reflects a regulatory imagination still shaped by the cigarette.

• That creates a problem. If pouches are regulated only as a youth threat, adult smokers may lose access to lower-risk alternatives. If they are promoted without guardrails, youth uptake may expand.

• The task is not to choose one reality and deny the other. It is to regulate by user, product, risk, and context.

• That means strict age controls, marketing restrictions, product standards, surveillance, and honest communication about comparative risk.

Equity Implications

• The missing figure in much of the WHO’s framing is the persistent adult smoker.

• As smoking declines, it becomes more concentrated among people facing psychological distress, low income, precarious work, interrupted schooling, and social exclusion. For many of them, quitting is not simply a matter of information or willpower.

• A public-health model that rejects lower-risk alternatives because they fall short of abstinence may leave the most vulnerable smokers with the most harmful product.
  

Communication

• The WHO is right to expose some language of commercial seduction.

• But public health also has a language problem of its own. When it refuses to distinguish nicotine from combustion, or lower-risk products from cigarettes, it produces confusion in the name of protection.

• And confusion favors the cigarette. When everything is made to sound equally dangerous, the most familiar product keeps its advantage.

The Strategic Question

The question is not: How do we stop nicotine pouches?

The better question is: Can public health prevent youth capture without denying harm reduction to smokers still exposed to combustion?

Recommended Actions

For Regulators & Public-Health Agencies

• Separate youth-prevention policy from adult harm-reduction policy.

• Regulate marketing, packaging, flavors, age access, nicotine strength, and product quality.

• Communicate clearly that lower risk does not mean risk-free.

• Monitor initiation, dual use, substitution, cessation attempts, and relapse separately.

• Stop treating all nicotine use as morally equivalent to smoking.

For Politics

• Do not use precaution as a substitute for proportionality.

• Keep combustion at the center of tobacco policy.

• Recognize that harm reduction is not surrender; it is a response to the limits of abstinence-only models.

• Ask whether restrictions reduce harm or preserve the cigarette’s dominance.

• Treat the nicotine policy as a question of inequality, evidence, markets, and risk, not only youth protection.

For Journalists & Opinion Leaders

• Avoid turning the report into a simple “new nicotine epidemic” story.

• Distinguish initiation, experimentation, dual use, substitution, and cessation.

• Keep adult smokers in the frame.

• Report marketing risks without collapsing all nicotine products into cigarettes.

• Explain the difference between nicotine, tobacco, and combustion.

The Risk of Misreading

This is not a defense of nicotine pouches as harmless products.

It is a critique of a public-health reflex: seeing every new nicotine technology primarily through the moral memory of the cigarette.

The WHO report is strongest when it exposes certain commercial tactics. It is weakest when it treats ambiguity as a regulatory inconvenience rather than as the central fact of the post-cigarette nicotine landscape.

Bottom Line

The WHO can see the danger of nicotine pouches as products of initiation. It still struggles to see their possible role as products of substitution. That is the unresolved public health problem after the cigarette.

Argentina has not simply legalized vapes. It has been admitted that prohibition no longer controls.

For more than a decade, electronic cigarettes were formally banned while circulating through kiosks, social media, informal deliveries, suitcases, school backpacks, and parallel markets. The law said absence. Daily life said coexistence.

ANMAT’s 2026 reversal, therefore, marks less a conversion to harm reduction than a bureaucratic recognition: the market had already arrived, grown, and escaped meaningful oversight.

The new regime brings electronic cigarettes, heated tobacco products, nicotine pouches, liquids, cartridges, and sticks into the legal sphere, but only under strict registration, traceability, taxation, flavor limits, health warnings, and state surveillance.

Argentina is not opening the market. It is trying to make it visible.

Why It Matters

The Argentine case exposes a basic policy failure: prohibition can survive legally while collapsing administratively. A ban may still exist on paper even after the state has lost the ability to inspect products, verify composition, prevent youth access, tax sales, or influence consumer behavior.

That is the real significance of the reform. Argentina is no longer regulating a future threat. It is trying to govern an accomplished fact.

The harder question is whether the new legal market will actually displace the informal one. If registered products become expensive, scarce, flavor-restricted, and surrounded by communication so cautious that adult smokers cannot understand relative risk, the reform may produce only a formal surface.

At the same time, the old gray market continues underneath it.

Evidence at a Glance

• Argentina banned electronic cigarettes in 2011, but the market continued to circulate informally.

• On May 4, 2026, ANMAT revoked the previous prohibition.

• The agency acknowledged that absolute bans can push consumers into informal and illegal circuits where products of unknown origin and composition circulate.

• Resolution 549/2026 created a Registry of Tobacco and Nicotine Products covering electronic devices, vape liquids, heated-tobacco products, sticks, and nicotine pouches.

• Disposable vapes remain banned; liquids and sticks may only use tobacco flavor; nicotine pouches may use tobacco or menthol.

• Decree 305/2026 increased import duties on several non-combustion nicotine products, bringing their tax burden closer to traditional tobacco.

• The Ministry of Health cited that 35.5% of adolescents had tried an electronic cigarette at least once — evidence that youth use had expanded before legalization, not because of it.

Why This Matters

Scientific

• The reform forces a distinction that much of Latin American public health still avoids: nicotine is not the same as combustion.

• No nicotine product is risk-free. Dependence, youth uptake, and product quality all matter. But treating every nicotine product as morally and scientifically equivalent protects the cigarette by default. For adult smokers, the relevant comparison is not vaping versus clean air. It is vaping versus continued smoking, informal products, or no realistic pathway away from combustion.

Regulatory

• Argentina is choosing a middle path: neither full consumer-market liberalization nor pharmacy-style medicalization.

• But the middle path is not automatically balanced. It can become a corridor so narrow that only large companies, expensive products, and highly controlled formats survive legally. The core test will not be the elegance of the decree. It will be enforcement: kiosks, e-commerce, parcels, borders, social networks, and sales to minors.

• The old mistake was believing prohibition meant control. The new mistake would be believing registration does.

Equity Implications

• Legalization does not guarantee access.

• Laboratory testing, registration, certification, traceability, import duties, and compliance costs favor large operators. Smaller importers, independent shops, and informal sellers may remain outside the legal market. Adult smokers, especially those with lower incomes, may face legal products that are more expensive, less varied, and harder to find than the informal alternatives already available.

• A harm-reduction pathway that exists only in regulation does not reduce harm. It must exist at the counter: affordable, available, understandable, and capable of competing with the cigarette.

Communication

• Argentina wants to legalize without appearing to endorse. That is politically understandable, but risky.

• If public messaging says only that “no product is risk-free,” without explaining comparative risk, adult smokers may hear equivalence. And when everything sounds equally dangerous, the cigarette keeps its advantage: familiarity.

• The state must prevent youth-oriented marketing without silencing information for adult smokers. Protection for minors and clarity for adults are not the same task.

The Strategic Question

The question is not: Are vapes safe?

The better question is: Can Argentina create a legal market restrictive enough to limit minors’ appeal, but accessible enough to help smokers move away from combustion?

Recommended Reflections and Actions

For Journalists & Opinion Leaders

• Do not describe the reform as simple legalization. It is legalization under surveillance.

• Keep the cigarette in the story: the most harmful product remains legal, familiar, and widely available.

• Follow the street, not only the Official Gazette: prices, shelves, kiosks, online sellers, parcels, borders, and school access.

• Avoid the false binary of “pro-vape” versus “anti-vape.” The real story is control, informality, youth protection, adult substitution, and relative risk.

For Regulators & Public-Health Agencies

• Build a registry that is fast, transparent, technically credible, and publicly accountable.

• Distinguish youth prevention from adult harm reduction.

• Monitor price, access, product availability, illicit-market persistence, and adult substitution away from cigarettes.

• Communicate relative risk clearly without turning products into lifestyle objects.

• Evaluate whether flavor restrictions reduce youth use or simply preserve the informal market.

For Politics

• Stop treating prohibition as proof of seriousness.

• Invest in the administrative capacity the reform requires: laboratories, inspectors, customs control, digital monitoring, and enforcement.

• Ask who the new compliance system favors: public health, consumers, large corporations, or the state’s need to appear in control.

• Measure success by outcomes, not decrees: less smoking, less illicit supply, less youth access, more traceability.

The Risk of Misreading

This is not a clean victory for harm reduction. Argentina has not fully embraced substitution, nor guaranteed meaningful access for adult smokers.

It is also not a meaningless bureaucratic shift. It ends a fiction: the idea that prohibition had kept vapes outside Argentine life.

The danger now is replacing one illusion with another, moving from pretending prohibition was control to pretending traceability is governability.

Bottom Line

Argentina has stopped pretending that prohibition worked. Now it must prove that regulation can do more than document what it still cannot control.

For deep reading:

Small, white, almost imperceptible, the nicotine pouch seems designed to escape not only other people’s gaze, but also the classic categories of tobacco control.

It produces no smoke. Leaves no smell. Does not burn. Raises no columns of vapor. Contains no tobacco leaf. Slips beneath the lip. It can be used in silence: in a meeting, on a flight, in a living room.

And yet it carries nicotine — a substance whose public-health meaning changes radically depending on how it is consumed and, above all, on the product it replaces.

For decades, the enemy seemed easy to name. The cigarette condensed dependence, combustion, and death into a single object. Anti-smoking efforts were organized around that clarity. Smoking killed. The consensus was solid because the harm was, too.

Nicotine pouches broke that geometry.

Unlike cigarettes, they deliver nicotine without combustion and, with it, without the primary mechanism that produces most of the toxins associated with smoking. But they do so through devices designed to appear clean, discreet, and compatible with a daily life governed by productivity, mobility, and self-improvement — an aesthetic already familiar from products that promise focus, performance, and balance.

Discretion, pleasure, performance, convenience, and design now come to orbit a molecule historically linked to harm, dependence, and the moral imagination of the cigarette.

It was precisely this ambiguity that led the World Health Organization to sound the alarm. In its report, Exposing Marketing Tactics and Strategies Driving the Global Growth of Nicotine Pouches, published on May 15, the WHO describes a market outpacing the capacity to regulate it. To a large extent, the document reads this phenomenon as a technological update of older tobacco-industry strategies.

Its concern centers on categories that are already familiar: fruit and candy flavors, eye-catching packaging, influencers who replace mass advertising with the continuous intimacy of personalized feeds, sports sponsorships, aspirational branding, and the use of “tobacco-free” language in campaigns that can turn nicotine dependence into a lifestyle aesthetic.

The concern is not imaginary.

In Great Britain, a study by Tattan-Birch, Jackson, Shahab et al. published in The Lancet Public Health estimated that nicotine pouch use among 16-to-24-year-olds rose from 0.7% in January 2022 to 4.0% in March 2025; among men in that age group, it reached 7.5%. But those numbers, on their own, do not fully explain what this growth means. The study shows substantial overlap with smoking and vaping, and it also suggests that some smokers are using pouches in quit attempts. What it does not establish, by itself, is how much of the increase reflects initiation, dual use, temporary experimentation, or partial substitution for cigarettes.

In the United States, data from Han, Harlow, Miech et al. also found that nicotine pouch use among 10th- and 12th-grade students increased from 2023 to 2024, along with a rise in dual use with e-cigarettes. The pattern suggests a shift in the youth nicotine market, but it does not, by itself, establish that this is simply a new epidemic of initiation.

WHO’s warning moves chiefly on the terrain of precaution. Less as a response to conclusive evidence that pouches are creating, on a large scale, a new population of dependent users among non-users, and more as a reaction to the convergence of sensory appeal, discreet use, aspirational marketing, and low risk perception.

The controversy deepens because the disagreement lies not only in the regulatory responses but in the very causal premises of the debate.

Peter Hajek, for example, has questioned the robustness of some claims about permanent nicotine-related damage to the adolescent brain. He argues that many such inferences derive from animal models exposed to doses and conditions only weakly comparable to real human consumption. Researchers such as Lion Shahab and Cristine Delnevo, meanwhile, challenge the causal reading of the so-called gateway effect. For them, the association between trying non-combustible nicotine products and later smoking may reflect less a gateway than a shared predisposition to risk-taking behavior, which part of the literature calls common liability.

Nicotine itself, moreover, is pharmacologically less simple than the public imagination usually allows. That does not make it harmless. But it does make the old equivalence between nicotine, combustion, and harm less stable.

But this is where the debate grows more complicated than the WHO’s precautionary logic seems able to accommodate.

Because the very attributes that may widen experimentation among adolescents — discretion, flavors, the absence of smoke — also appear, for millions of adult smokers, as concrete means of replacing the cigarette.

The same product that may function for some as a gateway can operate for others as a route out.

And perhaps it is precisely this uneasy coexistence that contemporary regulatory systems have not yet learned how to govern.

But perhaps the hardest part of this debate does not lie with adolescents who may begin. That group matters, of course — epidemiologically and ethically. The problem is that contemporary public health has come to focus almost exclusively on those who might start using nicotine, and less and less on those who have never managed to stop.

While governments and international bodies concentrate their energy on containing new forms of initiation, another population remains partly out of frame: millions of smokers who go on consuming combustible cigarettes despite decades of campaigns, tax increases, health warnings, and cessation policies.

For a significant share of these smokers, quitting ceased long ago to be a simple matter of public health information. And those who still smoke today no longer resemble the average smoker of the 1980s or 1990s.

As smoking declined, it also became more concentrated. More and more, it came to settle among socially vulnerable groups: people living with psychological distress, exposed to precarious work, low income, interrupted schooling, social exclusion, and more persistent forms of dependence.

In many countries, smoking has ceased to be a habit evenly distributed across the population and has become, instead, a marker of inequality.

From here on, the discussion of risk shifts scale.

At the individual level, no nicotine-containing product is entirely without risk. No substance introduced into the human body is biologically neutral: dose, frequency, age, clinical condition, and individual vulnerability all matter. And dependence remains dependence.

But from a toxicological point of view, the distance between a nicotine pouch and a combustible cigarette is immense.

The main public-health devastation caused by smoking has never come from nicotine in isolation, but from combustion: tar, carbon monoxide, ultrafine particles, and thousands of compounds generated by burning tobacco.

By that logic, replacing cigarettes with non-combustible products may represent a substantial reduction in harm for persistent smokers.

And it is precisely this difference that creates an important political discomfort.

Public health rarely governs a single kind of risk. It has to decide, all at once, what to do with the harm of a product in itself, with the harm of that product relative to what it may replace, and with the aggregate effects of its circulation in society.

In the case of pouches, those scales do not converge easily.

Absolute risk reminds us that no nicotine product is neutral. Relative risk shows that the toxicological distance between a pouch and a combustible cigarette is enormous. Population risk asks a different question: how many adolescents may initiate use, how many smokers may leave combustion behind, how many will remain dual users, and how many non-users may be drawn into the nicotine market.

The problem is that each of those questions may push public policy in a different direction.

Advocates of harm reduction often point to the Swedish experience as population-level evidence of this shift. In Sweden, where the use of oral nicotine products such as snus has historically replaced a significant portion of cigarette consumption, lung cancer rates and tobacco-related mortality are among the lowest in Europe. Critics respond that highly specific cultural and regulatory contexts make simple generalizations difficult. Even so, the Swedish case remains one of the most uncomfortable facts for regulatory models that tend to treat all forms of nicotine as equivalent in risk.

Part of the difficulty lies, too, in the scale chosen to interpret the phenomenon.

The recent rise of nicotine pouches among adolescents is often narrated in relative terms: it “quadrupled,” it “exploded,” it “advanced rapidly.” And in some specific markets, the expansion has indeed been fast.

But relative growth and population magnitude are not the same thing.

Even in the countries where the increase among young people has most alarmed health authorities, pouches are still circulating at levels far below those historically reached by combustible cigarettes.

And yet the global map of youth tobacco use itself prevents combustion from disappearing from view.

In its Global Report on Trends in Prevalence of Tobacco Use 2000–2030, WHO estimated that 9.7% of adolescents aged 13 to 15 were using tobacco in 2022; in the regional projections through 2030, no region falls below 9%. Even where the rate is lower, as in Africa, it remains around 9.5%; in Europe, it reaches 11.6%.

None of this diminishes the importance of prevention among adolescents. But it does suggest that contemporary nicotine policy may be trying to respond, at the same time, to two distinct phenomena: the massive persistence of combustion and the much more recent, and numerically smaller, emergence of alternative non-combustible products.

The risk, then, is that the symbolic speed of the new may obscure the epidemiological persistence of combustion.

The codes no longer belong to the classic imagery of tobacco: smoke, ashtrays, yellowed stains on the fingers, the smell embedded in clothes.

The new products circulate through a different aesthetic. They come in colorful, seductive packaging, draw on pop culture references, offer flavors that evoke fruit, candy, or energy drinks, spread through digital platforms, and carry with them a constant promise of discretion.

For much of the twentieth century, the tobacco industry sold a sense of belonging through images of masculinity, risk, and rebellion. Now the repertoire has changed. Contemporary consumption rarely presents itself as excess. It prefers the language of balance, efficiency, and self-management.

It is within this landscape that WHO locates its central concern: the possibility that products designed to appear clean, modern, and tobacco-free may lower the symbolic barriers to entry for adolescents and young adults.

What unsettles some public health authorities may not be the presence of nicotine alone, but the possibility that it might once again circulate socially without carrying the full moral iconography of the cigarette.

For a long time, nicotine, harm, combustion, and morality were compressed into a single symbolic entity. Nicotine pouches break that compression.

Contemporary life, after all, already runs on continuous architectures of stimulation. Breakfast arrives calibrated in caffeine. Midday demands focus and output. The afternoon comes in cans of sugar, taurine, and neurochemical marketing. At night, apps turn anxiety into a monthly subscription, while alcohol, melatonin, or anxiolytics artificially reorganize rest.

None of this erases nicotine’s specificity or its physiological potential for dependence. But it does help explain why pouches circulate with relative ease within a cultural ecosystem already accustomed to discrete, continuous, and socially normalized forms of behavioral capture.

Perhaps the contemporary problem lies not only in the existence of these mechanisms of capture, but in the way we decide which of them to treat as moral deviance, and which to absorb, without much alarm, as lifestyle.

The problem begins when attributes such as flavor, discretion, and convenience come to be read almost automatically as signs of youth capture.

These attributes do not carry a fixed epidemiological meaning. For an adolescent who has never smoked, sweet flavors may function as a path to experimentation. For an adult smoker who has consumed a pack a day for twenty years, those same flavors may help break the sensory bond with the cigarette.

It is this ambiguity that unsettles the old categories of tobacco control.

For decades, nicotine, cigarettes, and death could be treated almost as a single moral entity. The dominant harm was concentrated in the combustible cigarette, and any expansion of nicotine use seemed, by definition, threatening.

Pouches break that equivalence. They reduce a substantial part of the harm associated with cigarettes while, at the same time, making dependence more discreet, more palatable, more compatible with the contemporary aesthetic of performance and convenience.

The WHO report itself moves within this frame. In describing pouches as products designed to sustain dependence, and in warning that their commercial strategies may expose a new generation to addiction, the document is not speaking only about toxicology or regulation. It translates the circulation of these products into a moral language of capture, manipulation, and generational threat.

It is here that the report reveals, at once, both its strength and its limit. It is right to identify a sophisticated contemporary grammar of commercial capture. Nothing different from other products. But it stumbles when it tries to govern ambiguous technologies through moral categories forged for far more homogeneous threats.

The report reveals, in the end, that international nicotine policy seems to operate more comfortably in the face of the emerging risk of initiation than in the face of the historical persistence of combustion.

* * *

World Health Organization (2026). Exposing marketing tactics and strategies driving the global growth of nicotine pouches. World Health Organization. https://iris.who.int/handle/10665/385691. License: CC BY-NC-SA 3.0 IGO

Source notes

Public health studies and reports

• Alkharaan, Hassan, Abdulaziz Alrubayyi, Majed Kariri, et al. “Investigating Oral Nicotine Pouch Use Among Adults in Riyadh, Saudi Arabia: Prevalence, Awareness, Susceptibility, and Associated Symptoms.” Frontiers in Public Health 13 (2025): 1607656. https://doi.org/10.3389/fpubh.2025.1607656.

• Conde, Monserrat, K. Tudor, R. Begh, et al. “Electronic Cigarettes and Subsequent Use of Cigarettes in Young People: An Evidence and Gap Map.” Addiction 119, no. 10 (October 2024): 1698–1708. https://doi.org/10.1111/add.16583.

• Dautzenberg, Bertrand, et al. “Systematic Review and Critical Analysis of Longitudinal Studies Assessing Effect of E-Cigarettes on Cigarette Initiation Among Adolescent Never-Smokers.” International Journal of Environmental Research and Public Health 20, no. 20 (2023): 6936. https://doi.org/10.3390/ijerph20206936.

• Delnevo, Cristine D. “E-Cigarette and Cigarette Use Among Youth: Gateway or Common Liability?” JAMA Network Open 6, no. 3 (March 2023): e234890. https://doi.org/10.1001/jamanetworkopen.2023.4890.

• Farsalinos, Konstantinos. “Nicotine Pouches: An Aid in Smoking Cessation, or a New Public Health Hazard?” Internal and Emergency Medicine 21, no. 3 (April 2026): 843–858. https://doi.org/10.1007/s11739-026-04278-1.

• Shahab, Lion, Emma Beard, and Jamie Brown. “Association of Initial E-Cigarette and Other Tobacco Product Use with Subsequent Cigarette Smoking in Adolescents: A Cross-Sectional, Matched Control Study.” Tobacco Control 30 (2021): 212–220.

• Sun, Ruoyan, David Méndez, and Kenneth E. Warner. “Association of Electronic Cigarette Use by US Adolescents With Subsequent Persistent Cigarette Smoking.” JAMA Network Open 6, no. 3 (March 2023): e234885.

Clinical research and neuroscience

• Barreto, George E., Alexander Iarkov, and Valentina Echeverria Moran. “Beneficial Effects of Nicotine, Cotinine and Its Metabolites as Potential Agents for Parkinson’s Disease.” Frontiers in Aging Neuroscience 6 (January 2015): 340.

• Belluardo, Natale, G. Mudò, M. Blum, and K. Fuxe. “Central Nicotinic Receptors, Neurotrophic Factors and Neuroprotection.” Behavioral Brain Research 113, nos. 1–2 (August 2000): 21–34. https://doi.org/10.1016/S0166-4328(00)00197-2.

• Goniewicz, Maciej L. “Biomarkers of Electronic Nicotine Delivery Systems (ENDS) Use.” Addiction Neuroscience 6 (2023): 100077.

• Green, Harry Jacob, et al. “An Exploratory, Randomized, Crossover Study to Investigate the Effect of Nicotine on Cognitive Function in Healthy Adult Smokers Who Use an Electronic Cigarette After a Period of Smoking Abstinence: Study Protocol.” International Journal of Clinical Trials 9, no. 2 (2022): 136–142.

• La Rosa, Giusy Rita Maria, et al. “Self-Reported Oral Health Outcomes After Switching to a Novel Nicotine Pouch Technology: A Pilot Study.” Acta Odontologica Scandinavica (2025). Advance online publication.

• Nop, Olivia, et al. “Nicotine and Cognition in Cognitively Normal Older Adults.” Frontiers in Aging Neuroscience 13 (May 2021): 640674. https://doi.org/10.3389/fnagi.2021.640674.

• Quik, Maryka, Xiomara A. Perez, and Tanuja Bordia. “Nicotine as a Potential Neuroprotective Agent for Parkinson’s Disease.” Movement Disorders 27, no. 8 (2012): 947–957.

• Rezvani, Amir H., and Edward D. Levin. “Cognitive Effects of Nicotine.” Biological Psychiatry 49, no. 3 (2001): 258–267.

• Spasova, Violeta, et al. “Impact of Nicotine on Cognition in Patients With Schizophrenia: A Narrative Review.” Cureus 14, no. 4 (April 2022): e24576.

Market analysis and behavior

• Fearon, Ian M., et al. “Curiosity and Intentions to Use Myblu E-Cigarettes and an Examination of the ‘Gateway’ Theory.” Drug Testing and Analysis 15, no. 10 (October 2023): 1252–1261.

• Minton, Michelle. “Perverse Psychology.” Competitive Enterprise Institute, January 2020.

• Russell, Christopher, Willie J. McKinney, and Ian M. Fearon. “Behavioral Intentions Assessment of a Disposable E-Cigarette Among Adult Current, Former, and Non-Smokers in the United States.” Drug Testing and Analysis 15, no. 10 (October 2023).

• Warner, Kenneth E., and David Méndez. “E-Cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation With the Potential Benefits of Increasing Smoking Cessation.” Nicotine & Tobacco Research 21, no. 1 (2019): 41–47. https://doi.org/10.1093/ntr/nty062.

Conferences, talks, and other documents

• Benowitz, Neal L. “Nicotine Addiction: From Biology to Regulatory Policy.” Presentation at the CAsToR Symposium, May 17, 2023.

• Newhouse, Paul A. “Long-Term Transdermal Nicotine for the Treatment of Mild Cognitive Impairment.” Vanderbilt Center for Cognitive Medicine / Vanderbilt University Medical Center, talk/interview, 2022.

• Yang, Zhongli, and Ming D. Li. “Effects of Tobacco on Feeding and Energy Homeostasis.” Unverified institutional citation; likely a chapter, lecture, or review rather than a standalone journal article.

The Core Tension

Smoking has declined, but not equally. The cigarette has retreated from offices, prestige culture, and public space, yet it has not disappeared from the lives of those most exposed to social and economic vulnerability.

The central tension is this: tobacco control often celebrates aggregate decline, while the remaining burden of smoking becomes increasingly concentrated among poorer and more precarious groups. What looks like public-health success at the population level may conceal a harder reality: harm has not vanished. It has moved down the social gradient.

The cigarette is no longer simply a habit, an addiction, or an individual choice. In many contexts, it has become a marker of class — not because smoking has changed in itself, but because its persistence now tracks the line between those able to move away from harm and those left closer to it.

Smoking has ceased to be socially diffuse and has become concentrated, which changes its political meaning .

Why It Matters

The decline of smoking is real. But treating that decline as a uniform victory is analytically lazy and politically dangerous.

It ignores the fact that those who continue to smoke are increasingly people whose lives are shaped by low income, precarious work, interrupted education, mental distress, weaker support networks, and irregular access to quit.

Public health often speaks of “the smoker” as if this were a neutral and universal category. It is not.

The term can erase the material conditions under which smoking persists. When campaigns rely mainly on warning, stigma, taxation, and individual responsibility, they assume that all people have the same capacity to respond. They do not.

Evidence at a Glance

A study by Sarah Jackson, Sharon Cox, Jamie Brown, and Vera Buss, published in Nicotine & Tobacco Research, used data from 2022 to 2024 for England, Scotland, and Wales.

Average consumption among smokers was estimated at 10.4 cigarettes per day, equivalent to 28.6 billion cigarettes per year.

Smoking prevalence was 18.8% in C2DE social grades, compared with 10% among higher-income groups.

Daily consumption was also higher among more vulnerable smokers: 11 cigarettes per day, compared with 9.4 among wealthier groups.

Annual per-capita consumption sharpened the inequality: 755 cigarettes among the most vulnerable groups, versus 343 among the wealthiest.

The central finding is not only that cigarettes are still consumed at scale, but that consumption is socially patterned. Harm is concentrated where vulnerability is already concentrated.

Why This Matters for Policy

Scientific

• Smoking should not be studied or discussed only as an aggregate behavior. The relevant question is no longer simply how many people smoke, but who continues to smoke, where, under what pressures, and with what realistic options for quitting or reducing risk.

• This requires a more stratified public-health lens. Class, income, geography, mental health, housing insecurity, education, race, gender, and access to care are not secondary variables. They are part of the conditions through which smoking persists.

• The scientific mistake is to treat behavior as detached from circumstance. The political mistake is to call that detachment neutrality.

Regulatory

• Policies designed for “the population” may fail when the burden has already become concentrated in a specific segment of society. Generic warnings, higher prices, denormalization campaigns, and punitive restrictions can produce unequal effects when applied to unequal lives.

• This does not mean abandoning tobacco control. It means making it more intelligent. Regulation should continue to reduce the appeal, availability, and harms of combustible tobacco, but it must also recognize that taxation and stigma alone cannot produce equal outcomes in unequal social conditions.

• A serious regulatory approach would ask not only whether a measure reduces smoking in aggregate, but whether it reduces the burden among those who are most exposed.

Equity Implications

• If smoking is increasingly concentrated among poorer and more vulnerable groups, then tobacco harm has become an equity issue. The remaining smokers are not merely people who failed to absorb public-health messaging. They are often people living under social conditions that make quitting harder, relapse more likely, and alternatives less accessible.

• Smoking now draws a border: not simply between smokers and non-smokers, but between those who were able to move away from harm and those who remained exposed to it.

• That matters because policies that treat unequal populations as if they were equal may look universal while functioning unjustly.

Communication

• Public-health communication still too often relies on moral simplicity: the responsible subject quits; the irresponsible subject persists. This framing may be rhetorically efficient, but it is socially crude.

• The language of individual responsibility can obscure the conditions that sustain smoking. It turns structural inequality into personal failure. It makes the smoker appear as someone who refuses correction, rather than someone whose options may be materially narrower.

• Journalists, advocates, and public-health institutions need to stop reproducing the abstract figure of “the smoker” without asking what kind of life that figure is being made to stand in for.

The Strategic Question

The strategic question is not: Why do people still smoke?

That question is too thin.

The better question is:

Who continues to smoke, under what pressures, in which social conditions, and with what real possibilities of escape?

Once the question changes, the policy horizon changes with it.

The issue is no longer only individual cessation. It becomes the unequal distribution of harm, and the failure of public policy when it treats unequal lives as if they were equally free.

Recommended actions

For regulators and public health agencies

• Stop designing tobacco policy around an abstract, universal “smoker.”

• Stratify smoking data by class, income, geography, mental health, housing, ethnicity, gender, and access to care.

• Evaluate tobacco control measures not only by the aggregate decline in prevalence, but also by their effect on the most exposed groups.

• Combine cessation support with mental health services, social support, and targeted community interventions.

• Treat harm reduction as an equity issue and not just a regulatory controversy.

• Avoid policies that intensify stigma without expanding realistic pathways away from combustible tobacco.

For Politics

• Stop using individual responsibility as a substitute for social policy.

• Recognize that smoking persists where other vulnerabilities accumulate.

• Address the harms of tobacco as part of a broader inequality agenda that involves poverty, housing, work, mental health, and access to care.

• Ask whether current policies reduce harm among the most vulnerable – or simply make smoking less visible to the most protected.

• Avoid the false comfort of universal policies that appear neutral but work unevenly.

For journalists and opinion leaders

• Avoid portraying remaining smokers as simply irrational, irresponsible, or ill-informed.

• Report the decline in smoking along with the concentration of smoking. Aggregate success without distributional analysis is incomplete.

• Ask who benefits from current political narratives and who disappears into them.

• Cover harm reduction without caricature: Lower-risk alternatives are not harmless, but blocking them can also have human costs.

• Replace the moral drama of “bad choices” with the more difficult story of unequal conditions, limited agency, and concentrated exposure.

The risk of misreading

This argument does not absolve the market. It does not romanticize smoking. It does not deny addiction, illness, or death.

The issue is clearer: a political mentality that reduces smoking to individual failure cannot explain why smoking declines most quickly among the protected and persists where life is most precarious. It also fails to explain why moral pressure alone cannot reach those who live under the harshest restrictions.

The danger is not that tobacco control becomes too serious about smoking. The danger is that it remains serious in the wrong way: morally severe, socially blind, and insufficiently attentive to the unequal distribution of harm.

Bottom Line

Smoking no longer describes society as a whole. Reveals where protection ends.

The Core Tension

• The combustible cigarette remains legal, visible, and widely available.

• Lower-risk nicotine products — vapes, snus, nicotine pouches, heated tobacco — are often treated with greater suspicion than cigarettes.

• Since 2014, the Global Forum on Nicotine has served as one of the main spaces where this contradiction is openly examined.

• The central dispute is not only scientific, but moral, regulatory, economic, political, and communicational.

• The 2026 theme, Prohibition and Public Health, returns to the unresolved question: what is public health protecting when the deadliest product remains available while less harmful alternatives are restricted?

Why It Matters

The debate over nicotine is often presented as a conflict between public health and industry. But the deeper question is whether public health can still distinguish between products, risks, contexts, and people. When all nicotine use is morally collapsed into the cigarette, policy loses the ability to reduce harm where abstinence has failed.

The GFN matters because it forces a difficult question into public view: if millions continue to smoke, and if noncombustible alternatives carry lower levels of risk, then prohibition is not automatically protective. It may become a way of preserving the cigarette’s dominance under the language of caution.

Evidence at a Glance

• 2014: GFN begins in Warsaw around the distinction between nicotine, dependence, combustion, and death.

• 2015–2017: The Forum shifts from endgame rhetoric to harm reduction, accountability, technology, and consumer inclusion.

• 2018–2019: The debate expands from toxicology to language, perception, compassion, and the moral imagination of public health.

• 2020–2022: Pandemic-era digital expansion turns GFN into a broader platform for mediation, archiving, translation, and public debate.

• 2023–2025: The Forum becomes less peripheral, confronting the interpretation of evidence, economics, communication, misinformation, and political resistance.

• 2026: “Prohibition and Public Health” crystallizes the paradox: why prohibit lower-risk alternatives while cigarettes remain legal?

Why This Matters for Policy

Scientific

• Public-health language often merges nicotine, tobacco, combustion, and harm into one moral category.

• Harm reduction depends on distinguishing dependence from the main drivers of smoking-related disease.

• Evidence must be interpreted by product type, use pattern, exposure, and population — not by symbolic association with smoking.

Regulatory

• Bans on lower-risk products can unintentionally protect the combustible cigarette.

• Regulation should differentiate risk instead of treating all nicotine products as equivalent.

• Overly restrictive rules may push consumers toward informal markets or back to cigarettes.

Equity Implications

• Smoking is concentrated among populations marked by inequality, dependence, precarious access to care, and misinformation.

• Policies built around ideal behavior often fail people who cannot or will not quit immediately.

• Harm reduction becomes an equity question when safer alternatives are available only to the informed, wealthy, or legally protected.

Communication

• The conflict is no longer only about what science shows.

• It is about what journalism, institutions, platforms, and public-health messaging allow society to hear.

• Miscommunication can become regulation by other means.

The Strategic Question

The question is not whether every nicotine alternative should be celebrated. The question is whether public health can regulate according to real differences in risk, or whether moral discomfort will continue to produce policies that leave the cigarette structurally protected.

Recommended Actions

For Regulators & Public-Health Agencies

• Regulate nicotine products according to relative risk.

• Separate youth-protection policy from adult smoking-cessation policy.

• Preserve access to lower-risk alternatives while controlling marketing, quality, labeling, and age restrictions.

• Treat prohibition as an intervention with consequences, not as a moral default.

For Politics

• Stop using “protecting public health” as a substitute for measurable outcomes.

• Ask whether bans reduce smoking or simply reorganize the market.

• Include consumers, clinicians, researchers, and affected communities in policy design.

For Journalists & Opinion Leaders

• Avoid collapsing vaping, heated tobacco, pouches, snus, nicotine, and cigarettes into one category.

• Report conflicts of interest without using them as a shortcut to avoid evidence.

• Cover both risks: youth uptake and adult smokers being denied lower-risk options.

The Risk of Misreading

• Harm reduction is not deregulation.

• Lower risk does not mean harmless.

• Industry involvement does not necessarily create real conflicts of interest.

• Youth protection remains necessary.

But none of these facts eliminates the central problem: cigarettes kill through combustion, and policies that obscure that distinction may preserve harm.

Bottom Line

Warsaw keeps asking the question public health keeps postponing: what is being protected when the cigarette survives, and its alternatives are treated as the greater threat?

The forbidden product acquired the functional invisibility of tolerated things. It needed no official storefronts, no public recognition. It only had to move through the right channels, among people accustomed to living in a country where the distance between rule and reality is rarely an administrative accident; sometimes, it is the very method of government.

The ban remained on paper—reaffirmed by ANMAT in 2016, as though repeating a prohibition were enough to make it real. The market, however, already existed in everyday life.

On May 4, 2026, the Argentine state decided to interrupt the performance, or at least rearrange the stage.

ANMAT, the health authority responsible for medicines, food, and medical technology, revoked the ban it had imposed in 2011.

This was not exactly a liberal conversion. Still less was it a sudden enthusiasm for harm reduction, an idea still treated with unease by much of Latin America’s public-health bureaucracy. It was something rarer: a tacit admission that a rule can survive for years after it has lost contact with the world it claims to govern.

Administrative Order 2543/2026 overturned the rule that had prohibited, throughout Argentine territory, the importation, distribution, sale, and advertising of electronic cigarettes and their accessories. The ban that had promised control had ended up producing something else: a market without registration, without reliable traceability, and without effective health oversight.

In bureaucratic language, that literary genre governments deploy when they need to admit failure without ever uttering the word, the agency acknowledged that absolute prohibitions, when faced with dynamic markets and a high capacity for substitution, can push consumers into informal and illegal circuits, where products of unknown origin and even murkier composition circulate.

Translation: vapes did not disappear. They merely migrated into zones where the state could no longer see them, even as it continued to pretend to control them.

At bottom, Argentina did not decriminalize a desire. It tried to bring back to the surface a market that had never agreed to live entirely underground.

The Confession

ANMAT Administrative Order 2543/2026 is not merely a health regulation. Its recitals carry something rarer than a regulatory shift: the quiet admission that an absolute ban produced precisely what it had promised to prevent.

For years, products of unknown origin circulated without effective health oversight. The state could prohibit them. But prohibiting has never been the same as knowing. Still less as monitoring.

The word “failure” does not appear. Official documents rarely allow themselves that degree of exposure. They prefer cushioned verbs, impersonal constructions, and technical abstractions carefully designed so that no one has to claim authorship of the disaster.

They do not say: “We were wrong.”

They say: “accumulated experience has shown.”

They do not say “the ban failed.”

They say: “absolute prohibition schemes may encourage informal channels.”

Contemporary bureaucracy almost never acknowledges its dead. It merely recalibrates categories, updates protocols, and publishes new guidelines.

The 2011 ban belonged to another world.

At the time, the electronic cigarette was still treated as a technological eccentricity: an object difficult to classify, part imported gadget, part public-health threat, part internet curiosity.

The state answered with the reflexive grammar of defensive public health: prohibit first; understand later—provided there was still time.

But the market did not remain within the legal definition. What in 2011 fit under the narrow label of “electronic cigarette” had, fifteen years later, become an entire architecture of devices, liquids, salts, sticks, disposables, parallel imports, digital sellers, and informal circuits able to change shape faster than any regulatory agency can publish a resolution.

The law stood still. The market did not.

That is why ANMAT’s confession runs deeper than it seems. It does not repeal a failed rule. It recognizes, though without saying so outright, that public policies can fail not for lack of intention but from an excess of abstraction: when they begin governing imaginary categories while real life takes place somewhere else.

In trying to erase the market, the state lost the ability to see it.

The Ministry of Health added a politically uncomfortable figure to the diagnosis: according to the ministry itself, 35.5 percent of adolescents said they had tried an electronic cigarette at least once.

The percentage matters less as a moral scandal than as an administrative symptom. It reveals that vaping had already entered young people’s everyday lives long before formal legalization, and without any minimally consistent public-health mediation.

For better or worse, then, Argentina is not regulating a future possibility. It is trying to recover some degree of legibility over a phenomenon that expanded first and only afterward entered the institutional field of vision.

That changes the very meaning of public policy. The country is not trying to regulate the arrival of an unknown product. It is trying to catch up with something that has already arrived, and settled in before registration, before laboratories, before health warnings, and, in many respects, before the state itself had the capacity to understand it.

The reform, then, does not appear to spring from an ideological conversion to harm reduction. It emerges from a colder calculation, almost humiliating for a state that spent years mistaking prohibition for control: if the market does not disappear, perhaps what remains is at least the possibility of tracing it, taxing it, measuring it, and reducing part of the opacity in which it thrived.

What Changes in the Air

The market now being born will be legal, but narrow.

The new regulation bans disposable electronic cigarettes with prefilled solutions, restricts flavors, and tightly controls how products may be presented. Liquids and sticks may taste only of tobacco; nicotine pouches, of tobacco or menthol.

It is a public-health policy, of course. But it is also an aesthetic policy.

For those accustomed to the informal market—artificial fruits, chemical desserts, mentholated ice, fluorescent packaging, and devices designed to look like fashion accessories—the authorized market will seem almost monastic. The official palette will have few colors. The permitted smell will, almost always, be that of the old tobacco that public policy itself claims to want to overcome.

There is something paradoxical in this: the conventional cigarette remains available in every kiosk in the country, sold in standardized packs, yet fully integrated into Argentine daily life. Products without combustion, by contrast, enter the market as bodies under permanent surveillance, authorized only under aesthetic restraint and regulatory suspicion.

Then come the administrative reins.

Resolution 549/2026 created the Registry of Tobacco and Nicotine Products, a single database for manufacturers, importers, products, and packaging. The rule covers electronic devices, vape liquids, heated-tobacco products, sticks, and nicotine pouches.

The Undersecretariat for Health Planning and Programming will have forty-five days to put the system into operation. The bureaucratic detail matters less for the deadline than for what it reveals: even under a government that has turned anti-state rhetoric into a daily spectacle, reorganizing the market will require exactly what Mileiism most likes to declare obsolete: a robust, slow, far-reaching, and permanently interventionist administrative machine.

The market, then, is not simply being thrown open. It is being born conditional on the construction of that machinery.

Only registered products will be allowed to circulate legally. Manufacturers and importers will have to demonstrate origin, composition, quality, traceability, labeling, and health responsibility.

The technical details fill the annexes. But the political meaning is simpler and much older: the state is trying to regain control over a market that spent years operating without formal authorization, though never without consumers.

The third layer is economic.

Decree 305/2026 brought heated tobacco products, cartridges, bars, electronic cigarettes, and nicotine pouches under the temporary increase in the Extrazone Import Duty, applying to these goods the ceiling that Argentina has consolidated before the World Trade Organization.

The official justification is to bring their tax burden closer to that already imposed on traditional tobacco products.

The message, however, is more transparent: these products may lose their clandestine status, but they must not become cheap, abundant, or culturally seductive.

Legality arrives accompanied by labels, traceability, high taxation, and symbolic restraint. As if the state were saying: you may exist, but only without enthusiasm.

Neither the United Kingdom nor Australia

Argentina is not alone in this impasse. The whole world is trying to work out what to do when nicotine detaches itself from combustion and, for the first time in more than a century, the cigarette ceases to be its inevitable technological form.

No country has fully solved the problem. What exists are competing models of regulatory anxiety.

The United Kingdom chose to treat electronic cigarettes as a cessation tool aimed at adult smokers. For years, the NHS publicly maintained that vapes are far less harmful than combustible cigarettes and can help smokers give up tobacco. But that defense of substitution has always come with a carefully drawn boundary: the products are not recommended for nonsmokers and may not be sold to anyone under eighteen, even if they smoke cigarettes.

Even so, the British model may have been the first major contemporary state experiment built on an idea that remains politically uncomfortable for parts of the international public health community: nicotine and combustion need not remain morally inseparable.

The United States took another path, more legalistic, slower, and more corporate. To legally market a new tobacco product, companies must obtain prior authorization from the FDA, which assesses whether its release is “appropriate for the protection of public health,” weighing risks and benefits for both users and nonusers.

The decisive detail lies precisely in that formula: “public health” includes not only current smokers, but also future, hypothetical, statistical bodies, especially adolescents who might never have smoked, but whom contemporary regulatory rhetoric has turned into the central character in almost every debate about nicotine.

In May 2026, the FDA authorized new ENDS products, including the first items in that category with flavors that were neither tobacco nor menthol. The decision does not dismantle the American regulatory filter. It merely shows that even rigid systems end up making exceptions when they must acknowledge what part of the political discourse still resists admitting: relative risk matters.

Australia went to the pharmaceutical extreme of the equation. Since July 2024, vapes can be sold only in participating pharmacies, including nicotine-free versions. Since October of that year, pharmacists have been allowed to supply therapeutic products containing up to 20 mg/ml of nicotine to adults without a medical prescription, provided certain clinical and regulatory conditions are met.

The result is a curious model: nicotine remains legal, but surrounded by the symbolic atmosphere of a controlled medicine. As if the Australian state accepted its existence only once it had been converted into a clinical object, almost stripped of culture, pleasure, or autonomy.

Argentina is trying to draw an intermediate formula. It does not prescribe vapes as medicine. It does not release them as ordinary consumer goods. It does not explicitly adopt the language of harm reduction. Nor does it maintain absolute prohibition.

It registers, taxes, limits, traces, and watches.

It is a middle-ground policy. But the middle ground, especially in an age of regulatory panic and mutating markets, rarely means balance.

Sometimes it means only managed hesitation.

Who Gets In and Who Is Left Out

The new market is being born legal, but not necessarily accessible. Every regulation draws its own maps of belonging. On one side are actors capable of translating bureaucratic demands into economic operation. On the other are those too small to sustain legal departments, laboratory certifications, formal traceability chains, and permanent negotiations with health authorities.

The ban filtered by illegality.

The new order may instead filter by the ability to survive the cost of compliance.

For large companies, the new regime means regulatory adaptation. For small importers, independent manufacturers, and specialized shops, it may mean something else: the transformation of legality into an economic barrier.

The requirement of laboratory testing, certificates, technical documentation, traceability, batch control, compliance, and individual registration for each product favors those who already have working capital, a consolidated legal structure, access to laboratories, and a long history of managing their own legitimacy.

The multinationals start ahead, which would hardly surprise anyone watching a government that routinely denounces the excesses of the state while reorganizing markets in profoundly selective ways.

Philip Morris International, the owner of Massalin Particulares in Argentina, suspended in 2023 a $300 million plan to produce next-generation products at its Merlo plant after the Ministry of Health banned heated tobacco devices.

British American Tobacco, for its part, already operates globally with comprehensive portfolios across great vapor, heated tobacco, and modern oral products, including brands such as Vuse, glo, and Velo.

This is precisely the kind of company for which the vocabulary of contemporary regulation—traceability, compliance, certification, monitoring—does not pose an existential threat. It provides market infrastructure. Because large corporations do not merely survive bureaucracy. They often grow through it.

Small operators face another landscape.

Some will manage to formalize probably more in retail and distribution than in the manufacture of technically complex devices.

Others may remain where they have always been: in the gray zone between social tolerance, practical illegality, and economic survival. Especially if legalized products reach shelves expensive, limited in variety, and slow to arrive.

The reform may therefore produce an ambiguous effect: pulling part of the market out of the shadows while concentrating the legal surface in the hands of those who already had enough scale to pay for the right to remain visible.

The Smoker at the Half-Open Door

For the adult smoker, public policy rarely arrives as theory. It arrives at the counter, priced. As the presence or absence of stock. As packaging that is intelligible, or deliberately opaque. As the concrete difference between finding a possible alternative and, almost without thinking, returning to the familiar pack.

In the best-case scenario, the reform will produce a banal scene: an adult walks into an authorized shop, finds a registered product, reads the nicotine concentration, identifies the manufacturer, understands at least minimally what he is buying, compares prices, and decides to try something else.

Nothing epic. No public-health redemption. Just the small daily gesture of not lighting the next cigarette.

In the worst-case scenario, the scene changes.

The legalized product arrives expensive, scarce, limited in variety, tobacco-flavored, and surrounded by language so cautious it can barely explain its own existence.

The package warns but does not inform. The seller fears saying too much. Public discourse avoids any nuance that might sound less abstinence-minded than is acceptable. And so the smoker returns to what he already knows: the traditional pack or the same informal market the reform claimed it wanted to replace.

This is where harm reduction stops functioning as a technical slogan and faces its hardest test: existing materially.

An alternative confined to bureaucratic registration does nothing to reduce harm. It merely produces the administrative appearance of public policy.

To compete with the cigarette, it has to exist in the real world: at a possible price, with concrete access, in everyday circulation, through intelligible information, and in that gesture repeated thousands of times a day, the decision to postpone, replace, or simply not light the next one.

The Argentine government avoids calling this logic by the name it almost touches but never fully embraces: harm reduction.

Its grammar prefers the aseptic language of administrative technique—risk management, surveillance, monitoring, control. There is no enthusiasm for substitution. Nor any explicit recognition that adult smokers may deserve clear access to potentially less harmful alternatives.

There is, instead, a permanent discomfort with any policy that accepts discussing nicotine outside the classic language of blame.

ANMAT itself states that no tobacco or nicotine product is risk-free and that all involve potential dependence and adverse effects.

That is true.

But it is also a carefully incomplete truth.

Public health rarely operates in moral absolutes. It works through differences in risk, gradations of harm, comparative probabilities, and imperfect choices made by real people in real conditions.

The decisive question, then, was never whether nicotine is completely safe.

The question is: safe compared with what?

And it is precisely there that contemporary health discourse begins to hesitate.

Resolution 549/2026 recognizes that the public should be informed about differences in relative risk among products associated with traditional cigarettes, with or without tobacco, with or without nicotine. But legally recognizing this is easier than culturally accepting it.

Because informing people about differences in risk means admitting something politically uncomfortable for parts of the public-health bureaucracy: different products may not deserve the same moral frame.

The problem is that silence also produces regulatory effects.

When the state—captured by the interests of whoever happens to hold the net—avoids distinguishing combustion from substitution, it creates a discursive fog in which radically different products begin to look equivalent. And in that carefully managed confusion, the conventional cigarette preserves its greatest historical advantage: familiarity.

In the end, the answer will not lie only in the text of the rules. It will stand in front of the shelf. In what the smoker finds. In what he can understand. In what he can afford. And in what he decides—or manages—not to light.

The Paradox of the Lit Cigarette

No image better captures the Argentine reform than this: the conventional cigarette, a product whose health risks have been documented for decades, remains legal, available, and perfectly integrated into the everyday landscape of kiosks across the country.

Meanwhile, products that deliver nicotine without combustion enter the market amid regulatory suspicion: restricted flavors, monitored packaging, rigorous technical requirements, permanent traceability, and limits that the traditional cigarette never faced as it cemented its cultural presence over the course of the twentieth century.

The cigarette has a brutal historical advantage: it arrived before contemporary guilt. It established itself as a taxable commodity, a social habit, and a familiar object at a time when our societies had not yet developed the current moral, scientific, and regulatory machinery around nicotine.

The new products arrive too late to receive any presumption of innocence.

They enter a world that already knows the human cost of tobacco, and so, from the moment of their regulatory birth, they carry a kind of hereditary guilt.

Argentine policy does not resolve this paradox.
It merely rearranges it administratively.

For advocates of harm reduction, the contradiction seems obvious: the deadliest product remains widely accessible, while non-combustion alternatives appear surrounded by preventive restrictions and permanent institutional distrust.

Health authorities, however, tend to frame the question differently. The focus shifts from the existing adult smoker alone to future, hypothetical, statistical adolescents, young people who might never have smoked, but who have become central figures in the contemporary regulatory imagination.

The concern is not illegitimate. The problem begins when it is used to justify responses that cannot distinguish among combustion, substitution, relative risk, and adult use proportionately.

At that point, the debate no longer operates only in the field of public health. It also becomes a symbolic administration of fear.

Between these two pressures—the concrete harm faced by the smoker now and the potential risk posed to the adolescent projected into the future—Argentina is trying to draw a narrow corridor.

And narrow corridors rarely remain neutral for long.
Sooner or later, they reveal who is actually allowed through.

The Future That Has Already Arrived

The most sensitive point in the reform is, as almost always happens in debates over nicotine, youth.

The figure of 35.5 percent among adolescents became politically explosive not only because of the number itself, but because it reveals something more uncomfortable: vaping had already entered young people’s everyday lives long before formal legalization, and long before the state had any consistent capacity to monitor it.

The Precautionary Principle, evidently, failed.

For better or worse, then, Argentina is no longer responding to a future hypothesis. It is trying to manage an accomplished fact.

The official strategy seeks to reduce appeal: it bans disposables, restricts flavors, imposes health warnings, prohibits packaging associated with children’s or adolescents’ worlds, controls advertising, tracks products, and seeks to remove from the market any aesthetic that brings nicotine into pop culture.

The regulatory text seems to be waging war not only against devices but also against a specific visual language: artificial sweets, saturated colors, toy-like design, objects made to circulate on social media, school backpacks, and the emotional economies of youth.

There are reasons for this.

With or without proportionality, and almost always without a minimally serious discussion of combustion, relative risk, substitution, or the informal market, disposables have become, in several countries, the great visual emblem of the contemporary crisis of adolescent vaping.

By removing them from the legal market, Argentina is trying to prevent regulatory formalization from being mistaken for cultural legitimation.

But the problem with almost every policy based on symbolic containment is that it inevitably meets the street.

Real life.

Who will inspect kiosks, specialty shops, e-commerce, social networks, international parcels, and sales to minors?

How often?

With what budget?

With which laboratories?

With which inspectors?

With which borders that are genuinely controllable in a region crossed every day by informal circuits of goods?

Will Argentina have the technical capacity to verify composition, emissions, and nicotine concentration?

Will it have enough customs infrastructure to contain unauthorized products coming from Paraguay, Bolivia, Brazil, Chile, and Uruguay?

And will the registry be able to keep pace with a market whose principal skill has always been changing shape before the state finishes writing its next resolution?

Perhaps the reform’s fragility lies less in its normative architecture than in the administrative fantasy that so often accompanies such projects. Because, if enforcement fails, the country may end up producing two parallel markets: one formal, expensive, narrow, and concentrated in the hands of large operators; the other informal, cheap, varied, and as invisible to the state as it has always been.

Or perhaps even more invisible precisely because there is now a political need to pretend it is under control.

The Corner Test

The law changes in the Official Gazette. The market decides afterward whether to follow. It is, then, on the corner and not in ANMAT’s recitals that Argentina’s reform will truly be tested.

At the moment when a teenager looks for a disposable, an adult smoker tries to replace a pack of cigarettes; a seller chooses between registering and continuing to operate outside the system; an inspector decides whether to go in or look away; a parcel crosses—or crosses with no difficulty at all—the border.

The new regime is born surrounded by requirements: mandatory registration, traceability, high taxation, technical limits, flavor restrictions, health warnings, advertising controls, and the permanent promise of enforcement.

It may reduce some of the risks associated with the clandestine market.

But it may also produce something else: economic concentration, barriers to entry, high prices, unequal access, and the persistence of the very same informal circuit the reform promised to illuminate. Because markets rarely disappear when they lose formal legitimacy. They merely learn new ways to circulate.

Faced with this landscape, will the Argentine state be able to see more clearly what, for years, it preferred to pretend did not exist?

The answer will not lie only in laboratories, customs offices, or digital registries. It will be in the street. In the speed with which the informal market adapts. In the state’s capacity—or incapacity—to keep pace with mutating markets. In the difference between real control and administrative choreography.

Because an uncomfortable possibility hangs over the whole reform: that the country spent years mistaking prohibition for control and now risks mistaking traceability for governability.

And perhaps that is the true Argentine paradox.

After more than a decade trying to expel vapes from the legal surface, the state has finally decided to recognize them. But recognition is not the same as understanding. Still less as control.

In Practice

Are vapes legal now?

Yes, but only within the new regulatory regime. Products will have to be registered and meet requirements for traceability, labeling, health oversight, and inspection. The sale of unregistered items will remain prohibited.

Which products fall under the new rules?

Electronic cigarette devices, vape liquids, heated-tobacco products, sticks, and nicotine pouches. The legislation tries to gather under a single regulatory architecture an ecosystem that, for years, grew precisely through fragmentation and informality.

What changes for adult users?

In theory, legal products will have to disclose origin, composition, nicotine concentration, manufacturer, and health registration.

But the authorized market will be far narrower than the informal one. Disposables remain banned; liquids and sticks may only be tobacco-flavored; nicotine pouches are restricted to tobacco or menthol.

Legalization arrives accompanied by aesthetic, fiscal, and regulatory restraint.

And for smokers?

For the first time, there is a legal possibility of accessing non-combustion nicotine products within a formal system of control.

But real access will depend on something less abstract than decrees: price, availability, permitted information, and the legal market’s ability to compete with what already exists outside it.

Can minors buy them?

The legislation aims to make access harder by restricting flavors, advertising, packaging, disposables, and traceability.

But laws do not enforce themselves. Effectiveness will depend on the Argentine state’s real capacity to control physical sales, e-commerce, social networks, and informal circulation.

Are prices likely to rise?

Probably.

Import duties, laboratory testing, registration, certifications, and regulatory costs tend to make legal products more expensive than the informal versions already available on the parallel market.

And parallel markets tend to thrive precisely when the distance between legality and accessibility becomes too large.

Does the traditional cigarette remain legal?

Yes.

The reform changes the regulatory status of non-combustion products. Still, it does not alter the legality of conventional cigarettes, which remain fully available, taxed, and woven into the country’s daily routine.

What remains unknown?

Which products will actually be approved. How much they will cost. How quickly the registry will function. How enforcement will be carried out. And, above all, whether the legal market will manage to reduce the relevance of the informal circuit, or merely coexist with it.

Because regulating a market is one thing.
Convincing that market to leave clandestinity behind is another.

There is, in almost every contemporary public dispute, a recurring detail: before you can win the argument, you must win the form. Before reason, the field; before proof, the device that determines what can count as proof.

Who speaks.
In what format.
By which method.
With what vocabulary.
By what criteria of validity.

Contemporary politics and health policy, perhaps more than any other domain, rarely exclude voices through outright censorship. It excludes them through the design of the room, the syntax of the protocol, and the quiet liturgy of procedures.

Some experiences make it into spreadsheets, systematic reviews, and technical reports. Others remain outside, reduced to testimony, to noise, to isolated cases, to affect without status. They are not so much refuted as managed downward — demoted in category.

It is from this fissure that THR Global emerges.

Conceived by Kurt Yeo — co-founder of Vaping Saved My Life, a South African consumer group that advocates for tobacco harm reduction and vaping-related education, and a longtime smoker who claims to have quit through flavored vapes — the platform condenses a drama larger than himself: the attempt to make a private experience pass through the customs of evidence and enter, with some degree of legitimacy, the space where policy takes shape and circulates as official language.

At first glance, the initiative may seem like just another advocacy site in an already saturated ecosystem of campaigns, manifestos, reports, and testimonials on vaping, nicotine, and smoking cessation. Look closer, however, and its ambition runs deeper.

THR Global does not simply aim to publish stories; it seeks to recalibrate the regime of value in which those stories circulate. It seeks to transform what, for years, has been treated as a dispersed, subjective, and politically minor experience into something closer to a legible body of social evidence.

In simple terms, the platform seeks to address a problem that advocates of tobacco harm reduction have long recognized: despite possessing thousands — perhaps millions — of stories, the movement still lacks proportional weight in the arenas where policy takes shape, acquires normative force, and is enforced.

This is THR Global’s central point: not merely to give visibility to consumers, but to give institutional form to that visibility.

What begins to take form

Public discourse about digital platforms tends to exaggerate their novelty, as if each interface inaugurated a world. In the case of THR Global, however, what matters is not the technology but what it seeks to discipline: the shape of experience. This is not about technical innovation, but methodological ambition.

The platform rests on a simple — and deeply political — premise: personal accounts from former smokers who switched to lower-risk alternatives have been systematically underestimated, not only because of what they say but because of how they appear: fragmented, discontinuous, confined to the least-valued format of public debate: the isolated testimony.

The proposed response is standardization.

Each submission follows a structured format: smoking history, prior quit attempts, product used, and perceived outcomes. A seemingly neutral gesture, simple, almost administrative. But this is where the operation begins.

Instead of scattered narratives, a series.
Instead of the irreducible anecdote, comparability.
Instead of “my case,” the possibility of a pattern.

It is less innocent than it appears.

Because in standardizing testimony, the platform is not merely organizing information. It is intervening in the conditions under which something can be recognized as knowledge.

It is claiming a place within a hierarchy that has historically separated lived experience from valid evidence — not as a substitute for clinical science, controlled trials, or epidemiological surveillance, but as what these frameworks tend to overlook: the thickness of practice, the time of trial, the silent accumulation of trajectories that do not fit within experimental designs.

What “anecdote” does

Every public controversy generates its own glossary and its own instruments of disqualification. In the debate over tobacco harm reduction, one of them gained particular force: “anecdote.”

Consumers, activists, and pro-THR groups have, for years, heard variations of the same sentence: personal stories are not enough; testimony is not science; individual experiences cannot guide population-level policy.

In strictly methodological terms, the objection is not trivial. Self-reported accounts carry well-known limitations: selection bias, fallible memory, retrospective enthusiasm, lack of controls, and an inability to establish causality with the rigor required by certain research designs.

But “anecdote” does more than point to a technical limitation. It functions as a boundary-making device. It turns a vast body of experience into disposable material. It draws a line, often a comfortable one, between what can circulate as legitimate knowledge and what can be consigned to the sphere of inconsequential subjectivity.

THR Global enters at that boundary. Its most audacious gesture is not to claim that individual testimony is worth more than science, but to suggest that science itself — when translated into policy — may operate incompletely by systematically excluding those who experience the concrete effects of its decisions.

A subtle inversion.
And for that reason, a powerful one.

The question is no longer “are these stories just anecdotes?” It begins to unfold into others. Politically, why do millions of convergent experiences still lack proportional weight in the arenas where health policy is made? Scientifically, why are they still treated as epistemologically invisible, even when, taken together, they begin to delineate a pattern that resists easy dismissal?

What centralization makes possible

Every platform is, first and foremost, a technology of centralization. And every act of centralization — sooner or later — becomes a struggle over power: whoever organizes, defines; whoever defines, hierarchizes; whoever hierarchizes, decides what can circulate as relevant.

In the world of harm reduction, fragmentation among actors, roles, and levels of action has long been a structural weakness.

There are consumer associations in different countries — sometimes more than one within the same territory — as well as support groups, forums, local campaigns, independent studies, and a wide range of narratives scattered across spaces that barely intersect or rarely act in synergy.

Each node operates with what it has at hand, stretching its capacities to cover gaps that more coherent coordination might distribute differently. This disorganization of the symbolic and political division of labor does not stem from individual failure but from the absence of articulation among existing capacities.

The volume is there.
The energy is there as well.
What is often missing is a mechanism to convert dispersed capacities and talents into coordinated action. Without it, collective force tends to fall short of its critical mass.

What is dispersed almost always appears smaller than it really is.

And, in the case, what does not present itself within a shared regime of collection, classification, and presentation tends to seem inconsistent — even when it reflects recurring patterns. This is not merely a question of quantity. It is a question of institutional legibility: the capacity of an experience to be read, compared, retained, and ultimately admitted to the circuits where reality acquires administrative and political consequence.

It is at this point that THR Global intervenes: not in the content of the stories, but in the conditions of their legibility. By centralizing testimonies within a common format, the platform seeks to produce what bureaucracies, reports, and policy frameworks more readily recognize: series, repetition, scale, and archive.

It aims to show that some individuals have managed to quit smoking using less harmful alternatives, and that this outcome recurs across contexts, countries, and conditions, with a consistency that becomes increasingly difficult to ignore.

This is the project’s real ambition: not only visibility but also a more stable form of inscription in the debate — a shared point of reference, an archive that can serve as a resource when those voices are once again reduced to the status of exception, noise, or particular interest.

Questions of credibility

But every platform that sets out to correct a narrative imbalance runs into the same question sooner or later: who authorizes the authorizer?

In the field of tobacco and nicotine, this question is far from rhetorical. Few issues carry such a dense history of corporate fraud, scientific manipulation, aggressive lobbying, and institutional capture. For decades, doubt was manufactured as a survival strategy. That history has not faded; it continues to operate as a lens, a suspicion, a mode of reading.

It is on this mined terrain that THR Global encounters its central paradox.

For its supporters, the project corrects a historical exclusion: it restores presence to consumers systematically marginalized in health debates. For critics — and even for more cautious observers — it occupies a zone of ambiguity, where the language of harm reduction can function as a pathway for the reentry of commercial interests under a new moral and regulatory grammar.

In this context, distrust is not a detail; it is a condition of reading. The platform is not merely competing for attention but for legitimacy. And that contest will be decided less by the sheer volume of testimonies than by how they are produced, organized, scrutinized, and made auditable.

In other words, centralizing stories is not enough. It will be necessary to demonstrate that this centralization functions not merely as a refined technology of persuasion, but as a transparent infrastructure capable of turning lived experience into material that can be examined, compared, and engaged with within public debate.

On the force of biography

Kurt Yeo’s presence in the project’s announcement helps explain why it resonates. He embodies a recurring figure in contemporary harm reduction politics: the long-term smoker who claims to have found, in alternative products, especially flavored vapes, a way out that decades of failed attempts could not provide.

This type of biography — to which, in some way, I also belong — carries a particular force. It strains purism. It displaces the pedagogy of guilt. It suggests that public health does not always prevail when it demands complete and ideal abstinence, and that it may save more lives when it allows for imperfect solutions that are nonetheless less lethal than combustible cigarettes.

The power of this narrative lies in its capacity to speak of failure and survival. Not of theory, but of the body. Not of abstract regulatory design, but of the daily reality of someone who tried to quit and could not — until they did, by a path that many policymakers still hesitate to legitimize.

Yet it is this same biography that exposes a tension difficult to reconcile at the center of the debate. Health authorities view the flavors that, for some adults, were decisive in quitting through a different lens: not as individual experience but as a matter of population-level prevention.

The same product, the same substance — but a regime of evaluation that does not quite know how to handle the concrete success of a smoker when it appears to disrupt the abstract calculus of collective risk. What a personal story describes as redemption may, on the other side, be read as a disturbance to an equilibrium that was never designed to accommodate this kind of evidence.

THR Global situates itself within this contradiction without resolving it.
Perhaps that is not its role. Perhaps its function is different: not to arbitrate between lived success and regulatory concern, but to make the incommensurability between these two regimes more visible and more documented — and harder to dismiss without making explicit which one is being privileged and why.

Perhaps this is the debate’s blind spot: not the absence of data, but the difficulty of allowing distinct forms of evidence to coexist without one negating the other.

Data, and dignity

There is something deeper at stake here than the dispute between clinical studies and what has come to be known as real-world evidence. Platforms like THR Global operate in a zone where information and recognition cease to function as separate spheres. What is at issue is not merely what counts as data, but who is authorized to appear as a subject of knowledge.

For many consumers of lower-risk products, exclusion from the debate does not register merely as a technical error. It is experienced as a form of diminishment: the feeling of not being taken seriously, of not being heard on one’s own terms, of being continually translated into categories that fail to recognize the path one has lived.

This is not only a matter of underrepresentation.

More often, it is the perception of being reduced to an object of policy, never a legitimate interlocutor. In this displacement, something is lost: a form of epistemic dignity. Experience exists, but acquires no status. It speaks, but produces no effect.

This friction produces more than discomfort. It produces a form of revolt — not only against decisions, but against the way certain bureaucracies listen, or fail to listen. There are moments when a voice is recognized only when it confirms the expected script. Outside it, it becomes noise.

This revolt is understandable and, for that reason, vulnerable to capture. It can be mobilized both as a legitimate demand for recognition and as an argument for the dissolution of any form of regulation. The line between autonomy and exposure is not always clear.

THR Global speaks to this discomfort, but does not control it. Its subtext is clear: consumers are not merely recipients of public policy, but producers of knowledge about what worked, what failed, and what remained unresolved in their trajectories.

What the platform offers, therefore, is not merely the collection of data. It is a form of symbolic restitution — an attempt to restore status to experience, not as absolute truth, but as part of a field that has, until now, operated through poorly examined exclusions.

This gesture gains force especially in fields marked by asymmetries of voice, where lived experiences circulate widely but rarely arrive intact at the sites where they acquire institutional weight.

In such environments, gathering testimonies becomes more than an act of documentation. It becomes a form of self-inscription: we were here, we made this transition, our trajectories exist beyond the narrow categories through which they are typically read.

On the limits of the project

But any serious reading must resist the temptation of easy celebration.

First: standardization strengthens, but it also simplifies. Translating life stories into comparable fields entails selection, compression, and variable choice. Part of the density of individual accounts is lost when they are fitted into the model that enables their aggregation. What makes each experience singular — socioeconomic context, regulatory environment, consumer culture, comorbidities, unequal access, family pressures, trajectories of relapse — rarely fits entirely within structured forms.

Second: the classic risk of any advocacy platform — becoming a selective mirror of its most engaged participants. Who submits testimony? Who does not? Who feels compelled to participate — and who remains at the margins? Who has had negative experiences and chooses to remain silent? A collection of this kind can reveal patterns, but the logic of voluntary participation will always shape it.

Third, and most decisive: transforming testimonies into standardized data does not resolve the problem of causality or population-level generalization. A person who quit smoking using vapes may have done so for other reasons — changes in routine, life circumstances, coincidence, or placebo effect. The platform does not control for these variables. It records correlations; it does not establish causation.

This does not invalidate it.

But it imposes a limit and requires humility in how its findings are presented.

The relevance of a platform like THR Global will depend, to a large extent, on its willingness to clearly state what it can and cannot demonstrate. Its political strength lies in the organization of experience, not in any claim to rival, on its own, the best available science.

If it attempts to occupy that position, it weakens itself. If it embraces its specific role — that of a civic infrastructure aimed at making visible a form of evidence often underestimated — it may become harder to ignore. Yet there remains a dissonance that no formulation fully resolves. For those who have lived through this transition — and I include myself — the problem rarely presents itself as a question of method.

It presents itself as a question of time — of repeated attempts, of persistence. It is in this interval that the distance between analysis and experience ceases to be merely theoretical and becomes something far more difficult to sustain.

Where the question shifts

At its core, THR Global is not merely intervening in narratives about vaping or nicotine. It is contesting something more fundamental: the definition of who has the authority to shape what counts as reality.

Global public health organizes itself around aggregated data, meta-analyses, guidelines, conferences, and treaties. Necessarily. But it also rests on silent exclusions: which lives enter the frame as relevant data, and which remain reduced to personal cases without collective consequence.

The platform strains this arrangement by asserting that organized consumer experience can be part of political deliberation — especially in matters involving behavioral transition, risk substitution, and engagement with products that fall outside the classic pharmaceutical model.

The conflict, therefore, is not merely scientific.
It is epistemological and institutional.

THR Global shifts the question: when public policy regulates alternatives to cigarettes, why is the voice of those who have successfully transitioned still denied, or, when it does enter, so late, so weakened, and so often under suspicion? And what would happen if that voice, consistently assembled, began to operate as a pattern rather than an exception?

The answer does not yet exist.
But the question now has infrastructure.

Perhaps the most revealing aspect of THR Global is this: its emergence says as much about the state of the harm reduction movement as it does about the limits of traditional channels of representation. Platforms like this emerge when entire communities come to understand, in practice, that existing instruments were not designed to absorb what they have to say.

THR Global is both a symptom and a strategy.

A symptom of a prolonged impasse between consumers, regulators, researchers, and governments who observe the same phenomenon through distinct moral frameworks and evidentiary models.

A strategy because it attempts to correct this asymmetry not through direct rhetorical confrontation, but through infrastructure: collection, standardization, visibility, scale, memory.

Instead of responding to exclusion with protest alone, it responds with an archive. Instead of reacting to the charge of anecdote with indignation, it responds with method.

A lucid choice. And a risky one.

Lucid because it recognizes that, in the contemporary world, what does not become a system rarely becomes influential.

Risky because any attempt to convert suffering and relief into comparable data runs the risk of being read as advocacy in another guise — or of losing, in the process, part of what gave it force.

In the end, it is difficult not to recognize what is being built.

Calling THR Global a database is accurate, but insufficient.
Calling it an advocacy tool is also accurate, but it’s still not sufficient.
What is emerging is a more ambiguous, counter-chamber of public health policy, where experiences that previously existed in fragments now aim for public consistency.

The premise is clear: that the organized repetition of accounts can generate pressure; that the consumer voice, once made legible, will no longer sound like an exception; that the archive, at times, can do what an isolated argument cannot — sustain presence.

What remains open is how this will be read: as inconvenient evidence to be confronted, or as well-structured advocacy to be neutralized.

For those who know this transition from the inside, that reading is never abstract: it determines whether a lived trajectory is treated as knowledge or returned to the domain of suspicion.

And there is another, quieter risk. In a field marked by deep asymmetries, caution itself can become a vulnerability. Epistemic restraint — necessary to avoid overstating what can be demonstrated — may, on the other side, be read as a lack of force. Between asserting limits and sustaining presence, a difficult interval opens.

Perhaps, for now, THR Global’s most decisive contribution lies not in convincing its critics, but in shifting the terrain of the dispute. In showing that, in the twenty-first century, the struggle for recognition in public health is waged not only in laboratories, guidelines, or treaties, but also in the design of platforms that determine who can be seen, compared, counted, and ultimately considered.

In the global debate on tobacco and nicotine, this may be the most consequential dispute of all. Not because the platform will prevail, but because it has already changed the question.

No longer whether individual stories matter, but how they are assembled into a collective force that counts.

He had grown up in a family where smoking was less a habit than an atmosphere.
His parents smoked. So did his uncles, his aunts, and his grandfather. As a child, he was sent to the corner store to buy cigarettes for the adults—and paid, sometimes, with the change.

He started smoking at twenty. By his late twenties, he was already smoking heavily.
His father died at fifty-three, of a heart attack, just before Kurt’s wedding.

What followed was not a decision, but a sequence: attempts, failures, returns.

What eventually worked did not look like a solution. It was an early, rudimentary vaping device with a small blue light at the tip. It helped him reduce. Not quit.

The shift came later, with a different device bought informally from someone selling equipment out of the boot of a car. Within days, he stopped smoking.

The result was immediate. The meaning was not.

“I tried to quit for years,” he says—the kind of sentence that usually closes a conversation rather than opens one.

Millions have said some version of it.
And yet these stories rarely cross the line that separates experience from evidence.

This interview begins at that boundary and asks what it takes to cross it.

When did you first realize that the issue was not only quitting smoking, but the fact that this experience had almost no recognized place in public debate?

Kurt: That realization came gradually, but it became clear once I started speaking to more people who had successfully moved away from smoking, using alternatives like vaping or other reduced-risk products.

What stood out wasn’t just that people had quit smoking; it was how similar many of their experiences were — and yet how invisible those experiences were in any formal discussion.

People could tell you, quite clearly, how long they had smoked, how many cigarettes they used per day, what they switched to, how long they had been smoke-free, and whether they had tried to quit before.

These are not vague stories; they are structured, recallable pieces of information that align closely with the kinds of questions we ask in the THR Global testimonial form.

But outside of informal conversations, none of this seemed to have a recognized place.

In public debate, the focus is often either on clinical data or on population-level statistics.

The lived experience of switching — what actually happens between being a smoker and becoming smoke-free — tends to fall into a gap.

It’s often dismissed as anecdotal, even when thousands of people are describing very similar journeys.

That was the turning point for me.

It wasn’t just about quitting smoking anymore; it was about the fact that these real-world transitions, which are happening at scale, weren’t being captured in a way that could be meaningfully aggregated, understood, or even acknowledged in policy discussions.

THR Global is really a response to that gap.

Not to replace science, but to ensure that these experiences are collected in a structured, consistent way, so that they can at least exist alongside other forms of evidence, rather than being excluded entirely.

When did you understand that the issue was not a lack of stories but that even thousands of them still did not count as evidence?

Kurt: That became clear once the volume of stories stopped being the issue.

Early on, you assume that if enough people share similar experiences, that in itself will start to shift the conversation.

But what I began to see is that volume alone doesn’t change how something is treated.

You can have thousands of people describing very similar transitions, which they do, but it still doesn’t “count” in any formal sense.

The reason is structural.

These experiences exist, but they’re scattered, inconsistent in format, and not captured in a way that enables aggregation or comparison.

One person writes a paragraph on social media, another gives a quote in a news article, someone else shares a comment in a forum, and consumer groups like the one I founded in South Africa provide space to capture these stories.

Even if the underlying information is similar, it doesn’t accumulate into something that can be easily recognized or engaged with as a body of evidence.

That’s when it became obvious that the issue wasn’t a lack of stories; it was the lack of a consistent framework for capturing them.

With THR Global, the intention is to take what people already know about their own journeys and structure it in a simple, consistent way.

The same core questions are asked of everyone.

Individually, each story still matters.

But when that information is collected in a standardized format, it starts to do something different; it becomes possible to see patterns, to understand scale, and to at least present these experiences in a way that can be engaged with more seriously.

It doesn’t automatically turn them into clinical evidence, and it’s not trying to.

But it does move them out of being isolated anecdotes and into something more coherent, something that can no longer be dismissed simply because of how it’s presented.

When lived experiences are labeled as “anecdotes,” are we describing a methodological limit—or enforcing a boundary on what can be taken seriously?

Kurt: I think it’s a bit of both, but in practice, it often functions as a gatekeeping mechanism.

There is a legitimate methodological point; individual experiences, on their own, are not controlled studies. They can’t establish causality in the way clinical research is designed to.

That’s understood, and it’s important not to overstate what a single story can prove.

But what I’ve seen is that the label “anecdote” is applied very broadly, regardless of what the experience actually contains.

Many people can give quite specific, structured accounts of their journey: how many years they smoked, how many cigarettes per day, how many quit attempts they made, what they switched to, and how long they’ve remained smoke-free.

These are not just impressions or opinions; they are consistent data points that people can reliably report about themselves.

The problem is that when these experiences are not captured in a consistent format, they remain fragmented.

And once they are fragmented, it becomes easy to dismiss them collectively as anecdotal, even when thousands of them are describing very similar patterns.

So while there is a methodological limitation at the level of a single account, the way the term is often used prevents these experiences from even entering the conversation in a meaningful way.

It’s less about what the information is and more about how it is presented and whether it fits existing formats.

What THR Global tries to do is address that second part.

By asking the same core questions of every participant.

Alongside their written story, the aim is to bring consistency to these experiences.

That doesn’t turn them into clinical trials, but it does make them more comparable and more visible as a collective body of real-world transitions.

At the very least, it challenges the idea that all lived experience can be dismissed in the same way, simply because of the label that’s applied to it.

When did it become clear to you that the issue wasn’t the stories themselves, but the absence of a common structure to make them visible?

Kurt: That idea emerged once it became clear that the problem wasn’t what people were saying; it was how those experiences were being captured.

After seeing so many similar stories, the next step was trying to understand why they still weren’t being taken seriously.

And the answer was quite practical: there was no consistency.

The same underlying information was there, but it was scattered across different formats, different platforms, and different levels of detail.

That makes it very difficult for most to engage with it as a coherent body of information.

The shift in thinking came when I started looking at what people were actually able to report about themselves in a structured way.

Most people can answer the same core questions: how long they smoked, how much they smoked, when they started, how many times they tried to quit, what they switched to, whether they still use that product, and how long they’ve been smoke-free.

Alongside that, they can describe, in their own words, what that transition looked like.

Once you realize that, the gap becomes obvious.

The issue isn’t that the data doesn’t exist; it’s that it hasn’t been consistently collected.

That’s where the idea for THR Global took shape.

The written story still matters; it provides context and meaning, but the structured data points allow those experiences to be grouped, filtered, and understood at scale.

It doesn’t change the nature of the experience itself, but it does change how it can be seen.

Instead of isolated accounts, you begin to see patterns.

And once patterns become visible, it becomes much harder to dismiss the entire category of experience outright.

So the idea wasn’t about changing the stories; it was about changing how they are organized so they can actually be recognized for what they collectively show.

What is lost when a lived experience is translated into a standardized format?

Kurt: Something is definitely lost, and it’s important to be honest about that. When you standardize an experience, you inevitably compress it.

A person’s journey from smoking to being smoke-free is often complex.

It includes moments of relapse, personal motivations, social context, and even identity.

When you reduce that to structured fields like years smoked, cigarettes per day, number of quit attempts, product used, and years smoke-free, you’re selecting only certain aspects of that experience.

The nuance, the emotion, and the individuality don’t fully translate into those fields.

That’s why, for me, the written testimonial is not secondary; it’s essential.

It allows people to explain how and why the transition happened in their own words, which no structured format can fully capture.

But the trade-off is deliberate.

Without some level of standardization, those experiences remain difficult to compare or aggregate.

You can’t easily see patterns across thousands of people if every story exists in a completely different format.

So there’s a balance.

The structured questions (smoking history, quit attempts, product use, outcomes) provide a common framework that makes the experiences comparable.

The written story preserves the human context that would otherwise be lost.

THR Global doesn’t try to replace one with the other.

It’s about holding both at the same time: enough structure to make the information usable at scale, and enough openness to ensure that the individual experience isn’t reduced to just a set of data points.

Would you say that the problem today is not a lack of evidence, but the limits of what we are prepared to recognize as evidence?

Kurt: I think that’s a fair way to describe part of the problem. There isn’t a shortage of people who have successfully moved away from smoking and use safer alternatives.

You can see that in the consistency of what people report about themselves: that information exists and is repeated across many individuals.

The issue is that this type of information doesn’t always fit neatly into the formats that are typically recognized as evidence in formal settings.

If it’s not generated by a specific study design, it tends to fall outside the main body of what gets considered, regardless of how consistent or widespread it is.

At the same time, it’s important not to overstate what these experiences can do. They don’t replace clinical trials or population-level studies, and they’re not meant to. They can’t answer every question, particularly around causality or long-term risk.

What they can do is show, in a structured and consistent way, how people are actually transitioning in the real world. And that’s a dimension that isn’t always fully captured elsewhere.

So the gap isn’t simply about having more or less evidence; it’s about the types of evidence we’re set up to recognize.

THR Global is really about making sure that this particular type of information is at least visible and organized, so it can sit alongside other forms of evidence rather than being excluded because of how it’s presented.

To what extent does the exclusion of consumer experience shape not only public debate, but the very questions that scientific studies are built around?

Kurt: It has a real impact, because what gets discussed publicly often shapes what gets studied in the first place.

If consumer experience is largely absent from the conversation, then the research questions tend to be framed without that perspective.

Studies may focus on product characteristics, risks, or usage patterns in general, but they don’t always reflect the actual transition people go through.

We also see exaggerated claims based on the mere existence of a toxin, rather than on necessary levels based on how it is used in the real world.

What’s interesting is that many of these elements are things people can report quite consistently about themselves.

In the THR Global form, we ask straightforward questions, and when you start seeing that information across large numbers of people, you begin to get a clearer picture of the pathway, not just the endpoint.

If that kind of structured, real-world experience isn’t visible, it’s harder for it to inform study design.

The result is that certain aspects of the transition may be underexplored or treated as secondary, simply because they’re not part of the initial framing.

That doesn’t mean scientific studies are doing something wrong, as they rightly operate within established methodologies for good reason.

But it does mean that if a whole category of experience isn’t systematically captured and surfaced, it has a limited opportunity to influence what questions are asked or how studies are structured.

What THR Global aims to do is make that layer of experience more visible and more consistent.

Not to direct research, but to ensure that there is a clearer, organized account of what people are actually doing in the real world.

From there, it becomes easier for that perspective to at least be considered alongside other inputs when research questions are being shaped.

If this disconnect persists, where, if at all, does user experience enter the research process?

Kurt: At the moment, it tends to enter the process in quite indirect and inconsistent ways.

You might see it at the very beginning, where researchers draw on general observations or prior literature to frame a question.

It can also appear later, when studies include self-reported measures.

But even then, that input is usually tightly constrained by the study’s design, rather than coming from a broader, organized body of consumer experience.

Outside of formal studies, user experience often sits in the background, in surveys, small qualitative studies, or cited as context in discussions, but it’s not consistently structured or aggregated at scale.

That makes it difficult for it to play a more central role in shaping hypotheses or interpreting results.

What’s largely missing is a middle layer: a way to capture real-world transitions in a consistent, structured format for large numbers of people, without trying to turn that directly into a clinical study.

That’s where something like THR Global fits in.

By asking the same core questions and recording a written account, this approach creates a dataset of lived experience that is both human and structured.

It doesn’t replace formal research, but it can sit upstream of it.

In practical terms, that means user experience can start to inform the process earlier and more clearly, helping to highlight patterns, raise relevant questions, and provide context that might otherwise be missed.

So right now, user experience does enter the research process, but often in a fragmented way.

The aim here is simply to make that contribution more visible, more consistent, and easier to engage with, without overstating what it represents.

The platform does not replace science, but it suggests that certain dimensions of experience fall outside traditional models. Do you see that as a flaw or as a structural limitation?

Kurt: I would describe it more as a structural limitation than a flaw. Traditional scientific models are designed to answer specific types of questions, under controlled conditions, with a strong emphasis on isolating variables and establishing causality.

That’s exactly what they should be doing, and it’s why they are so important.

But because of that design, they don’t always capture the full shape of real-world behavior, particularly transitions from smoking to safer alternatives, which are often non-linear.

People don’t always switch in a single or consistent step.

They may try to quit multiple times, move between products, use more than one product for a period, or adjust their behavior over time before becoming fully smoke-free.

These are aspects of experience that people can describe quite clearly about themselves.

When you look at those responses collectively, you start to see patterns in how these transitions actually happen in practice.

The limitation is that traditional models are not always designed to capture such evolving, real-world pathways in a broad, continuous way.

They tend to take snapshots under defined conditions, which is necessary for their purpose, but it means certain dimensions of experience sit outside that frame.

So it’s not about one approach being right or wrong; they’re doing different things.

THR Global aims to make those real-world pathways more visible and consistently captured so that they can coexist with more formal research.

If anything, the value is in recognizing that both perspectives are needed.

One provides controlled, testable insights; the other shows how people are actually navigating these changes in everyday life.

In practice, who decides what counts as a valid story—and how do you ensure the platform doesn’t reproduce the same filters that have historically excluded these experiences?

Kurt: In practice, the platform itself doesn’t try to define a “valid story” subjectively. Instead, it defines a valid submission as one that meets a clear set of structured criteria.

Every testimonial goes through the same process. We ask the same core questions, alongside a written account of their experience.

There are also basic checks, such as email verification and moderation, to filter out spam or duplicate entries.

So the gatekeeping, to the extent that it exists, is technical rather than interpretive.

We’re not assessing whether someone’s experience is “good enough” or whether it aligns with a particular narrative.

If someone can provide a coherent account of their own journey and complete the required fields, their story has a place.

That’s quite deliberate.

One of the issues historically is that experiences get filtered after the fact; they’re selected, summarised, or excluded depending on how well they fit a particular framework.

What we’re trying to avoid is introducing that kind of subjective layer at the point of collection.

At the same time, we do have to be realistic.

The structure itself is a form of filtering.

By deciding which questions to ask, we are shaping how the experience is captured.

That’s unavoidable.

The difference is that the framework is transparent and applied consistently to everyone.

It doesn’t change depending on the story being told.

So the aim isn’t to remove all filters; that’s not possible, but to make them explicit, consistent, and minimal.

That way, the platform doesn’t decide which experiences matter; it simply provides a common structure through which those experiences can be shared and understood.

The platform does not resolve that. It makes it visible. And in doing so, it leaves something more difficult than a lack of evidence: that the limits may lie not in what we know, but in what we are prepared to recognize as knowledge at all.

If THR Global works as intended, what changes first: the conclusions, or the boundaries of what can be recognized as evidence?

Kurt: If it works as intended, the criteria change first or at least begin to expand. THR Global isn’t designed to produce new scientific conclusions on its own.

It’s not running controlled studies or testing hypotheses.

What it does is make a large body of real-world experience visible in a structured and consistent way.

Right now, much of that experience falls outside what is typically recognized as evidence, not because the information isn’t there, but because of how it’s captured and presented.

By standardizing the core data points, alongside the written story, the platform makes it easier to see patterns across many individuals.

The first shift, then, is not that conclusions suddenly change, but that this type of information becomes harder to ignore.

It starts to sit more clearly alongside other forms of evidence, rather than being dismissed outright as disconnected anecdotes.

Over time, that can influence how questions are framed, what gets explored further, and how different types of information are weighted.

But that’s a secondary effect.

So the immediate impact is on recognition, expanding what is seen as relevant and worth engaging with.

Any change in conclusions would come later and would still depend on how this structured, real-world data is considered alongside more traditional forms of research.

Today, what is the question the harm reduction debate still struggles to ask—perhaps because it would require changing the very way we understand evidence?

Kurt: One of the questions that still isn’t comfortably asked is the following:

What do real-world transitions actually look like at scale when people move away from smoking and use safer alternatives?

Not in theory, and not in tightly controlled conditions, but in practice, across large numbers of people.

It sounds like a simple question, but to answer it properly, you need a type of information that doesn’t fit neatly into the usual categories.

You need to understand not just whether people quit but how they got there: how long they smoked, how much they smoked, how many times they tried to quit, what motivated the quit attempt, what methods they attempted, why those attempts were unsuccessful, whether they switched gradually, whether they used more than one product, and how long they’ve remained smoke-free.

Individually, people can answer those questions quite clearly about themselves.

But collectively, that information hasn’t really existed in a way that allows it to be seen as a coherent body of insight.

At the moment, the debate tends to focus on endpoints or controlled comparisons.

The pathway—the lived process of switching—is less visible, partly because we don’t have a widely accepted way of treating that kind of information.

So it’s not that the question is impossible to ask.

It’s that answering it properly challenges the boundaries of what we currently recognize as evidence.

And until those boundaries shift, that question remains only partially explored.

* * *

Before any framework, before any platform, before any argument about what counts, there are people like Kurt: trying, failing, returning, and trying again.

Long before these stories became a problem of evidence, they were already a matter of survival. THR Global is one attempt to provide them with a place where they can gather, be compared, and be heard.

https://thrglobal.org

The platform does not resolve the tension. It gives it form.

And in doing so, it leaves something more difficult than a lack of evidence: the possibility that the limits may lie not in what we know, but in what we are prepared to recognize as knowledge at all.

What follows, then, is not an answer, but an attempt to think through that limit.

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?

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

Rates have fallen, and cigarettes have moved out of the center of social life.

But tobacco control did not simply reduce smoking. It reorganized where smoking remains, concentrating it among those for whom quitting was never merely an individual choice.

Over the past several decades, few stories have been told with as much consensus as those of tobacco control. It runs through reports, treaties, and scientific papers as one of those rare victories public health likes to display without lowering its eyes: a widespread problem, deeply embedded in social life, gradually pushed to the margins until it seemed, at least on the surface, to be under control.

One need only look at the curves.

They slope downward with an almost pedagogical docility, as if they recorded not only what happened, but the proper way to read it: this is what works, this is the path, this is the proper way to govern risk.

In that sense, the curves do more than measure. They instruct. They organize perception. They indicate where the problem is assumed to lie, and, just as importantly, where it no longer appears to be.

In institutional presentations, those curves appear clean and noiseless.
Clear, steady lines, almost a little too persuasive.
But lines conceal things too.

Their clarity depends, in part, on what they leave outside the frame: who continued smoking after the cigarette had already been expelled from the center, under what conditions smoking persisted, and who came to bear, in body and in life, the residual weight of what came to be called success.

This narrative did not arise on its own. It took shape through experiments carried out in the United States—especially in California, a pioneer from the late 1980s onward in programs that combined tax increases, media campaigns, and, above all, a deliberate effort to dislodge the cigarette from the center of social life and push it toward its farthest edges.

Before long, what had once occupied the hands of movie stars and the tables of cafés was driven out of pubs, restaurants, offices, and airports, until often all that remained was the sidewalk.

More than a regional case, this process established a repertoire of strategies that would, over time, become a model. Governments and international organizations adapted and disseminated them until they were consolidated, in negotiating rooms and technical documents alike, as the very language of what it means to control tobacco. In the early 2000s, through successive rounds of meetings, delegations from dozens of countries began negotiating the terms of that consensus. It would take institutional form in the Framework Convention on Tobacco Control.

From a sufficient distance, this trajectory cannot be explained by any single measure, but by a rare convergence: robust, well-funded science; persistent policymaking; supportive media; and a measurable shift in collective behavior.

A success difficult to dispute. Especially when told this way.

But this story was not only about taxes, campaigns, and effective regulation. It also relied on something less visible and more far-reaching: the transformation of smoking’s social role. Denormalization did not simply reduce the acceptability of cigarettes. It recoded smoking as an increasingly awkward, discreditable, and publicly inconvenient practice. Smoking ceased to be only a risk; it became a sign of conduct to be displaced, corrected, and kept at a distance.

It is precisely here that the narrative of success becomes most persuasive—and most misleading. The decline in prevalence supplies its clearest marker; the reduction in morbidity and mortality, its public-health justification; regulatory consolidation, its institutional face; denormalization, its normative culmination.

And yet the narrative does not quite hold.

At a certain point, the very success recorded by the indicators begins to expose their limits. Aggregate decline does not dissolve the inequalities that structure tobacco use. In many settings, those inequalities persist; in others, they sharpen. As smoking recedes from the center of social life, it becomes increasingly concentrated among those with fewer material, social, and psychological conditions for leaving it behind.

The question, then, is no longer merely whether the interventions worked. It is what kind of success they produced, where smoking was made to remain, and who came to bear, more intensely and more visibly, the material and moral weight of what, in the aggregate, came to be called progress.

What the Averages Conceal

From Aggregate Decline to Social Concentration

Aggregate decline no longer suffices as evidence of effectiveness—much less of justice. The question can no longer remain sheltered within the technical language that once seemed able to contain it. It is no longer simply a matter of how many people smoke less, but of where smoking remains, who was better positioned to respond to policy, and who stayed more exposed both to tobacco-related harm and to the burden of the measures designed to combat it.

This shift changes the object itself. What once appeared as a collective trajectory now reveals a more uneven pattern: the social concentration of a practice that is increasingly abandoned by those with greater stability, support, and the room to comply. Tobacco control did not simply reduce smoking across a uniform population. It reorganized where smoking would remain, concentrating it along existing lines of inequality.

As Lapalme observes, the point is not to deny the overall effectiveness of tobacco control, but to recognize that it has long coexisted with persistent inequality from within. Smoking does not disappear. It is redistributed—and tends to settle precisely where the material and symbolic conditions for giving it up are scarcest.

A closer look at the map makes this visible. The global decline is uneven: in some regions, it barely moves; in others, it advances slowly; in still others, it shows signs of exhaustion. The Western Pacific region, for example, has seen the slowest decline—around 8 percent between 2010 and 2024—driven by high prevalence in countries such as China and Indonesia. In Europe, progress has been similarly sluggish, with rates among women more than double the global average. In several countries—including Indonesia, Egypt, Congo, and Jordan—prevalence has scarcely shifted over the past decade.

But these numbers do more than describe variation. They trace a pattern. Smoking is not distributed at random. It follows the fault lines of the societies in which it takes hold. Where inequality runs deeper, smoking becomes denser, more persistent, and harder to dislodge.

This gradient is now one of the most consistent findings in the epidemiology of smoking—and one of the least comfortable. The lower the income and the level of education, the higher the prevalence, and the more difficult cessation becomes. In countries with relatively low overall prevalence, the pattern remains: smoking becomes progressively more common the further one descends the social scale.

But inequality is not limited to who smokes. It appears even more starkly in who manages to quit.

Low-income smokers show significantly lower abstinence rates—often roughly half those seen in more advantaged groups. Lower adherence to treatment, cohabitation with other smokers, greater dependence, and weaker support networks help explain the gap. But the problem begins earlier: in precarious material conditions, unstable routines, persistent stress, and the scarcity of time and energy that make giving up tobacco harder to initiate and harder still to sustain.

Even so, to explain is not the same as to understand. These factors do not operate in isolation. They accumulate, overlap, and reinforce one another until quitting smoking ceases to be merely difficult and becomes, for many, improbable.

This accumulation is most visible in low- and middle-income countries, where roughly 80 percent of the world’s 1.3 billion smokers live. There, the distance between what works in clinical trials and what is possible in ordinary life becomes stark. Treatments such as nicotine replacement therapy or varenicline may cost between $100 and $500 a year—amounts beyond the reach of much of the population. In some settings, that cost can approach 20 percent of a smoker’s monthly income, while cigarettes remain relatively cheap. Public coverage is limited, and access to behavioral support remains uneven.

In that setting, what the indicators record as behavioral persistence begins to reveal itself as something else: the cumulative effect of social conditions that make quitting smoking not merely painful, but structurally improbable.

Taken together, these patterns point to something more unsettling than the narrative of success usually allows. Population-wide policies have been effective, but not neutral. They did not merely reduce smoking; they reorganized where it would remain, on whom its burdens would concentrate, and under what conditions that persistence would be lived.

The averages record fewer smokers, lower exposure, and greater social disapproval of cigarettes. The distribution tells another story: one of progressive concentration among those for whom quitting is more costly, more constrained, and less compatible with the conditions of everyday life.

What the curves show clearly, the margins quietly undo.

The Remaining Smoker

Class, Suffering, and Social Concentration

More often than not, someone lights a cigarette before even noticing that a decision has been made. The gesture emerges in an interval: between one task and the next, between one shift and the one to follow, between a worry that has just ended and another already beginning. It is a pleasure. But not only pleasure. Nor merely dependence. It is, above all, a way of organizing time—opening a pause where no pause has been given.

The global decline in prevalence has altered the epidemiological landscape—and with it, the figure of the smoker who remains. Persistent smoking is no longer diffusely distributed across the social body. It thickens. And it thickens, above all, where economic insecurity, political neglect, and accumulated suffering are already dense. The remaining smoker is not simply someone who failed to respond to public-health messaging. More often, he or she occupies the point where behavioral language encounters the limits of its own explanatory power.

Here, Hilary Graham remains indispensable. Persistent smoking is not merely a risky behavior, nor a simple residue left behind by successful policy. It is a situated social practice—interwoven with class, income, gender, and place—and deeply inscribed in suffering, constraint, and inequality accumulated over the course of a life.

That perspective unsettles one of the most comforting assumptions in tobacco control: that continued smoking is primarily a matter of ignorance, irrationality, or insufficient motivation. Quitting does not take place in a vacuum. It depends on predictability, support, access to care, and some degree of control over one’s own life—conditions that are unevenly distributed, and often scarce precisely where smoking remains most prevalent.

In contexts of economic insecurity, housing instability, and mental distress, the cigarette takes on functions that exceed chemical dependence. It operates as emotional regulation, as a fragile interval within exhausting routines, as a way of sustaining the body and the day when other forms of support are scarce. It can become an anchor in the day: something inscribed in breaks at work, in transit, in the intervals between domestic tasks—in those minimal moments when the act of lighting a cigarette offers structure, marks off a boundary, and opens a brief space to breathe. What appears, from the outside, as persistence may also be a form of maintenance: a way of holding together what would otherwise come apart.

Qualitative studies reflect this with unusual clarity. Many smokers describe the habit less as addiction than as a form of everyday support: relief from anxiety, time of one’s own amid overload, a resource for regulating emotions that might otherwise spill over. In these accounts, there emerges something like a precarious economy of care—the cigarette as a tool for enduring the unendurable.

Research conducted in Brazil points in the same direction. Smoking appears as a palliative for sadness, discouragement, and isolation. In routines marked by precarity, that function intensifies. The cigarette ceases to be merely a habit and becomes instead a mediator between the subject and an everyday life that offers few alternatives for pause, relief, or self-regulation.

This dimension becomes clearer still when one considers the broader landscape of suffering. Persistent smoking is strongly associated with mental distress and traumatic experience. People with histories of abuse, depression, or anxiety smoke more—and find it harder to quit. What appears, in epidemiological terms, as behavioral persistence begins to shift in meaning. It is not simply dependence, but the overlap between dependence, suffering, and structural inequality. Under these conditions, cessation is not merely difficult. It becomes, in many cases, scarcely viable.

This reveals a persistent mismatch. The field of tobacco control recognizes these inequalities, but struggles to reorganize its responses accordingly. Equity appears in the discourse; in policy, far less so. Instead, many strategies continue to treat smokers as a homogeneous public. National campaigns, standardized protocols, universal approaches—tools that scarcely register how radically the conditions for cessation vary across income, place, and mental health.

As smoking declines, another transformation takes shape. The smoker’s social position becomes more sharply defined—and more heavily marked. Denormalization does not simply reduce the acceptability of cigarettes. It also produces identities. The smoker ceases to be merely someone exposed to risk and becomes increasingly legible as someone who has failed—morally, socially, and individually.

That shift is not abstract. It materializes in everyday life: in the glance that condemns, the body that withdraws, the subtle experience of being out of place. In domestic space, it appears as silence, interruption, or reproach. In health services, it can take the form of judgment—and, at times, of retreat.

For those already living under conditions of disadvantage, that experience intensifies. Smoking becomes not only a stigmatized practice, but a marker of social failure—one that may be internalized as shame, guilt, and diminished self-worth.

What emerges from this convergence is one of the most difficult tensions in contemporary public health. Policies designed to confront a widespread behavior now act upon a population that is smaller, more concentrated, and more vulnerable. In that setting, smoking can no longer be read simply as a matter of individual risk. It condenses something larger: inequality, suffering, and the uneven distribution of the conditions required to abandon it.

At that point, the question changes. If persistent smoking is not merely a behavior but a situated practice—anchored in constraint and unequal access to support—then the problem can no longer be framed solely in terms of why individuals continue to smoke. It must also be asked how public-health interventions act upon this uneven terrain, and what happens when policies designed for a widespread habit come to bear upon a socially concentrated one.

Invisible Costs

Regressivity, Stigma, and Legitimacy

If smoking has ceased to be a widespread habit, the policies devised to confront it have, to a large extent, remained the same. Taxation, spatial exclusion, denormalization campaigns, and standard cessation protocols were designed to act upon relatively diffuse populations. But the terrain has changed. Once smoking becomes socially concentrated, these instruments no longer fall upon a broad and heterogeneous public in the same way. They bear down most heavily on those with the least room to absorb their effects.

This is not only a distributive problem in the narrow sense. It is also a moral one. Tobacco control does not merely regulate products and behaviors; it distributes pressure, legitimacy, and blame. And once smoking is concentrated among socially vulnerable groups, the burden of that distribution becomes harder to ignore.

Tax increases remain one of the most effective tools for reducing average consumption. But the same measure operates differently across unequal social worlds. For those able to quit, higher prices may function as an incentive. For those whose smoking is entangled with instability, dependence, and scarcity, the effect is often less cessation than compression: other parts of the household budget contract so that smoking can continue under more punitive conditions. Some shift to cheaper alternatives, including illicit ones; others absorb the higher cost by cutting elsewhere.

The harm does not disappear. It is redistributed.

What is no longer spent on other needs—food, health care, education—comes to sustain a habit from which it is harder to escape. A policy effective in the aggregate thus reveals its regressive face.

It is here that the consensus begins to creak, even within the literature. Raising the price of cigarettes is, at once, one of the most effective tools for reducing consumption and one of the clearest demonstrations of the inequality of its effects. For those who manage to quit, it works. For those who do not—and who often live under greater material and mental vulnerability—it becomes a form of continuous penalization.

But the costs are not only material. They are symbolic as well—and for that very reason, harder to measure. Policies do not merely regulate behavior; they also distribute responsibility. Among low-income smokers, smoking often comes accompanied by guilt, shame, and social judgment. These experiences are not peripheral. They shape one’s relationship to the habit itself—and often to the health-care system as well.

At this point, denormalization ceases to be merely a public-health tool and becomes a mechanism of social classification. Making smoking socially undesirable was central to the success of tobacco control. But that success had ambivalent effects. In reducing the acceptability of cigarettes, it also helped fix around the smoker an identity marked by reproach and devaluation.

Once smoking is concentrated among vulnerable groups, this process no longer operates only as prevention. It also intensifies experiences of exclusion.

The tension deepens because many persistent smokers live under conditions that make cessation especially difficult. When the institutional response relies chiefly on restrictions and symbolic sanctions—high prices, exclusion from spaces, moral condemnation—it may increase the weight of those difficulties without offering proportionate support for confronting them. The result is a structural mismatch: equity appears as a principle, but rarely translates into policy design.

At that point, the question can no longer be framed solely in terms of effectiveness. It becomes a question of legitimacy. Interventions capable of producing broad population-level benefits may still be justified even when they impose individual costs. But that justification grows more fragile when those costs fall systematically on the very people who already live under multiple forms of disadvantage.

To take tobacco control seriously, then, is not to reject it, but to judge it more rigorously: not only by how much prevalence has declined, but by how its benefits and burdens are distributed, and by who comes to bear, more intensely, the residual weight of its success.

An Imperfect Victory

Justice, Proportionality, and the Limits of Behavioral Rule

In light of this new configuration, the standard of evaluation must change. It is no longer enough to ask whether tobacco control worked. The more difficult question is what kind of political and moral rationality its success has relied upon, and whether that rationality remains defensible once smoking is concentrated at the social margins.

Classical indicators—prevalence, consumption, mortality—remain indispensable. But taken on their own, they reveal less than they seem to. They register aggregate movement while remaining largely silent about social concentration, unequal exposure to burden, and the moral classification of those who remain. It is in that silence that the problem of justice begins.

What is at stake, then, is not only whether public-health gains were achieved, but how they were achieved—and under what assumptions about responsibility, conduct, and the location of the problem itself. A policy may save lives and still remain normatively narrow. It may reduce risk while deepening shame. It may improve averages while consolidating, in practice, a way of governing that treats as failures of conduct what are also expressions of suffering, inequality, and unmet need.

At that point, the problem ceases to be only tobacco. It becomes a test of public health itself: of whether it can recognize the limits of a framework that reads socially rooted practices primarily through the language of behavior, discipline, and correction.

This tension offers no simple resolution. The point is not to abandon tobacco control, nor to deny its gains. The difficulty lies elsewhere: in recognizing that a policy may be effective and yet remain distributively unequal and ethically incomplete.

To take that tension seriously is to confront the rationality that guided this success. By privileging abstinence, discipline, and disapproval, tobacco control has often treated as a failure of conduct what is also a demand for care—what condenses, in practice, accumulated inequality, constraint, and suffering.

From this point on, certain positions within the field become harder to sustain as merely technical. When smoking is concentrated among vulnerable groups, insisting exclusively on the eradication of behavior—without expanding the repertoire of responses—begins to appear less as prudence than as a narrowing of what counts as a legitimate form of care.

Viewed in this light, tobacco control ceases to be only a success story. It begins to expose the internal tensions of public health itself. It shows that effective policies can transform the epidemiological landscape of a problem while operating through a grammar ill-equipped to engage those who remain at its margins.

When that happens, public-health success loses the innocence of averages. Counting lives saved is no longer enough. We must also ask what forms of care were legitimized, what forms of suffering went unanswered, and which subjects came to be treated less as people to accompany than as behaviors to correct.

In the end, the curves do not lie. But they do not tell the whole story either. They show decline, improvement, and measurable gain. What they cannot show is how that success is lived, how its burdens are distributed, and how its remainder is governed.

At that point, the problem ceases to be only tobacco.

It becomes control.

Notes and Sources

The consolidation of tobacco control as a public-health paradigm, often told as a story of success, can be traced through the Californian experience revisited by Roeseler and Burns in “The Quarter That Changed the World” (Tobacco Control, 2010), as well as through the institutional literature that followed.

Denormalization, which was central to displacing the cigarette from accepted social norms and driving its gradual marginalization, is discussed by Bayer and Stuber in “Tobacco control, stigma, and public health” (American Journal of Public Health, 2006), and by Bell in “Legislating Abjection?” (Critical Public Health, 2011) and “Tobacco control, harm reduction and the problem of pleasure” (Drugs and Alcohol Today, 2013). See also Bell et al., “‘Every space is claimed’” (Sociology of Health & Illness, 2010), and “Smoking, stigma and tobacco ‘denormalization’” (Social Science & Medicine, 2010).

The persistence of inequality within aggregate decline, and the progressive concentration of smoking among socially disadvantaged groups, is developed by Graham in “Why social disparities matter for tobacco-control policy” (American Journal of Preventive Medicine, 2009) and “Smoking, stigma and social class” (Journal of Social Policy, 2011), and succinctly synthesized by Lapalme in “Tobacco control’s effects on social inequalities in smoking” (European Journal of Public Health, 2020).

The ethical dimensions of tobacco control, especially when its effects are distributed unequally, are examined by Voigt in “Smoking and social justice” (Public Health Ethics, 2010); by Breton and Sherlaw in “Examining tobacco control strategies and aims through a social justice lens” (Public Health Ethics, 2011); and by Thomas et al. in “Population tobacco control interventions and their effects on social inequalities in smoking” (Tobacco Control, 2008).

The social and subjective consequences of denormalization—including stigma, withdrawal, and marginalization—are explored in Ritchie, Amos, and Martin, “‘But it just has that sort of feel about it, a leper’” (Nicotine & Tobacco Research, 2010), and in Stuber, Galea, and Link, “Smoking and the emergence of a stigmatized social status” (Social Science & Medicine, 2008) and “Stigma and smoking” (Social Service Review, 2009), as well as in Bell et al., “Smoking, stigma and tobacco ‘denormalization’” (Social Science & Medicine, 2010).

Recent debates about equity, legitimacy, and the limits of the so-called tobacco “endgame”, especially once smoking has become concentrated at the social margins, include Malone, “Justice, disparities and the tobacco endgame” (Tobacco Control, 2021); Mills et al., “Recommendations to advance equity in tobacco control” (Tobacco Control, 2022); Lund and Sæbø, “Challenges in legitimizing further measures against smoking…” (Harm Reduction Journal, 2024); and Meier and Shelley, “The fourth pillar of the Framework Convention on Tobacco Control” (Public Health Reports, 2006).

The shift in emphasis, from aggregate effectiveness to the social distribution of outcomes, is formulated with particular clarity by Lapalme in “Tobacco control’s effects on social inequalities in smoking” (European Journal of Public Health, 2020).

The social determinants of smoking including life conditions, support networks, and unequal access to cessation are discussed by Garrett et al., “Addressing the social determinants of health to reduce tobacco-related disparities” (Nicotine & Tobacco Research, 2015); Paul et al., “The social context of smoking” (BMC Public Health, 2010); and Boland et al., “‘I’m not strong enough…’” (International Journal for Equity in Health, 2017).

The understanding of persistent smoking as a situated social practice shaped by class, suffering, and accumulated inequality owes much to Graham, especially “Smoking, stigma and social class” (Journal of Social Policy, 2011).

The ethical and legal implications of “endgame” strategies, especially with respect to proportionality and legitimacy, are addressed by Thomas and Gostin in “Tobacco endgame strategies” (Tobacco Control, 2013), and further developed by Voigt in “‘If you smoke, you stink’” (2013) and in “Tobacco as a matter of public health,” in The Oxford Handbook of Public Health Ethics (2019).

The persistence of inequality within policies widely regarded as successful is also examined by Malone (Tobacco Control, 2021) and Mills et al. (Tobacco Control, 2022).

For a normative framework grounded in equity, proportionality, and dignity, especially relevant when the burdens of policy become concentrated, see Voigt (Public Health Ethics, 2010); Breton and Sherlaw (Public Health Ethics, 2011); and Voigt in The Oxford Handbook of Public Health Ethics (2019).

The ethical problem posed by denormalization, particularly when it becomes entangled with stigma and exclusion, is developed by Bell (Critical Public Health, 2011; Drugs and Alcohol Today, 2013) and by Bayer and Stuber (American Journal of Public Health, 2006).

The tensions among care, exclusion, and legitimacy, particularly visible when public health success coexists with the social concentration of harm, are evident in Malone (Tobacco Control, 2021), Lund and Sæbø (Harm Reduction Journal, 2024), and Meier and Shelley (Public Health Reports, 2006).

Atem und Wandel – Breathe for Change did more than name the conference.

It established its mood. “Breath” carried an obvious literal meaning, given Barmelweid’s close association with respiratory care. But it also carried a moral one, linking cessation, clean air, prevention, and behavioral change. The English subtitle, together with the presence of the WHO and the ENSP, placed the event in a familiar register: locally anchored, internationally legible.

The image of the clinic set against greenery, and the column of seals a few pages later, completed the effect. Before anyone spoke, the event had already been framed through care, order, certification, and authority.¹

The seals mattered. Barmelweid foregrounded its international Gold recognition within the network of tobacco-free healthcare services. At the same time, the network itself described certification not only as a mark of commitment but also as a valuable signal to insurers and referring physicians. The effect was not merely symbolic. Certification did not just affirm a principle; it helped place the institution within a hierarchy of credibility.²

The conference projected public health, certainly. But it also projected standing.

Its organizing core was local. It centered on Klinik Barmelweid, a Swiss specialty and rehabilitation clinic with a strong focus on pulmonology and nicotine-cessation counseling, and on the FNBS, which appeared in the program through Susann Koalick, head of the clinic’s nicotine counseling service and president of the forum. Barmelweid maintained a formal cessation structure; FNBS presented itself as a nonprofit platform supporting institutions and professionals in implementing evidence-based standards for nicotine prevention.¹˜³

A second layer came from transnational legitimation. By opening with José Luis Castro, the WHO Director-General’s Special Envoy for chronic respiratory diseases, and Cornel Radu-Loghin, secretary-general of the ENSP, the meeting placed itself under two established forms of authority: the WHO’s norm-setting role and the European tobacco-control advocacy represented by the ENSP. The conference presented itself not simply as training, but as part of a wider field organized around nicotine control. ¹˜⁸

A third layer came through practical translation. The program spanned oncology, dentistry, child and adolescent psychiatry, cardiology, addiction medicine, occupational health management, work psychology, and digital communication. In that arrangement, nicotine appeared not as a narrow clinical issue but as a cross-cutting problem touching cancer, mental health, youth, workplace culture, and public communication. The session on Rauchfrei-Kultur, featuring hospital managers and human-resources personnel, was especially revealing. The focus shifted from the individual smoker to institutional governance and the production of smoke-free and nicotine-free environments.¹

That shift matters. The conference did not simply ask how to reduce smoking. It also asked who would define the legitimate terms of prevention, which institutions would be recognized as exemplary, and how those standards would circulate.

The most visible interest was preventive and sanitary. The program framed nicotine as a matter of reducing tobacco and nicotine use, protecting young people, integrating cessation into cancer care, cardiology, mental health, and dentistry, and responding to the spread of newer products such as snus, pouches, and electronic cigarettes. But a second interest was also visible: the consolidation of a field. By convening the WHO, the ENSP, hospitals, clinicians, psychologists, prevention specialists, and communication professionals, the organizers were doing more than assembling a conference. They were assembling a network of authority.¹˜⁸

Two sessions made that especially clear: Nikotinindustrie und Sprache and Chancen digitaler Reichweite für Nikotinprävention. The struggle here was not only clinical or regulatory. It was also semantic. The program treated nicotine not simply as a substance to be governed, but as a narrative terrain to be occupied: the language of prevention had to compete with the language of innovation, lifestyle, and harm reduction. In that sense, the event did not merely communicate a position. It also worked to stabilize the vocabulary through which the problem would be understood.¹

The omissions helped define its character. On the publicly listed event page, no industry representatives, vape consumers, harm-reduction associations, or openly dissenting voices were visible. That fact alone does not invalidate the meeting. But it does clarify what kind of meeting it was. This was not a forum designed to test disagreement at its outer edge. It was a forum of alignment.¹

The same logic becomes clearer once one looks beyond the program and into the infrastructure behind it.

The network ran on both money and legitimacy. Revenue came from membership dues, certification fees, training revenue, project-related contributions, and the host clinic’s economic base. Legitimacy came through certification, international recognition, and alignment with cantonal programs and healthcare mandates. Together, those elements produced a more durable kind of standing within the health system: greater authority to speak in the name of prevention, greater value as a reference point, and greater credibility with insurers, referring physicians, and institutional partners.²˜³˜⁵

The clearest starting point is an official record. The 2nd Nikotintagung Klinik Barmelweid received 9,000 Swiss francs from the Swiss Tobacco Prevention Fund between April 2007 and May 2008. The project was framed not as a commercial activity, nor simply as an academic exercise, but as information and awareness-raising and as part of a broader effort in networking and creating favorable conditions for prevention. In the final report, the organizers described the conference as a platform for exchange, a means of expanding knowledge in research and practice, and a way of supporting the implementation of smoke-free measures in hospitals and healthcare institutions. From the beginning, then, the tagung appears less as isolated professional training than as an instrument for organizing a field.⁴

By 2026, that structure no longer looked experimental. The 11th Nikotintagung again placed Barmelweid at the center, with Koalick in a key role, explicit support from the FNBS, and a schedule populated almost entirely by actors from public health, prevention, hospital management, and preventive communication. Registration was set at CHF 300. What appeared in 2008 as a publicly supported effort to build exchange among specialists had, by 2026, become recurring infrastructure: a site where common language, professional visibility, and institutional alignment could be reproduced.¹˜⁴

Its financial base was mixed. The Swiss Tobacco Prevention Fund states that it receives 2.6 rappen per pack of cigarettes sold and disposes of roughly 12 million Swiss francs per year to finance tobacco- and nicotine-prevention measures. Part of this world, in other words, rests on a stable public revenue stream anchored in the very consumption it seeks to reduce.⁴

The statutes of the former FTGS, later renamed FNBS, make the association’s revenue structure explicit: membership fees, certification income, project-related contributions, contributions from the Confederation, cantons, and municipalities, donations, service revenue from activities such as training, and investment income. This was not a body sustained by a single grant. It was built to operate as a platform: part association, part service provider, part intermediary for public and institutional money. Even the membership forms point in that direction. Individual membership costs CHF 80 per year; collective membership requires a CHF 250 entry fee and CHF 450 in annual dues. These are not large sums. But they show that affiliation was not only symbolic. It also generated structure.³

The material center of this arrangement was Klinik Barmelweid itself. In 2024, the clinic reported CHF 80.1 million in total revenue, almost all of it from services and deliveries, including CHF 70.6 million from medical and nursing services. It also held positions on the hospital lists of Aargau, Basel-Landschaft, Basel-Stadt, and Solothurn. That mattered because its place in the system did not rest on reputation alone. It rested on cantonal mandates, payer recognition, and formal insertion into the Swiss healthcare infrastructure.⁵

Certification is where these strands converge most clearly.

FNBS offered three certification levels for healthcare institutions—Bronze, Silver, and Gold—with formal pricing, staged requirements, and periodic recertification. More important than the fees was what the standards covered: leadership, communication, training, identification and support for cessation, tobacco-free environments, workplace health, public engagement, and evaluation. Certification, in this sense, did not merely attest compliance. It organized a model of institutional conduct.⁶

The signets extended that logic into the visual environment. FNBS marketed registered “Smoke Free” and “Smoking Area” signage, linking prevention to signage, space, and institutional design. Prevention, here, was not only advice or counseling. It also took material form as an organizational product.⁶

The strategic value of certification was stated most clearly by the network itself. In an interview on the Barmelweid blog, Susann Koalick described certification as a valuable signal to insurers and referring physicians and as something that strengthened the institution’s standing in other quality-certification processes. Barmelweid likewise emphasized that it had been the first Swiss clinic to receive this international Gold recognition in 2020 and the first to be successfully recertified in 2024. Certification did not, on its own, create the right to bill the mandatory insurance system that still depended on hospital lists and cantonal mandates. But it improved its relative position within the healthcare field. It made the institution more legible, more reputable, and more useful within the circuits of referral, reimbursement, and accreditation.²˜⁵˜⁷

At that point, certification ceased to be a detail and became an instrument.

What emerges from these documents is not a conspiracy, and does not need one. The interest is visible enough without it. Public-health language, public funding, certification, clinical infrastructure, and professional events were not operating separately. They were reinforcing one another. The result was a network able not only to advocate prevention but also to define standards, circulate recognition, organize training, convene aligned actors, and strengthen its own centrality within the field.

What remains unknown matters too. Within the public material reviewed here, there is still no audited breakdown of FNBS revenue by category, no precise weighting of each income stream, no full financing breakdown for the Nikotintagungen, and no complete public map of cantonal contracts and projects linked to the network. Those limits should be stated plainly. But they do not erase the pattern already visible in the available record.

That pattern is straightforward. Public money helped build the network. The network helped produce standards. Standards helped produce certification. Certification helped produce a position.

And position, in this case, had effects. It shaped access to recognition, referrals, institutional trust, and public partnership. It helped define what counted as exemplary practice. It generated recurring services around assessment, recertification, training, and materials. It made the network a more plausible partner for policy implementation and more influential in setting the tone of the debate.⁴˜⁵˜⁶˜⁷

The Swiss Barmelweid/FNBS network did not operate in isolation. It operated within a broader field in which the WHO, the ENSP, and philanthropic actors contributed to the financing, coordination, and dissemination of tobacco-control norms, campaigns, and institutional agendas. But the core mechanism is already visible at a closer range. In Barmelweid, prevention appeared not only as a medical or ethical imperative. It also appeared as a way of building position inside the health system, and of turning that position into further influence.⁸

In that sense, the question is not only what prevention opposes. It is also what prevention organizes, what it rewards, and what kinds of authority it helps reproduce.

Notes / Sources

1. Event framing, listed speakers, target audience, registration, and publicly visible omissions on the official page for the 11th Nikotintagung (2026):

https://fnbs.ch/events/11-nikotintagung-atem-und-wandel-breathe-for-change/

2. Barmelweid and network communications on certification value, international Gold recognition, recertification, and certification as a signal to insurers and referring physicians:

https://blog.barmelweid.ch/die-barmelweid-ist-eine-echte-vorreiterin/

https://www.barmelweid.ch/news/artikel/die-barmelweid-erhaelt-erneut-gold-in-der-tabakentwoehnung-international

3. FTGS/FNBS institutional continuity, statutes, revenue structure, governance, and membership categories/fees:

https://fnbs.ch/wp-content/uploads/2023/09/FTGS-Vereinsstatuten-2023.pdf

https://fnbs.ch/wp-content/uploads/2023/09/Einzelmitgliedschaft_Antrag.pdf

https://fnbs.ch/wp-content/uploads/2023/09/Kollektivmitgliedschaft_Antrag_d.pdf

https://fnbs.ch/ftgs-heisst-jetzt-fnbs-praevention-weitergedacht/

4. Swiss Tobacco Prevention Fund support for the 2nd Nikotintagung Klinik Barmelweid, including project record, final report, and TPF funding logic:

https://tpf-livingdocs.bagapps.ch/livingdocs.php?cq=2004%3B2025%3B0%3B%3B%3B%3B%3B0%3B&id=94&lang=de

https://tpf-livingdocs.bagapps.ch/data/pdf/94-0.pdf?v=1566208714

https://www.tpf.admin.ch/de/der-tabakpraeventionsfonds

5. Klinik Barmelweid institutional and financial profile, hospital-list status, cantonal mandates, insurance recognition, and patient admission pathway:

https://www.barmelweid.ch/fileadmin/user_upload/Dokumente/GB2024/Jahresrechnung_Klinik_Barmelweid_AG_2024.pdf

https://www.barmelweid.ch/ueber-uns/portraet/leistungsauftraege

https://www.barmelweid.ch/barmelweid/ihr-klinikaufenthalt/anmeldung

6. FNBS certification model, standards, pricing, recertification, and signets/signage materials:

https://fnbs.ch/zertifizieren/

https://fnbs.ch/produkt-kategorie/signete/

7. Certification as institutional signal and relative advantage within referral, reimbursement, and accreditation circuits:

https://blog.barmelweid.ch/die-barmelweid-ist-eine-echte-vorreiterin/

https://www.barmelweid.ch/news/artikel/die-barmelweid-erhaelt-erneut-gold-in-der-tabakentwoehnung-international

https://www.barmelweid.ch/ueber-uns/portraet/leistungsauftraege

8. Wider international coordination and financing ecosystem involving WHO, ENSP, EU-supported ENSP activity, Vital Strategies, and Bloomberg-linked tobacco-control programs:

https://www.who.int/teams/health-promotion/tobacco-control/implementing/capacity-building

https://ensp.network/wp-content/uploads/2017/05/ENSP-20-Years-LOWRES-ilovepdf-compressed.pdf

https://www.parlament.gv.at/dokument/XXVII/EU/38925/imfname_11019376.pdf

https://cordis.europa.eu/project/id/681109

https://ensp.network/wp-content/uploads/2022/02/ENSP-Annual-Report-2019_final.pdf

https://www.vitalstrategies.org/resources/tobacco-control-initiatives/

https://fctc.who.int/docs/librariesprovider12/technical-documents/global-progress-report-who-fctc-2023.pdf?download=true&sfvrsn=bd10da90_16

https://www.who.int/teams/health-promotion/tobacco-control/implementing/capacity-building

https://www.tobaccocontrolgrants.org/s/01-Tobacco-Industry-Interference-Grants-Call-for-Proposals-R5-Jan-final-2026-47fj.pdf

https://www.bloomberg.org/public-health/reducing-tobacco-use/bloomberg-initiative-to-reduce-tobacco-use

That may have been why it passed through the room without friction: the absence of conflict did not signal agreement so much as delimitation—a quiet recognition of what could be said, what need not be defended, and what had already been settled in advance.

The framing did not begin with the speech. It was already embedded in the program. Throughout the day, the themes aligned with minimal deviation: nicotine prevention, smoke-free culture, the industry's language, the impact of new products on children and adolescents, and digital strategies designed to contain their spread.

This kind of organization is hardly unusual in contemporary public-health gatherings, where the convergence of research, advocacy, and policymaking tends to narrow the space for explicit dissent. The language of prevention helps organize action, but it also prefigures the terms of debate.

What emerged was not a confrontation between competing interpretations so much as the reiteration of a shared vocabulary from multiple angles. In that arrangement, the conference functioned less as a site of reflection than as a mechanism of stabilization: before asking how risks, uses, and contexts might be distinguished, it had already determined which distinctions would count as relevant.

Its coherence is derived from that.
And so did its limit.

In this context, Castro’s position ceases to be incidental and becomes part of the arrangement itself. He speaks not from a distance, but from within a role that blends formulation, mobilization, and the defense of agendas. As a WHO Special Envoy, his task is to amplify messages, build alliances, and sustain institutional priorities.

This does not diminish the weight of what he says. But it does change how the speech must be heard. It operates not as an arbitration between competing hypotheses, but as a situated intervention within a broader effort to organize perceptions, align interpretations, and stabilize frameworks in public debate.

To his credit, Castro does not conceal this shift. He says so plainly: policy alone is not enough, because it is often “downstream from culture.” The issue, then, is not that the speech disguises its priorities, but that it relocates the center of gravity of the debate—from differentiating risks to defining the cultural and narrative terms through which those risks will be understood.

At that point, the problem no longer appears solely as one of evidence or scientific uncertainty, but as one of perception: how nicotine is seen, interpreted, and absorbed into the social imagination. Castro marks this shift explicitly when he frames prevention not only as a matter of regulation but also as a matter of understanding “how products are positioned, how language is used, and how perceptions of risk are shaped.”

He goes further. If policy is often “downstream from culture,” then what matters is “the story we are telling in the culture.” In his formulation, the concern is that “the narrative around nicotine is being shaped elsewhere,” in the language of innovation, choice, and harm reduction —and that, if left unchecked, it may “take hold before we have had a chance to define our own.”

With that move, the dispute extends beyond what is known to include which languages are granted legitimacy to describe the problem. The question is no longer only what counts as evidence, but who defines the narrative terrain on which that evidence will be interpreted.

That shift alters the nature of the problem. What once appeared as a question of differentiating risk now operates at the level of authority: who defines categories, who names phenomena, who establishes equivalences.

As that axis shifts, conceptual precision no longer occupies the center of the scene. Distinct products begin to circulate under a shared designation, sharing language before they share properties.

“New nicotine and tobacco products” becomes less a description than a container. Within it coexist the regulated e-cigarette used by an adult trying to quit smoking, the illegal device designed to maximize youth appeal, occasional experimentation, regular use, initiation, substitution, and relapse.

This cognitive economy is not trivial. In conditions of high complexity, broad categories facilitate communication, decision-making, and coordinated action. But they also reduce the capacity to distinguish among risks of different kinds, scales, and consequences.

The differences do not disappear. But they begin to matter less. What remains intact is the continuity of the category—and the cognitive economy it makes possible.

That cognitive economy was on display throughout the day. But once one returns to the empirical level—to the available data on youth use—the picture becomes less uniform than the language suggests.

Youth use of electronic nicotine devices, for instance, is unevenly distributed and does not follow a single trajectory. In many cases, it takes the form of episodic experimentation, often entangled with other risk behaviors and specific social settings. Part of that variability can be traced to factors that precede contact with the product itself, patterns of risk, family context, mental health, peer networks, and that resist reduction to any simple logic of exposure or access.

More persistent use tends to cluster among groups already predisposed to nicotine use or other forms of risk, which complicates linear explanations based solely on product characteristics, marketing, or availability. At the same time, in several countries, youth use appears to have peaked before declining or stabilizing, often alongside steeper declines in combustible cigarette use.

None of this erases the problem. But it does make it harder to treat it as a single phenomenon, with a single cause and a uniform solution.

Once those distinctions become secondary, policy design tends to follow the same logic. Interventions begin to operate as though they were addressing a homogeneous phenomenon, even when patterns of use, motivation, and risk differ sharply. Measures guided by simplified causal models focused on product, access, or marketing may leave the underlying drivers of demand largely untouched.

In some contexts described in the recent literature, this not only reduces policy effectiveness but also opens the door to less intuitive outcomes: users migrate across products, parallel markets expand, and potentially less harmful alternatives lose ground to more established forms of consumption.

Where alternatives are regulated without differentiation, demand does not simply disappear. It reorganizes itself, often toward more entrenched and, in some cases, more harmful patterns.

The problem, then, is no longer only risk itself, but the way risk is distributed and, at times, redistributed by the very responses designed to address it. That is what becomes harder to see once a single vocabulary settles too quickly over heterogeneous realities.

In public health, there is an inevitable tension between the need to simplify and the obligation to distinguish. Simplification helps organize action; it makes communication, mobilization, and scale possible. But every simplification carries a cost: it erases differences that, in some contexts, are precisely what matter most.

Simplification is inevitable. But not every simplification is innocent.

In Barmelweid, that balance seemed to tilt in a particular direction—not through any obvious error, but through the force of a consensus that arrived already structured, with its categories prepared, its urgencies defined, and its limits barely visible.

The risk lies not only in what is said about nicotine, but in what can no longer be recognized once language stabilizes too soon.

What is lost in such cases is not only nuance, but the capacity to adjust responses to realities that do not fit within a single category.

If Before the Numbers examines how consensus was made to sound natural in Barmelweid, what follows turns to the structure that helped make it so.

Its decline is real. But this shift was not merely epidemiological. It was also a change in the moral code. Smoking ceased to be a banal habit and came to signify a lack of self-command, a source of discomfort, a failure of self-discipline.

The mistake begins when this retreat is read as a uniform victory, as though the problem had diminished equally for everyone. It has not. What happened was something else: smoking ceased to be diffuse and became concentrated. And when harm becomes concentrated, its political character changes.

According to a study by Sarah Jackson, Sharon Cox, Jamie Brown, and Vera Buss, published in Nicotine & Tobacco Research and based on data from 2022 to 2024 for England, Scotland, and Wales, average consumption among smokers reaches 10.4 cigarettes per day —the equivalent of 28.6 billion cigarettes a year.

But the most important finding is not the sheer volume. It lies in the social pattern of consumption. Cigarettes are no longer distributed in a relatively even way across social strata. They are concentrated —and concentrated, above all, among the poor.

In the C2DE social grades, smoking prevalence stands at 18.8 percent, as against 10 percent among higher-income groups. Daily consumption is also higher: 11 cigarettes, compared with 9.4. On an annual basis, the gap becomes sharper still: 755 cigarettes per capita among the most vulnerable, versus 343 among the wealthiest segments.

These figures do more than measure consumption. They show how harm is distributed. In practice, that means smoking is no longer a habit spread across the social fabric; it has taken root in specific territories—neighborhoods, routines, and bodies in which quitting is not merely a decision, but a more remote possibility.

In this landscape, smoking can no longer be read simply as addiction, habit, or individual choice. It begins to function as a marker of class. Not because the cigarette has changed in nature or acquired some new sociological essence, but because its persistence tracks the line of inequality. When the better protected are able to exit first, and the most vulnerable are left behind, what emerges is not merely the persistence of a behavior, but the social concentration of harm—and, at the limit, a form of social triage.

This shift in the pattern demands a shift in language and in approach as well. Public debate about tobacco still speaks as though it were addressing an undifferentiated population: “the smoker,” “the user,” “the consumer.” They are convenient terms.

They erase low income, territory, interrupted schooling, precarious or exhausting work, psychic suffering, gender, ethnicity, the presence—or absence—of a support network, irregular access to treatment. In short, they erase the concrete intersections where vulnerability takes shape.

Those who continue to smoke are no longer a statistical abstraction. They are, increasingly, the point at which different forms of disadvantage converge. And policies that pretend not to see this end up treating as universal subjects people who have never lived under universal conditions.

Abstraction serves moral rhetoric well because individual blame is always easier to manage than structural inequality. It serves public policy badly.

For a long time, those who contest, occupy, and direct the state have learned to govern less through open prohibition than through the inducement to self-management. Health came to be demanded not only as a right, but also as a moral duty: proof of responsibility, a credential of active citizenship.

Within this regime, the good subject is one who calculates risks, corrects habits, manages the body, and lives up to what is expected of it. Whoever fails no longer appears as someone constrained by material limits, but as someone morally wanting: someone who has failed to govern himself.

It is here that the rhetoric of individual responsibility meets its limit. It can produce severe campaigns, effective slogans, and the appearance of moral firmness. But it does not explain why smoking recedes faster among the better protected and persists where life is more precarious. It does not explain why certain groups smoke more—and smoke more heavily. Nor does it explain why, when the habit loses social legitimacy, it does not disappear: it concentrates where protection is weakest.

Smoking does not vanish. It is pushed to the margins.

This displacement reveals something else: the consolidation of a way of seeing that Kirsten Bell and Hilary Graham help identify as a discursive hegemony. Certain public-health ideas no longer circulate merely as arguments; they circulate as common sense. The image of the smoker as someone who persists in error despite all the available information has become so intuitive that it scarcely needs defending anymore.

That is where the debate grows impoverished: when a worldview presents itself as a neutral description of reality. At that point, policy ceases to ask who still smokes, and under what conditions, and instead returns to the moral demand for individual self-correction.

But smoking does not distribute itself through the air. It concentrates where other forms of vulnerability have already piled up: in regions marked by deindustrialization, precarious work, overburdened public services, deteriorating housing, recurrent mental distress, and a narrower social horizon.

In these settings, the cigarette ceases to be merely a public-health risk. It begins to function as a symptom of social compression. It is not, of course, the only response to suffering—but it is one of the most visible. Smoke no longer appears simply as a private deviation; it becomes a record of collective wear and tear.

There is, then, an unavoidable political consequence. If the cigarette has become a marker of class, universal and morally abstract policies are no longer enough. Not because the state should downplay the harms of tobacco. Quite the reverse: to confront them seriously, it must recognize where they have become concentrated.

Measures designed for “the population” tend to fail when the problem has already taken hold in a specific segment—above all, a social segment historically pushed into invisibility. In such a case, universalism risks becoming, at best, a form of blindness posing as neutrality.

That is the point that ought to reorganize the debate. The problem of tobacco today lies not only in the product, though it begins there. It lies in the way harm is socially distributed.

When that harm is concentrated among the most vulnerable, public policy must abandon the fiction that warning, punishing, and taxing are enough to elicit equal responses from unequal lives. People do not respond in the same way because they do not live under the same conditions.

To treat the unequal as though they were equal may produce a tidy discourse. It produces, however, an unjust practice.

None of this absolves the tobacco industry or minimizes the toll of cigarettes on public health. Quite the opposite: it compels us to shift the question and expose the limits of a mindset that still dominates tobacco control—the mindset that reduces the problem to individual failure, insists on correcting behavior, and pushes to the margins the social conditions in which smoking persists.

It is not enough to ask why people still smoke. We must ask who continues to smoke, where, under what pressures, and with what real possibilities of escape.

That means reckoning, without caricature, with the harm-reduction paradigm. In many of the societies where most smokers are concentrated—above all in low- and middle-income countries—lower-risk alternatives remain blocked by regulatory uncertainty, illegality, criminalization, and stigma, as though any departure from the ideal of abstinence already amounted to a form of moral surrender.

The result is a politics that speaks in the language of protection yet often fails to offer a response proportionate to the risk faced by the very groups most exposed to combustion. And it does so in the name of an ideal of sanitary respectability, heavily marked by class values, that itself produces marginalization.

Smoking no longer sketches a general portrait of society. It draws a border. And, as Hilary Graham has shown, that border separates not so much smokers from non-smokers as those who were able to move away from harm and those who remained more exposed to it.

She counts the coins twice.
The first time is the gesture of someone who already knows the outcome.
The second is for someone who still hopes, against all evidence, that the numbers might have changed.

They haven’t.

The lighter fails twice; on the third, the flame comes up unsteady.
She lifts a leaflet from the health clinic as a shield.
On it, a darkened lung wavers in the wind.

“I keep borrowing from the future,” she says, to no one.
“I never know when it comes due.”

The sentence isn’t a metaphor; it’s a household budget.

Anna, twenty-eight, in a supermarket uniform, lives in the gap between what comes in and what runs out.

Here, the cigarette is not the abstract vice of anti-smoking campaigns. It is a small technology of survival: it structures waiting, marks a pause, holds open the distance between one bus and the next.

For decades, public health spoke in the language of the future: stop now to live later, defer pleasure in the name of a reward still to come.

Prevention rested on a quiet premise: that tomorrow was a credible horizon, something worth investing in.

But for millions, the future has lost weight; the horizon has shortened.

Between precarious work, fatigue, instability, and urgency, life is no longer organized around the promise of improvement, but around the management of the day.

It is on this terrain that prevention begins to lose its grip, not because people have become more ignorant or irresponsible, but because the logic of postponement requires a pact not everyone can enter into. When the present fills with exhaustion, fear, and improvisation, the long term no longer governs behavior with the same force.

The bus arrives. The doors open.
Anna steps on, drops in her coin, and moves toward the back.

The future is the interval between this cigarette and the next.

In a yellow-lit kitchen, an old fan turns without cooling the air.

August, seventy-three, shirt open at the chest, coughs over the sink; an old cough, one that already knows the way.

On the table, a full ashtray and a cup of cold coffee. On the refrigerator, a child’s drawing held by a magnet: a crooked sun, a house, three stick figures.

August picks up a pack. He begins the motion of lighting and stops. He looks at the drawing. He places the cigarettes in a glass jar, one by one, unhurried, as if storing something dangerous. Then he sets the jar on top of the cabinet, out of a child’s reach. His hand comes down slowly.

The scene belongs to the past, but it still pulses in the present. August is Anna’s grandfather. The interrupted gesture, the almost-lit cigarette, the jar lifted out of reach, condense something larger than an individual decision. The will was there. What was missing was ground.

For much of the twentieth century, the promise of progress was also a promise of time: present sacrifice would yield returns later on. To a large extent, collective life was organized around the idea that the future was worth the investment.

That arrangement has worn down in recent decades. Not all at once, but through erosion: successive crises, persistent precarity, accumulated distrust. Historians have called this narrowing of temporal experience presentism. Outside theory, though, the phenomenon is easy to recognize. When work is unstable, housing is uncertain, and rest is scarce, the long-term loses density. Planning ceases to be a habit and becomes a wager.

In Brazil, this contraction of the horizon is also distributed across territory and class. In São Paulo, the gap in average life expectancy between districts exceeds twenty years. It is as if two countries occupied the same space: one in which tomorrow stretches far enough to justify sacrifice, another in which it collapses from within. Smoking does not produce this divide, but it settles inside it.

The waiting room is a limbo of plastic and cold light.

An electronic display flickers numbers that don’t move.

On the wall, a blackened lung.
Next to it, a faded slogan:

“SUFFER NOW TO LIVE BETTER LATER.”

Someone coughs. Someone checks their phone. Anna holds a handful of coins inside her bag, as if she could protect them.

The doctor doesn’t look up from the chart.
“How long have you been smoking?”

Anna opens her mouth. “Since—”

She doesn’t finish. The doctor has already checked a box: training, neutrality. He slides a leaflet across the table, illustrated lungs, benefits, and a phone number.
Anna takes the paper with both hands, like someone receiving a promise she isn’t sure she can keep. She signs where she’s told. She doesn’t read.

For decades, public health has proposed the same bargain: give something up now — a pleasure, an immediate relief — in exchange for benefits later. Eat better, move more, quit smoking, adhere to treatment.

The exchange feels fair when the future is a livable horizon, when tomorrow still inspires trust. But prevention is not only a calculation of risk; it is also a moral contract, and that contract presumes stability. Above all, it presumes that delay is worth it.

In the waiting room, that contract already appears worn.

Anna signs without reading — not out of carelessness, but because the gesture of compliance has, for many, become an empty ritual, a formality that life quickly contradicts. Here, prevention fails not because of ignorance. It fails because it requires a kind of material and subjective ground that not everyone has.

There is a mismatch between the temporality of prevention and that of precarious life. The first operates in the long term: years without smoking, disciplined routines, benefits accumulated quietly. The second in the short: the money that runs out at the end of the month, the exhausted body that demands relief now, the urgency that does not wait.

As the public-health literature shows, quitting smoking is strongly associated with income, education, mental health, and access to support. Not because low-income smokers know less or want less, but because cessation is not simply an act of will. It requires time, care, margin, and protection against extreme stress, resources that are deeply unevenly distributed. On its own, will does not carry a person across a compressed present.

At the factory gate, the sky hangs low and dirty.

Damian, forty-two, his uniform stitched at the chest, wears a stopped watch on his wrist. He looks at it not to tell the time, but to confirm there is no time left.

The lighter fails twice; on the third, the flame comes up unsteady.
He cups his hand around it, shielding the fire from the wind.

The first drag is short, almost tentative. He coughs once, dry, then swallows it, glancing sideways, as if coughing were a minor fault.

Later, in another kitchen, another night. Anna is in sweatpants, her hair fallen loose with exhaustion. She washes a pan quickly, trying not to make a noise. She opens the window just enough to slip her arm through. The flame wavers, then catches. She inhales and holds the smoke for a second. It is not a pleasure. It is a suspension.

From the bedroom comes the sound of a child breathing.

In the hallway, a toy on the floor.
She almost trips. Stops. Looks.
Love, irritation, fatigue, all at once.

She exhales the smoke outward, trying to make it disappear before it can exist inside.

In both gestures — Damian at the factory gate, Anna at the window — the cigarette appears not as an abstract habit, but as a small everyday technology. It does not resolve suffering; it gives it shape. It marks an interval, introduces a ritual, and offers a brief, predictable reward in a day without contour. In lives where work, sleep, time, and care have lost their regularity, it functions as a minimal tool of self-regulation.

What appears irrational from a public-health standpoint becomes legible when one looks at what the cigarette provides in return. It is cheap, portable, and immediate. It requires no appointment, no line, no consultation, no free time. It is at hand. And for that reason, it often takes the place of other forms of relief and care that, for many, are expensive, scarce, or simply unavailable.

But its function is not only chemical.

The cigarette also organizes time: it marks the beginning and end of a pause.

In fragmented routines, irregular shifts, and schedules that disregard sleep, the minimal ceremony of lighting it opens an interval that still belongs to the smoker, however brief, however paid for with their own health.

In unequal contexts, smoking is more heavily concentrated among those pushed into precarious paths of income and schooling.

This difference does not stem only from unequal knowledge; it also reflects how rest, pleasure, and care are socially distributed.

In conditions of greater vulnerability, the cigarette takes the place of forms of listening, relief, and protection that are scarce, inaccessible, or simply nonexistent.

There is also a relational dimension.

The cigarette accompanies waiting, solitude, and the exhaustion of alienated work. It becomes a pretext to step out of a stifling room, a license for a minute away from children, bosses, and the demands that do not cease. For those who spend the day caring for others — children, the elderly, clients, patients — or converting their own time into income for others, it can become the only gesture that still feels like it belongs to their own body, even as it exacts a destructive cost.

On the ground, a faded yellow rectangle.

Inside it, a man lights a cigarette.
Clara approaches with grocery bags. She slows. Looks at the blue sign:

“SMOKING AREA.”

Looks at the rectangle.
She makes a small detour, as if the ground there were contaminated.
As she passes, she holds her breath for half a second.
Adjusts her coat with her fingertips.

Two steps later, she exhales. Her face does not register relief. It simply confirms.

In the elevator, the man steps in right after her. Clara presses the button for her floor. Without looking, she also presses the fan. The light comes on. A young woman pulls her backpack to her chest, like a shield. Someone shifts back an inch. No one speaks.

Later, in the building’s group chat, Clara writes: “Hi everyone, smoke has been coming up into my apartment. There are children and elderly people here. Please be considerate.” The reactions arrive within seconds: hearts, thumbs up, an “exactly.”

Clara is not a villain. She is someone who has internalized the moral language of public health as an almost natural extension of good manners.

In her gestures — the detour, the held breath, the press of the fan — there is no explicit cruelty. There is a boundary being drawn.

The smoker no longer appears as a subject with a history, a routine, an exhaustion. He becomes odor, nuisance, a failure of care.

Anti-smoking policy has produced real gains. The decline in smoking in Brazil, for example, is one of them. But part of its public language has remained tied to a moralizing imagination, in which the smoker appears as a deviation, a failure of will, and irresponsibility.

The social structure of suffering recedes from view; individual behavior takes over the entire stage. The result is the predominance of a pedagogy of shame.

This pedagogy does more than communicate risk; it teaches the smoker to feel out of place. The yellow rectangle on the ground, meant simply to contain harm, also marks an exception: one may remain there, so long as one remains apart.

The smoker’s body becomes a suspect body, polluting, displaced.

The phrase on the waiting-room wall — “SUFFER NOW TO LIVE BETTER LATER” — condenses this imperative. To suffer in the present appears as virtue; to refuse that suffering, as weakness. The problem is not informing people about harm, but turning the difficulty of quitting into a failure of character, as if smoking were merely an individual choice, rather than a socially produced condition, often shaped by exhaustion, precarity, and inequality.

There is also an economic dimension to this arrangement. Tobacco is heavily taxed, and the burden falls more heavily on those with less. The state regulates, collects, and warns; care, however, does not reach with the same breadth. For many, the equation looks like this: smoke, pay dearly, fall ill, carry the blame.

The effect of this combination — stigma, regressive taxation, uneven support — is the individualization of suffering. Not smoking ceases to be only a matter of health and becomes a marker of discipline, self-control, and belonging. What is at stake, then, is not only care. It is also status, distinction.

The nurse peels back the seal on the package.

The plastic snaps.

Anna sits with her hands in her lap; short nails, a pen mark on her finger.
She pulls up her sleeve without ceremony.

Cotton on the arm.
A dry touch.

The nurse applies the patch and smooths it with two fingers, counting silently. Anna watches the gesture: the way something is sealed that wants to come loose.

Days later, in the middle of the night, she is alone in the kitchen.

On the table, the box of patches and the crumpled leaflet. She pulls up her sleeve. The old patch is still there, one edge lifting. She removes it slowly.

The skin beneath holds the mark: a pale rectangle at the center of her arm.

She opens another. The plastic snaps softly. Applies it. Smooths it with two fingers. Presses the edge until it holds. Pulls her sleeve back down.

She stands there for a moment, as if waiting for her body to agree.

Later, at the bus stop, she takes a cigarette from the pack. Stops.

Her arm hangs suspended.
She puts the cigarette back.

From her bag, she takes a dark object, worn from use. She brings it to her mouth. A short pull. A small light flickers on and off.

The vapor dissolves into the cold air.

What these scenes show is not the redemptive victory of abstinence. It is something else: a movement of substitution, hesitant and imperfect, but guided by a logic that traditional public health takes too long to recognize. When someone cannot, or does not manage to stop immediately, care cannot simply withdraw.

Not everyone will interrupt harmful practices in the short term, and the conditions for doing so are unevenly distributed. Faced with that, the response is not to abandon those who continue to use, but to reorganize care around what is possible: to reduce risk, to lessen suffering, to widen the margin for breathing.

This is the moral turn of harm reduction. It replaces the question “how do we make someone stop?” with another, more modest and more concrete: “how do we make it so that, while they do not stop, they are harmed less?” It is not surrender. It is a refusal of the all-or-nothing logic. Care no longer demands purity in order to begin.

In the case of tobacco, this includes intermediate strategies: nicotine-replacement therapies, gradual reduction, and, for many, a shift to non-combustible forms of use. None of this eliminates risk. But for smokers who have repeatedly failed in attempts at complete cessation, these alternatives may mean less harm than continuing to smoke conventional cigarettes.

Resistance to this approach is not only technical. Part of it rests on some legitimate concerns: the long history of manipulation by the tobacco industry, uncertainty about the long-term effects of certain products, the risk of displacing, rather than dissolving, dependence, and the fear that intermediate strategies may reopen markets, normalize new forms of harm, or weaken decades of hard-won regulation.

But the resistance does not end there. It also arises from a moral discomfort with the idea that care might coexist with imperfection, with continued use, with bodies that do not purify themselves all at once.

Anna, at the bus stop, the vapor dissolving into the cold air, is not a success story by conventional standards. She still performs the gesture. She still depends on nicotine. But she no longer burns the clinic leaflet to light her cigarette. The change is ambiguous, negotiated, and still, it is the change that is possible.

In a well-kept garden bed, the leaves gleam with moisture.

A gardener, in thick gloves, trims the shrubs.

Snip. Snip.

Branches fall. Leaves fall.

He gathers everything with a shovel and pushes it into a black bag.

Two meters away, almost out of frame, a man sleeps wrapped in a thin blanket. From inside it comes a cough — small, persistent. The gardener does not look. He picks up the sprayer. Presses. The leaves take on a fresh shine. The man keeps coughing.

The scene is brief, but it condenses a question: What is the point of pruning dry leaves if the soil remains the same?

Harm reduction is an ethical and practical achievement. It allows care to continue where abstinence cannot begin. But it carries a risk: detached from structural transformation, it can become the humanized management of ruin.

The gardener tends to what is visible; what can be contained, trimmed, and made presentable. He does not alter the conditions that produce that body on the pavement. He does not alter the cold. He makes the garden appear habitable, while its actual inhabitant remains at the margins.

In health care, this logic reproduces itself easily. A patch, a brief consultation, an intermediate strategy — all of it is better than nothing. It reduces suffering, prevents greater harm, and widens the margin for survival. But if the social conditions that produce exhaustion, anxiety, and illness remain untouched, care risks being reduced to maintenance: it keeps the body functioning, however precariously, while leaving intact the ground that makes it ill.

The critique, then, is not of harm reduction but of what happens when it is stripped of its political dimension and returned to mere management. At that point, care ceases to be an opening and begins to function as containment: it intervenes on isolated bodies, manages symptoms, prolongs survival, but does not touch the world that distributes exhaustion, inequality, and illness. The collapse of the precarious is averted, without interrupting the order that produces it.

Anna, with the patch under her sleeve and the vapor dissolving into the cold air, has managed to exchange one technology for another. She has reduced the harm. But she remains at the same bus stop, with the same coins that don’t add up, the same faded uniform, the same endless waiting. The care she received has helped her not to worsen. It has not moved the world that keeps her there.

The bus sways.

Bodies lean together, in silence.

Anna rests her head against the fogged glass.
She wipes it with her sleeve, opening a small circle of visibility.

Outside, the street is coming into morning: people walking fast, a dog nosing through trash. In here, the silence of those already tired.

Anna’s hand goes to her arm by instinct.
She presses the patch, as if needing to confirm that it is still there.

Later, in the dark kitchen, she sits at the table.

The box of patches. The crumpled leaflet.

She pulls up her sleeve. The edge of the patch holds firm now. She smooths it once with her thumb. Opens the drawer. The crumpled pack is there.

She looks. Closes the drawer.
She rests her forehead against the cabinet for a second.

Breathes in through her nose. Lets the air out through her mouth, without a sound. Turns off the light.

There is no redemption in this scene: no heroic gesture, no solemn farewell.
Only a woman who looks at the pack and does not light it.

A hand that presses the patch, to feel that it is still holding.

The politics of the “still” is made of these minimal gestures. It promises no cure, demands no purity, expects no redemption. It works with what remains, insisting on doing something with that remainder.

Still alive. Still breathing. Still with some margin. Still capable of care.

It is a modest ethic, but not a minor one. In a time when the future has lost its density, it offers a form of care equal to exhausted lives: not the kind that abandons when someone fails, but the kind that remains, reduces harm, and sustains what is possible.

The politics of the “still” does not replace social justice. It does not make the coins add up, does not restore length to a horizon that has shortened. But it prevents the absence of social justice from becoming an alibi or a license for abandonment. While the ground does not change, it sustains those who are still standing on it.

Anna, in the dark kitchen, with the pack in the drawer and the patch on her arm, is not a success story. She is a case of persistence. And when the horizon contracts, persistence may be the only form of future that remains.

The bus moves on.
The glass fogs again.
Anna leans her head.
Her hand goes to her arm.

The patch is still there.

Note:

This essay began with a question: why does smoking remain so persistent among the poor?

Over time, the answer drifted away from the usual explanations: personal choice, lack of information, weak willpower. It began to emerge elsewhere: in exhaustion, in the brief pauses during precarious work, in money counted down to the last coin, in the constant pressure to get through the day, and in the difficulty of imagining a future that could justify sacrificing the present. In other words, in a life where both present and future have been compressed.

In that setting, smoking seems less like an abstract vice and more like something immediate and functional: a cheap anesthetic, a way to structure waiting, a small, reliable break. A minimal form of control in a world where almost nothing feels managed.

Between Breaths, a short-film script I wrote before this text, was an early attempt to explore that world from within, rather than from a distance of argument. The scenes are not reportage, but they are shaped by many real lives. They helped bring my attention closer to the concrete rhythm of those lives: fractured time, accumulated fatigue, and the small gestures through which a day is managed.

If the fiction attempts to stick with those gestures and pauses, this essay tries to make sense of what they reveal.

The deadliest nicotine product ever invented remains legal, visible, and routine. It is there in convenience stores, in the crumpled packs carried in a pocket, in the break during the workday, on the corner, in the habit itself. Almost everywhere, the combustible cigarette remains so readily available that its chemical violence nearly dissolves into the landscape.

The paradox requires no rhetoric. Around it, however, the language of prudence shifts in tone. Nicotine products that are substantially less dangerous, though backed by different kinds and degrees of evidence, such as vapes, snus, nicotine pouches, and heated tobacco, circulate in many countries under a regime of suspicion denser than the one reserved for the cigarette itself. In some places, they are banned. In others, they are tolerated grudgingly, hemmed in by restrictions or described in a public language that treats gradations of risk as though they were morally intolerable concessions.

This is where the Global Forum on Nicotine stops seeming like merely a niche conference. Since 2014, the gathering in Warsaw has become one of the clearest places in which this contradiction is examined without the easy protection of ready-made formulas. Researchers, physicians, regulators, consumers, industry representatives, web activists and harm-reduction advocates come together there not as a harmonious community but as a dissonant assembly, drawn by an impasse the global debate has yet to face with much honesty: how to lessen the deadly burden of smoking in a field where, for many institutions, distinguishing degrees of risk remains more uncomfortable than pretending they do not exist.

The question begins, in part, with Gerry Stimson, the British public-health social scientist and one of the defining figures in the history of harm reduction. In 2013, after years of watching part of the European debate treat tobacco and nicotine as though they belonged to the same moral order, Stimson arrived at a diagnosis almost too plain to be palatable: public health was failing to distinguish between what creates dependence and what, in combustion, causes death.

“We have known for a long time that people smoke for nicotine and die from the gases and tar.”

The line, which Stimson brought back at the Forum’s first gathering, needed no embellishment. It revealed a fault line. On one side stood the possibility of thinking in terms of relative risk, harm reduction, and regulatory innovation, without treating every nicotine product as if it were the burning cigarette. On the other stood a stubborn public grammar in which nicotine, combustion, and harm are still fused into the same condemnation.

From that fracture came the first Global Forum on Nicotine, held in Warsaw in June of 2014, with support from collaborators including Paddy Costall and Andrzej Sobczak. Some 220 participants from 26 countries attended the first gathering. The meeting was small. The problem was not. The Forum’s purpose was already clear: to create a space in which that distinction could be examined before it was moralized, flattened, or consigned to silence.

Since then, the GFN has become something more than an annual conference. It has served as a seismograph for the tensions reshaping the debate over nicotine, smoking, and harm reduction. With each edition, what returns is not simply a new theme but the same conflict particles in altered form: between evidence and orthodoxy, between the lived experience of people who smoke and the institutional languages that presume to speak for them, between the possibility of reducing harm and the persistent temptation to treat nuance itself as a form of weakness.

Over the years, the GFN began to take shape as a kind of recurring map of the tensions, shifts, and impasses reorganizing the debate over nicotine and smoking. Each edition captured less an isolated theme than the momentary state of a larger dispute.

In 2015, the dispute came into sharper focus. With “A Different Kind of Endgame” as its theme, the Forum began asking not only how smoking might end but also what sort of ending was being imagined. For years, the prevailing assumption had been that the cigarette would be defeated chiefly by ratcheting up pressure on people who smoke and on the industry. What the GFN began to frame more clearly at that point was another possibility: that lower-risk nicotine products might speed the cigarette’s decline by a route many still resisted recognizing, especially within public health itself.

The opening of the conference already made clear the axis of that shift. In the Michael Russell Oration, Derek Yach warned that the WHO Framework Convention on Tobacco Control would need a radical shift in emphasis to remain relevant. The point was straightforward: separating nicotine from tobacco-control policy was no longer some marginal provocation; it was becoming a precondition for thinking about the end of the cigarette itself without the usual rhetorical reflexes. By 2015, the GFN was beginning to show that the dispute was not just about products. It was about who would claim the authority to define the public-health horizon of the endgame.

By 2016, the ground was already beginning to shift. Under the banner Evidence, Accountability and Transparency, the Forum addressed a fast-changing landscape in which new nicotine-delivery systems were advancing faster than institutions could assess them without reverting to habit. The problem was no longer simply the arrival of new products, but the asymmetry between the speed of innovation and the slowness and, in some cases, the reluctance of regulatory response. In that setting, transparency and accountability referred not only to the data themselves. They also referred to the institutional and personal positions through which those data were being interpreted.

In his opening remarks, David Sweanor summed up the scale of the dispute: hundreds of millions of lives were at stake, along with hundreds of billions of dollars and the reputations of entire groups and individuals, all of it unfolding in an environment saturated with beliefs that were at once deeply entrenched and badly misinformed.

That year, the GFN was beginning to show that the debate over nicotine would be fought not only over evidence, but over who could be trusted to interpret it honestly and to expose, without pretense, the interests bound up in it. The European premiere of Aaron Biebert’s A Billion Lives pushed that shift further: the conflict was no longer calling only for regulation. It was also calling for a narrative.

By 2017, the Forum was speaking more plainly. With the theme Reducing Harm, Saving Lives, a sharper conviction was coming into view: ignoring lower-risk alternatives was not a way of preserving neutrality, but a way of consenting, through omission, to avoidable harm. As the science advanced and the regulatory landscape shifted by degrees, it became harder to keep treating harm reduction as a marginal hypothesis or a rhetorical concession. What was at stake was beginning to be stated with greater candor: if products less dangerous than the combustible cigarette exist, then rejecting them outright is also a choice, and one with a human cost.

That year’s Michael Russell Oration carried the shift further by another path. In “Drug Control and Tobacco Control: Parallels, Reform and Advocacy,” Ethan Nadelmann suggested that the debate over smoking had something to learn from the history of drug policy, particularly from the repeated failure of models that leave consumers out of the process and confuse protection with tutelage.

The first edition of the International Symposium on Nicotine Technology (ISoNTech), brought into the Forum that same year, extended the movement: the dispute was no longer only regulatory or epidemiological. It was also lodged in the material reality of innovation—the devices, their engineering, their evolution—and in the way technology might, in practice, reconfigure the possibilities of moving away from the cigarette.

With each edition, the same dissonance reappeared in a different form. On one side was a growing body of data, studies, successful regulatory experience, and testimony from consumers who had shifted away from cigarettes using noncombustible products. On the other hand, there was the persistence of a political culture hostile to nuance, in which distinguishing degrees of risk seemed more dangerous than preserving a single moral pedagogy.

By 2018, under the banner Rethinking Nicotine, the Forum was no longer arguing only about how to interpret the evidence, but about the very language in which the debate was conducted. The point was to rethink nicotine’s place in public health without falling back, by force of habit, on the inherited grammar of tobacco control as if every form of use had to bear, untouched, the cigarette’s historical guilt.

The growing presence of consumers, the creation of the Michael Russell Award, presented to Lars Ramström, and the launch of the Tobacco Harm Reduction Film Festival all suggested that the field was widening: it was no longer enough simply to produce data; it was necessary to contest the images, symbols, and narratives through which those data would be made legible.

In 2019, the forum returns under the theme “It’s Time to Talk About Nicotine.” It was no longer just a matter of rethinking nicotine, but of bringing it out of the regime of silence, discomfort, and simplification that public debate had built around it.

To talk about nicotine, in that context, was to reopen distinctions that much of the language of public health had learned to suppress: between the cigarette and nicotine, between combustion and consumption, between the ideal of abstinence and the possible reduction of harm.

It was meant to compel public health to recover a language capable of recognizing degrees of difference. And, with them, differences in fate.

The growing interest in that shift was already evident in the scale of the gathering: nearly 600 participants came to Warsaw that year, a significant increase over previous editions.

In accepting the Michael Russell Award, David Abrams distilled one of the crucial points the Forum had been trying to restore to the center of the debate: the issue was not only one of product, risk, or regulation, but whether people trying, in concrete ways, to change their relationship to nicotine would be met with acceptance, understanding, and compassion. “It’s about the people, the people and the people,” he said.

By 2019, the GFN was showing that the dispute over nicotine was not only about toxicology or policy. It was also about the moral imagination through which public health chooses to regard people who smoke.

Then the pandemic arrived, and with it a new kind of test.

In 2020, like nearly every international gathering, the GFN was pushed online. In its case, though, the shift did not reduce it to a digital replica. In some respects, it enlarged it. The need to build its own broadcast platform enabled the Forum to reach more people, launch GFN TV, and give its debate ecosystem a more continuous and visible form.

That year’s edition, with more than two thousand participants from over a hundred countries, made plain what had been visible for some time: the discussion around nicotine and tobacco was not only scientific or regulatory. It was also ethical, political, and deeply bound up with the language of rights and the everyday lives of ordinary people.

In a year defined by the theme “Nicotine: Science, Ethics and Human Rights,” the meeting brought together more than thirty speakers over two days to examine not only the growing body of evidence in favor of harm reduction but also the intensifying attacks on researchers, academics, and professionals associated with the field.

Entire organizations were being discredited; real or alleged ties were used as a mechanism of disqualification; and public debate seemed increasingly willing to descend into ad hominem attack.

It was in that atmosphere, saturated with fear, misinformation, and narrative struggle, that issues such as the lung-injury crisis known as EVALI took on particular weight, along with its mistaken attribution to nicotine vaping rather than to illicit THC products, the moral panic around youth use, and the influence of major philanthropists on the language and priorities of public health.

By 2020, the GFN was showing that the conflict no longer turned only on disputes over the evidence. It also turned on the very conditions that made debate possible.

In 2021, still under the shadow of the pandemic, the GFN began to press a question that carried the debate beyond the immediate crisis: what is the future of nicotine?

The formulation sounds abstract only at a distance. Up close, it drags behind it questions of science and investment, global inequality and consumer behavior, regulatory capacity and control policy, and at the center of it all, the persistent friction between orthodoxy and innovation.

Organized around The Future for Nicotine, that year’s program examined both the advances already visible in the world of lower-risk products and the often abrasive relationship between science and policy, the impact of technological innovation on public health, and the repeated failure of international bodies to hasten the end of the cigarette.

The Forum had not yet fully returned to an in-person format. The 2021 edition adopted a hybrid model, with a small core of speakers and attendees on site and broader participation online.

But that constraint revealed something else: the GFN was no longer functioning only as a gathering but as a platform for mediation, commentary, and archiving.

The creation of the GFN Commentary Team and the introduction of #GFNFives, which replaced academic posters with short videos submitted by participants, pointed to that change in scale.

By 2021, the Forum was making it clearer still that the dispute over nicotine would not be decided solely by the production of evidence or the drafting of rules. It would also depend on who managed to interpret, translate, and circulate that evidence in an increasingly fragmented public sphere.

When the Forum returned to Warsaw in person in 2022, it no longer made sense to think of it as merely an annual conference. The GFN had become an infrastructure for debate: a machine for producing, recording, translating, and circulating controversy.

The hybrid format, the broadcasts, the #GFNFives shorts, the GFN TV commentary, and the simultaneous translation expanded the Forum’s reach and altered its nature. What was at stake was no longer simply bringing people together in one city, but creating the conditions for certain ideas to travel beyond the room, cross borders, and remain open to public scrutiny. In a field so shaped by caricature, silencing, denial, and moral simplification, that was no mere technical detail. It was a form of intellectual intervention.

That year’s program gave real substance to the shift in scale. The Forum confronted misinformation around harm reduction head-on, examined the role of philanthropy in the field, returned to the uncomfortable question of the Framework Convention’s failure to bring smoking down in any meaningful way, debated the transformation of the industry without the usual comfort of ready-made formulas, and insisted that the problem was not exhausted by vaping, but pointed instead to an entire continuum of risk and displacement away from the combustible cigarette.

Other questions were also returning, now in sharper outline, questions that would no longer be marginal from that point forward: academic freedom in the field of tobacco control, and the question of whether regulation was actually helping to reduce smoking or simply narrowing the alternatives available.

The Michael Russell Award, given that year to Brad Rodu in recognition of more than two decades of research and advocacy for access to safer products, confirmed the sense that the GFN was no longer content merely to observe the dispute. It was becoming more and more one of the places where that dispute found language, contour, and public force.

The Forum’s tenth edition, in 2023, offered a rare chance to look back on its own trajectory without succumbing to self-congratulation.

A decade after its debut, the GFN could credibly claim a singular place in shaping the global debate over tobacco harm reduction. Over those years, it had helped draw researchers and advocates closer to one another, as well as regulators and consumers, voices from the Global South, and academic circuits still caught in the North’s gravitational field.

Above all, it had preserved a space for substantive disagreement, something that, in an age of performed polarization, had become not just rare but structurally at risk.

The anniversary, though, hardly warranted any naïve celebration. On one hand, the global use of vapes, snus, heated-tobacco products, and nicotine pouches continued to grow, as tens of millions of people sought out less risky alternatives. On the other hand, a persistent fog of regulatory and political confusion remained capable of blunting part of that movement.

The tenth edition unfolded in the shadow of a harder question: what happens when public uptake outpaces institutional imagination? The approach of the Framework Convention’s COP10, held later that same year in Panama, brought that tension into sharper relief.

In response, the GFN sought to broaden not only the debate itself, but also access to it. Alongside free streaming, live and on demand, came simultaneous interpretation into other languages, initially Spanish and Russian, and a more deliberate effort to open the space to people who had long orbited the debate without ever quite entering it.

The Michael Russell Oration, delivered by Professor Roberto Sussman and devoted to a rigorous critical assessment of the science around tobacco and nicotine, neatly captured the spirit of that moment: ten years on, the question was no longer simply how to produce more evidence, but who gets to interpret it, within what frame, and in service of what kind of future.

By 2023, the GFN was showing that it was no longer peripheral. It had become a force in the debate.

In 2024, under the banner Economics, Health and Tobacco Harm Reduction, the Forum pushed to the center a dimension that had long shaped the debate but had seldom been acknowledged as its organizing core: economics.

It was no longer enough to argue over evidence, relative risk, or regulatory design. The harder question was what it costs—in lives, money, and historical time—to regulate badly, or to prohibit, alternatives less dangerous than the combustible cigarette.

At that point, harm reduction had ceased to be merely a public-health or moral controversy. It was also revealing itself as a dispute over prices, access, taxation, incentives, and technological innovation. To talk about health without talking about political economy was to remain on the surface of the problem.

That year’s program made the point hard to ignore. What are the effects of overly restrictive regulation? Is it possible to quantify the health-care savings associated with the availability of safer products? Does the decline in tobacco-tax revenue, or the state’s dependence on that revenue, shape the regulation of alternatives? And to what extent do badly calibrated rules drive independent manufacturers out of the market and discourage the shift away from combustion?

The presence of figures such as Professor Andrzej Fal and the analyst Vivien Azer gave substance to that widening of perspective. The introduction of #ScienceLab, meanwhile, reinforced the effort to bring emerging research closer to public debate.

And the Michael Russell Oration, delivered by Cliff Douglas and centered on global action to end smoking, helped distill the impasse of that moment: the future of the combustible cigarette would no longer be decided only in the laboratory or the regulator’s office, but also on a less visible, and often less openly acknowledged terrain: that of markets and their asymmetries.

By 2025, the banner Challenging Perceptions: Effective Communication for Tobacco Harm Reduction read like a diagnosis of the times. The dispute was no longer unfolding only on the level of evidence, but in the realm of its public circulation, in whether it reaches people, or fails to reach them at a moment when journalistic rigor was losing its central place and social media, platforms, and the attention economy were beginning to shape collective perception through simplification, moral panic, and low-resolution truths.

Challenging perceptions had become the central task. Not because the science offered easy answers, but because the public sphere seemed less and less willing to tolerate nuance, context, and contradiction.

The paradox could no longer be dismissed as noise: as the scientific case for harm reduction grew more substantial, its public reception, in many places, was becoming murkier. Lower-risk nicotine products continued to erode the cigarette’s centrality. But that movement was advancing in an atmosphere of caricature, suspicion, and simplification that could delay, if not altogether block, the translation into policy.

That was the point at which communication ceased to be merely an adjunct to science. It became part of the conflict itself. It was no longer enough to produce evidence; it was necessary to contest the frame, correct enduring distortions, and ask who was still being left out of the conversation.

In an environment where discourse itself is an instrument of power, perception functions as a regulatory field, and institutional caution can serve as an alibi for inertia, the problem came to lie less in the absence of data than in the difficulty of making those data legible before they were immediately absorbed by the machinery of moral panic.

The choice of Fiona Patten for the Michael Russell Award distilled the spirit of that year with unusual clarity. An Australian politician, consumer, and longtime advocate of harm reduction, she brought together in a single figure lived experience, regulatory conflict, and the public struggle over language. By 2025, the GFN showed that the battle was no longer fought only over what science knows, but over what a society allows itself to hear.

That may be why the GFN provokes such strong reactions: the Forum inhabits a particularly uncomfortable corner of contemporary debate, where scientific evidence, lived experience, industrial interest, regulatory calculation, and moral judgment intersect without ever settling into ease.

Its critics surround it with suspicion; its defenders treat it as an indispensable space. In opposing registers, both recognize the same fact: the GFN is not peripheral. It carries weight in the debate.

It carries weight because smoking remains among the leading preventable causes of death in the world. It carries weight because millions of people continue to smoke not in the abstractions of the laboratory, but in lives marked by inequality, habit, pleasure, dependence, misinformation, and precarious access to alternatives. It carries weight because policies that fail to recognize relative risk can end up protecting the combustible cigarette in the name of regulatory purity. And above all, it carries weight because when public health loses its sense of nuance, it begins to drift away from the very people it most needs to reach.

With 2026 now underway, the trajectory of the GFN reads less like the history of a conference than like the portrait of a larger dispute. Since 2014, the Forum has returned, year after year, to a question that global policy still has not managed to resolve: what, exactly, is being protected when the deadliest product remains available while significantly less harmful alternatives are treated as a threat?

That is the question the thirteenth edition, under the banner Prohibition and Public Health, places once again at the center. Not as a doctrinal abstraction, but as a material, regulatory, and moral problem. If the combustible cigarette remains legal and widely accessible, why do successive waves of prohibition fall on lower-risk products across much of the world?

By insisting on that paradox, the GFN shifts the debate from the object to the logic that organizes it: examining how policies formulated in the name of protection can end up preserving, and even encouraging, exactly the harm they claim to want to reduce.

That might be the Forum’s strength: offering a space where facts can be examined with complexity before being overtaken by rhetoric. The question isn’t whether every alternative should be celebrated, but whether current policies, discourses, and mentalities accurately differentiate among products, use contexts, and actual risks. At that point, the GFN helps move the debate from the doctrinal to the public sphere.

* Photos: GFN/Gerry Stimson

Reader’s Note

This isn’t the screenplay of a film that already exists. It’s the screenplay for a film that might briefly exist, privately, in the reader’s mind.

It starts with a straightforward, uncomfortable question: when we talk about “good habits,” are we referring to health or to control?

The directions on these pages are not meant for a crew. They serve the narrative: what is seen, what is heard, what the body does, often without noticing itself.

The short film unfolding here is composed of movements, like irregular breathing. Sound—the hum, beeps, coughing, and crackle of plastic—builds the invisible landscape of everyday pressure. The camera stays on small gestures: a thumb turning a wedding band, fingers smoothing a nicotine patch, a hand covering the warning image as if hiding something private.

If you can, read this aloud, even quietly. See the peeling yellow rectangle on the ground. Hear the lighter fail. Feel, on your own arm, the edge of the patch starting to lift.

Cinema, here, is simply this: a discipline of attention.

* CHARACTERS: Anna, August, Damian, Clara, the Smoker, the Clinician, the Doctor, the Groundskeeper, the Man Under the Blanket, the Child, and many others who go unnamed.

I. The Promise, Undone

1 INT. WAITING ROOM — MORNING

Cold light. The HUM of a fluorescent fixture vibrates in the low ceiling.
Plastic chairs. A water cooler DRIPS.

A delayed electronic display blinks numbers that don’t advance.
On the wall: a blackened lung.

“STOP SMOKING.”

Beside it, crooked and peeling: “SUFFER NOW TO LIVE BETTER LATER.”

Someone COUGHS. Someone clears their throat.
A phone starts to ring and dies halfway.

ANNA (28), in a supermarket uniform, with a worn name badge, holds a crumpled bag. Her shoulder strap has carved a groove into her skin.

The mark stays.

She opens her bag. A thin wallet.
Coins. Not many.
She counts them with her thumb, slowly, one by one.
The display BEEPS.

METALLIC VOICE (O.S.)
Number forty-seven.

Anna stands.
The chair emits a damp, suction-like sound from the floor.

2 INT. EXAM ROOM — CONTINUOUS

A cluttered desk. Stacks of paper. A worn rubber stamp.
An old computer takes its time responding.
The printer CHOKES—metallic whine, like teeth chewing.

THE DOCTOR (50), white coat, a pen in her pocket, writes without looking up.

DOCTOR
How long have you been smoking?

Anna opens her mouth.

ANNA
Since—

She stops. Doesn’t finish.
The doctor has already checked a box —trained neutrality.

DOCTOR
Breaking the cycle lowers cardiovascular risk.
You’ll see benefits within weeks.

She slides a tri-fold pamphlet across the desk.
Illustrated lungs. A list of “benefits.” A phone number.

Anna takes it with both hands, as if it were a letter she isn’t allowed to crumple. She holds it the way one holds a promise.
A small nod—to herself, not to the doctor.
The doctor indicates a line.

Her short nail comes down to the paper and stays there.

DOCTOR
Sign here.

Anna signs without reading.
The printer SPITS out another sheet.
The doctor STAMPS

TACK.

Anna takes the paper and stands.
The chair scrapes the floor.

3 EXT. BUS STOP — MIDDAY6

Heat without shade. Asphalt gleaming like metal.
A bus speeds past. Doesn’t stop.
A cloud of DIESEL cuts the air.

Anna leans sideways against the bus stop pole, keeping herself from tipping into the street.

She opens her bag. Takes out the coins.
Counts.
Puts them away.
Counts again.
The numbers don’t match.

The pamphlet surfaces among her things—a white corner, insistent.
She pulls it out and folds it in half to make it fit her hand.

CRACK.

She folds harder. The paper resists. She insists.
As if the paper has to learn how to fit her life.

Anna takes a cigarette from the pack. The pack is soft, tired.

She tries the lighter.

CLICK. Nothing.

She shakes it.

CLICK. A brief spark. Dead.

Her mouth tightens—an old, learned gesture.

She uses the pamphlet as a shield, an improvised wall against the wind.

Tries again.
The flame catches. Flickers.
The paper trembles in her hand.
The cigarette lights.

A short drag.
She holds it.
Releases.

ANNA (V.O.)
I keep borrowing from the future.
I never know when it comes due.

A bus finally stops.
The doors open with a pneumatic SIGH.

People push off. People board without looking.
Anna steps on, the crumpled pamphlet in her hand.

The turnstile CHOKES on a coin.
Another slips free and ROLLS down the aisle.

Anna bends and retrieves it quickly.
Doesn’t complain.
Moves toward the back.

Doesn’t look behind her.
She’s done this before.

4 INT. KITCHEN — NIGHT (PAST)

Yellow light. An old fan creaks, useless.
On the refrigerator: a child’s drawing held by a magnet.

A crooked sun. A house. Three stick figures.

AUGUST (73), shirt unbuttoned at the chest, coughs into the sink.

A deep cough. An old one.

On the table: a full ashtray. A cup of cold coffee.
And a pamphlet identical to Anna’s—creased along the same folds.

August picks up the pamphlet. Unfold it carefully.
The paper makes a dry sound—

CRACK—

as if it were still alive.

Dried coffee stains the illustrated lung.
In the margin, a phone number was scribbled in pen.
Beside it: an OLD LIGHTER, heavy, scratched.

Worn metal. A tired spring.

August looks at it as if it belonged to someone else.
Picks it up.
Weighs it in his hand.

He opens a drawer.
Pushes the lighter to the back, behind the cutlery no one uses.
Closes the drawer with too much care.

He takes a cigarette.
Stops halfway through the gesture.
Look at the drawing on the refrigerator.
His hand lingers in the air a beat too long.

He opens another drawer. Takes out an empty glass jar.
Begins placing the cigarettes inside, one by one.

No hurry. No relief.

Contained violence, as if storing something dangerous.
The lid closes.

CLOC.

A child (Anna) runs past the hallway in the background, glancing in.
We only see her hair. A short laugh. Light footsteps.

August holds the jar for a moment, still.
Looks upward, as if measuring a distance.
He stretches his arm.
Places the jar on top of a cabinet.
Stands motionless.

His hand lowers slowly.

5 INT. SMALL BEDROOM — NIGHT (PRESENT)

A cramped room. Stained wall.
A fan that doesn’t help.
A box of clothes. A mattress on the floor.

On the bedside table: a past-due notice, folded and opened again.
Anna opens a drawer.
Inside: the OLD LIGHTER—heavy, scratched, worn metal.

The same tired spring.

A creased passport photo of August.
Anna picks up the lighter.
Doesn’t light it.
Just press the mechanism.

CLICK.

She lets go as if she’d burned the tip of her finger.
She touches the photo with her fingertips, as if it might tear.

From somewhere far off, the neighbor’s TV: canned laughter, outsourced joy.
Anna puts the photo back.
Closes the drawer.

6 FLASHES:

Coins clinking (a thin metallic chime) / The pamphlet trembling in the flame (CRACK, a faint hiss) / The glass jar filling (CLOC) / August’s cough / A coin rolling down the bus aisle / The passport photo / A coin rolling again / The CLOC of the jar lid.


SMASH CUT.

7 EXT. BUS STOP — NIGHT (PRESENT)

A different street. The same gesture.
Anna leans against the shelter wall.
Lights a cigarette. The flame flickers—holds.

Behind her, on the glass, a torn poster.
All that remains: “…OP SMOKING.”

She inhales. Air in. Air out. The cycle continues.

The bus arrives.
Doors open.
Anna steps on.
The doors close.

The engine sound pulls away, taking with it the little air she had.
What’s left is emptiness—and the city’s distant hum.

II. The World on Shift


8 EXT. FACTORY GATE — DAWN

Low sky, a dirty gray.
Wet ground. Puddles slicked with old oil.

A bus brakes—a long metallic hiss.
The doors open with a pneumatic sigh.

People step down in silence.
Footsteps. Turnstile clicks. Handrails. Backpacks scraping.

A metal gate.
A faded sign.

In the guard booth, a digital clock blinks the wrong number.

DAMIAN (42), name stitched across his uniform.
On his wrist: a stopped watch.
He looks at it—
not to check the time,
only to confirm there is none.

On his finger: a worn wedding band, deeply scratched.
He turns it once with his thumb.
A small rotation. Unnoticed.
He holds a plastic lunch container—lid warped.
And a crumpled pack of cigarettes, damp at the corner.

He leans against the wall.
Takes out a crooked cigarette, the tip bent.
Searches his pocket for the lighter. Impatient. Automatic.

CLICK. Nothing.

He shakes it.

CLICK. A brief spark. Dead.

Wind.

He cups his hand around it.
His hand trembles—cold and hurried.

CLICK.

Now it catches—a small, unstable flame.
The paper sticks slightly to his lip in the damp.
He adjusts it with his teeth, careful not to bite.
First drag—short. A test.

He coughs once—dry, contained—
and swallows it, glancing sideways,
as if coughing were a minor offense.

On the pack, the warning image is shown.
His thumb covers it without thinking.

Inside: a forklift BEEP, metal clanging, a short alarm.
Out here: the sound of his own lungs working.

His phone vibrates in his pocket.
He doesn’t take it out. Just feels it.
Another drag—deeper now—
as if pulling his body back into itself.

Ash falls into a puddle.
Turns to gray mud.
He crushes the cigarette underfoot, hard.
And goes in.

The sound of the factory swallows everything.

9 EXT. BUS STOP — MORNING

A scratched acrylic shelter.
An old advertisement peeling at the edges.
Light rain. Diesel in the air.

ANNA (33), supermarket uniform, badge crooked.
A bag with bread and a pack of diapers.

The heavy purse digs into her shoulder.
She steps two paces away from the group—
as if asking the air for permission.

The hand holding the cigarette is drier now, more worn.
A pale ring on the skin—
a mark where something once was.

She takes out a cigarette carefully.
Not from delicacy.
Because the pack is nearly empty and the cigarette breaks easily.

The lighter fails.

CLICK. CLICK.

A flame appears. The wind kills it.

A short exhale through her nose.
No broad gestures.
There’s no room for that.

CLICK.

This time it catches.

She inhales, watching the far end of the street—
where the bus should be.

The smoke slips from the corner of her mouth.
Not for elegance.

So it won’t drift toward the baby beside her.
The baby cries.

Someone rocks the stroller with a foot, without looking.
Eyes fixed on a watch.

A bus speeds past, sending up a gust of wind and dirty water.
The gust slaps the smoke from Anna’s mouth.
She closes her eyes for half a second.
Opens them quickly, as if rest were dangerous.

A deeper drag.

The filter nears her fingers.
Her hand carries the smell.

10 INT. SMALL APARTMENT — NIGHT

Old-building silence: pipes ticking, a neighbor walking,
a low television somewhere far off.
Cold kitchen light.
A full sink. A damp dish towel left out.

Anna is in sweatpants, hair loose with exhaustion.
She washes a pot quickly—so it won’t make too much noise.
The sponge scrapes the metal.

She opens the window only as far as her body needs.
Air comes in: distant frying grease, rain that’s been sitting around.

She lights a cigarette on the sill.
The flame flickers. Catches.

She inhales and holds the smoke for a second.
Not pleasure.

Suspension.

From the bedroom: a child’s breathing.
In the dark hallway: a toy on the floor.

Anna nearly trips.

Stops.

Looks.

Just a second—love, irritation, fatigue, all at once.

She doesn’t pick it up.
Keeps going.

She exhales the smoke outside,
trying to make it disappear before it can exist inside.

Ash falls onto the sill.
She runs a finger through it.
The ash sticks to her skin.

She wipes it on the dish towel.
A new stain.

She puts out the cigarette in a chipped saucer.
Slowly. Without sound.

Closes the window.

The glass makes a small *toc* against the frame.
In the quiet, it sounds loud.

She switches off the light.
Dark.

Only the dish towel was left on the edge of the sink.
Old stains.

The new one, still fresh.

In the dark, Anna braces her hands on the sink.
Still.

She presses the finger where a ring should be,
as if checking whether it still exists.

She rests her forehead against the cabinet for a moment.
Breathes in through her nose.
Lets the air out through her mouth, without a sound.
And walks away into the dark.

11 FLASHES:

Damian’s stopped watch / A thumb covering the pack’s warning image / Ash turning to sludge in an oil puddle / The strap gouging a groove into Anna’s shoulder.


SMASH CUT.

III. Good Habits


12 INT. OFFICE BREAK ROOM — MORNING

The coffee machine: PSHHT.
Paper cups lined up.
Napkins folded with care.

On the wall, a motivational poster:
GOOD HABITS, GOOD LIFE.

CLARA (35), impeccably dressed, opens a “clean” lunch:
salad cut evenly, fruit in a container, and her own utensils.

Before she touches a cup, hand sanitizer.

She rubs slowly until it dries—like a rite.
Her phone vibrates.

Group: “Condominium / Block B.”

She reads without changing her expression.
Only her eyebrow lifts a millimeter.

She puts the phone away with the same precision she used to snap the lunch lid shut.

A sip of coffee.

An inhale.

As if beginning the day “right.”

13 EXT. BUILDING ENTRANCE — LATE AFTERNOON

A blue sign:
SMOKING AREA.
On the ground, a peeling yellow rectangle.

A SMOKER stands inside the yellow boundary, leaning back.
The flame flickers. Holds. He inhales.
Clara approaches with grocery bags.

Slows.

Looks at the sign.
Looks at the rectangle.
She makes a small sidestep, avoiding the yellow.
Avoids it the way one avoids something that stains.

As she passes, she holds her breath for half a second—
without realizing she has.

She adjusts her coat with her fingertips,
as if protecting the fabric.

Two steps later, she exhales.

A brief, private relief.
Her face doesn’t celebrate.
It simply confirms.

14 INT. LOBBY / SANITIZER DISPENSER — CONTINUOUS

Automatic doors: PSHHT.
A steady hum of air-conditioning.
Clara steps inside.

The smell of the street stays behind; the smell of smoke tries to follow.

A MAN stops at the sanitizer dispenser.
Two pumps.
He rubs his hands methodically, staring ahead,
as if observing a rule no one needs to state.
Clara passes him

a little more upright than before.

15 INT. ELEVATOR — ASCENDING

A crowded elevator.
Clara steps in and takes her place near the doors,
hand on her bag.

The SMOKER enters right after.

A YOUNG WOMAN pulls her backpack to the front of her chest,
like a shield.

Farther back, someone retreats a centimeter:
a foot shifts, a knee locks—and holds.

Clara presses her floor button.

Without looking, she also presses the fan button.

The fan light comes on.
A neighbor steps in.
Clara smiles at him.
A clean, quick, competent smile.

The display climbs: 3… 4… 5…

No one speaks.

16 INT. HALLWAY — CONTINUOUS

White light.
Carpet that swallows footsteps.
Clara walks to her door.

Before going in, she takes a small spray from her bag.
Two bursts:
PSSHH. PSSHH.
She inhales.

Her face relaxes a millimeter.
She enters.

17 INT. LIVING ROOM / SOFA — NIGHT

TV low.
On the table, a glass with melting ice.
Clara scrolls.

A short video: someone smiling into the camera.
Caption: “Discipline is self-love.”

She likes it.
A heart appears.

Another video.
Another tip.
Another “good habit.”

She likes that one too, unhurried.

A notification from the building group chat.
Clara opens it and types:

CLARA (TEXT)
Hi, everyone… Please, the smoke has been drifting up into my apartment.
There are children and an elderly person here. Thank you.

She sends it.

Within seconds: reactions, little hearts, “agree,” “exactly.”
Clara holds the phone as if receiving a small certificate.

She rests her head against the sofa back.
Closes her eyes for a moment.
Breathes.

18 EXT. SMOKER’S WINDOW — NIGHT

A window opens just a hand’s width.
The SMOKER leans halfway out,
trying to be invisible.

He smokes quickly.
Short drags.
His phone vibrates.

On the screen: “Condominium / Block B.”
He looks.
Doesn’t open it.

He stubs the cigarette out halfway in a saucer.
His hand lingers in the air for a second,
uncertain what to do with the rest of the gesture.

He closes the window.

19 INT. HALLWAY / NOTICE BOARD — NEXT DAY

Clara comes out with a folder.
Stops at the notice board.
She tapes up a printed sheet:

REMINDER:
SMOKING ONLY IN THE DESIGNATED AREA.
PLEASE RESPECT THIS.

She smooths the paper with her palm, pressing out the bubbles.
Smooths it again.
Once more.
As if closing the matter.

20 INT. LIVING ROOM — NIGHT

Clara’s phone lights up: more reactions,
more “thank you for the notice.”

She turns the phone face down on the table;
a gesture of closure.

Takes a sip of water.
Breathes.

A micro-smile, meant only for herself.

SMASH CUT.

IV. The Garden and Its Limits

21 INT. SMALL EXAM ROOM — LATE AFTERNOON

White light. A noisy fan.

A Formica table scarred with old marks.
A jar of cotton balls. A box of patches.

The CLINICIAN opens a drawer.
The plastic packaging gives a dry sound.

Anna sits with her hands in her lap.
Short nails. A pen mark on one finger.
She pulls her sleeve up without ceremony.
Cotton on her arm.
A dry touch against skin.

The clinician applies the patch and smooths it with two fingers,
counting without speaking.

Anna watches the gesture.
The way one watches a wound being sealed from the outside.

The clinician points with a finger, no drama:

CLINICIAN
If you get dizzy, take it off. Water. Sleep without it.

Anna nods.
She puts the box and the pamphlet into her bag,
pushing to make it fit.

In another room, a phone rings.
Someone answers.

A baby cries somewhere far off. Stops.
Anna stands.
The plastic chair squeaks.

22 EXT. CLINIC EXIT / SIDEWALK — CONTINUOUS

The door closes with a tired click.
Traffic. Dust.

A bus roars past.
Anna steps down from the curb.

For a second, the white edge of the patch shows beneath her sleeve.

She crosses the street, avoiding a pothole filled with dark water.

On a pole, a street sign:
CHICO MENDES STREET.

The sign hangs crooked, bent at one corner.
Anna doesn’t look.
Her body is already elsewhere.

23 EXT. PLANTER IN FRONT OF A BUILDING — NIGHT

Streetlight.
A carefully designed planter,
contained by concrete borders.

Leaves shine with moisture.

A GROUNDSKEEPER, thick gloves on, trims the shrubs.

SNIP.

SNIP.

Branches fall. Leaves fall.

He gathers them with a shovel
and pushes them into a black trash bag.

Two meters away—almost out of frame—
a man sleeps curled beneath a thin blanket.

A cough comes from inside the blanket.
Small. Persistent.

The groundskeeper doesn’t look.
He takes a spray bottle.
Squeezes.

PSSHH.

The leaves take on a new shine.

24 INT. ANNA’S KITCHEN — NIGHT

Dim light. A sink full of dishes.
A damp dish towel left out.

The neighbor’s television bleeds through the wall.
Anna enters and drops her bag on a chair.
The chair creaks.

She takes out the pamphlet and leaves it unopened on the table.
Her sleeve rises: the patch is there— one edge lifting from sweat.

She presses it down with her thumb, firm,
|as if holding something that wants to slip away.

From the bedroom: a child’s breathing.
Anna opens the refrigerator.
Almost empty.

Closes it.

Sits.

For a moment, her hand rests on her arm,
feeling the patch through the skin.

Her phone vibrates.
She reads the message.
Doesn’t answer.

She takes a cigarette from the crumpled pack.
Stops halfway through the gesture.

Looks at the patch.
Looks at the window.
Searches for the lighter.

CLICK.

Nothing.

CLICK.

A brief spark. Dead.

CLICK.

It catches. The flame wavers.

She lights it.
A short drag.

She exhales quickly out the window,
as if erasing a trace.

Outside: a distant siren.
A dog barking.
An engine is climbing the street.

25 EXT. PLANTER — NIGHT (RETURN)

The groundskeeper ties the black trash bag.

He pulls.
The bag drags across the pavement—
a rough, scraping sound.
He walks away.

The planter remains immaculate.
Still.
Shining.

The coughing beneath the blanket continues.

26 INT. ANNA’S KITCHEN — NIGHT (RETURN)

Anna stubs out the cigarette in a chipped saucer.
Her nail scrapes the ceramic.

She rests her forehead against the cabinet for a second.
Breathes in through her nose.

Lets the air out through her mouth, without a sound.
Her hand returns to her arm.
Presses the patch down once more.
As if trying to hold something in place.

She switches off the light.

Dark.

V. The Still

27 INT. ANNA’S KITCHEN — PRE-DAWN

Blue darkness.
Her phone vibrates.

Anna silences it without checking the time.

From the next room: a child’s breathing.
She walks barefoot.
The floor is cold.

On the table: the box of patches,
the folded, crumpled pamphlet.

Anna pulls up her sleeve.

The old patch is still there; one edge lifted.
She peels it off slowly.
The skin beneath is marked:
|a pale rectangle, clean in the middle of her arm.

She opens a new one.
The plastic crackles softly.

Applies it.
Smooths it with two fingers.
Presses the stubborn edge until it holds.

Anna lowers her sleeve.

She stands still for a moment,
as if waiting for her body to agree.

28 EXT. BUS STOP — DAWN

Cold.
A streetlamp was still lit.
People are waiting with backpacks and coats.
No one looks at anyone.
Anna arrives.

Leans against the pole.
Her bag is heavy.
She takes a crumpled pack from her pocket.
Takes out a cigarette.

Stops.

Her hand hangs there for a second.
She puts the cigarette back in the pack.
Slips it away.

From her bag, she takes a small, dark object, worn from use.
Raises it to her mouth.

A short pull.
A small light glows, then disappears.

Vapor drifts out, faint, dissolving quickly in the cold.

The bus arrives.
Doors open.
Anna steps on.

29 INT. BUS — CONTINUOUS

The ticket reader BEEPS.
Bodies swaying.
Anna leans into the window.
The glass is fogged.

She wipes it with her sleeve,
clearing a small circle of view.

Outside: the street waking up,
people walking fast,
a dog nosing through trash.

Inside: the silence of tired people.

Her hand goes to her arm by instinct
and presses the patch,
as if confirming it’s still there.

The bus drops into a pothole.

JOLTS.

Anna closes her eyes
for half a second.
Opens them.

30 EXT. BUILDING ENTRANCE / SMOKING AREA — LATE AFTERNOON

Blue sign.
A peeling yellow rectangle on the ground.

The SMOKER stands inside the boundary.
Cigarette lit.
Shoulders slumped.

The wind pushes the smoke toward the entrance.

CLARA (the woman from the condominium) approaches with a grocery bag.
She makes her usual detour:
circles the yellow as one circles a habit.

She is about to keep walking.
Stops for a second.

Looks at the man—
not quite at his face,
more on the outline of him.

Then looks at her own hand gripping the bag,
as if remembering its weight.
She moves on.

31 INT. ANNA’S KITCHEN — NIGHT

Dim light.
A sink full of dishes.

The damp dish towel is in the same place.
The neighbor’s TV bleeds through the wall.
Anna comes in and drops her bag.

The chair creaks.

She rests her forehead against the cabinet for a second.
Breathes in through her nose.
Lets the air out through her mouth, without a sound.

She takes the small object from her pocket
and sets it on the table
as if setting down a key.

She pulls up her sleeve: the edge of the patch is firm now.
She smooths it once with her thumb.
She opens the drawer.

The crumpled pack is there.
She looks.
Closes the drawer.

She rests her forehead against the cabinet again.
Breathes in through her nose.
Lets the air out through her mouth, without a sound.

She switches off the light.
Dark.

The distant HUM
of a fluorescent lamp.

THE END

From that shift emerged the moral and regulatory prestige of smoke-free spaces, one of the most durable victories of tobacco control. The problem, Roberto Sussman suggests in his essay on the global intensification of vapor-free policies, begins when this logic is extended almost automatically to vaping and heated tobacco products as if vapor and smoke were simply different versions of the same phenomenon.

Over the course of two decades, smoke-free ceased to be merely a public-health slogan and became one of the most successful moral brands of our time. The phrase emerged from a concrete battle, grounded in robust evidence, against a product that killed on an industrial scale and exposed bystanders to risks they had never chosen to assume. In many countries, that victory changed the air and reshaped social etiquette, altering the very idea of coexistence. The cigarette lost its glamour and, with it, part of its cultural empire.

The problem begins when a victorious category stops being merely descriptive and starts operating as a reflex.

In his essay “On the Global Intensification of ‘Vapor-Free’ Policies (Part 1),” Roberto Sussman, a professor at UNAM, sets out to investigate precisely that shift. He asks how the logic that sustained the fight against cigarette smoke came to be extended almost automatically to vaping and heated tobacco products, even in open spaces, as if we were dealing with the same physical, chemical, and sanitary phenomenon.

His formulation is blunt. “The logic is crude and simple.” The reasoning, in essence, runs like this: if cigarettes are harmful to those who smoke and also to those who inhale the smoke, then any visible cloud exhaled in public should fall under the same principle. What Sussman disputes is not the idea of protecting shared air. It is the analogical short circuit that turns one problem into another without examination. “Passive vaping is not passive smoking.” And, more literally still, “e-cigarettes and HTPs do not emit ‘smoke.’”

This distinction, which may appear technical, is also political. Regulations do not arise from measurements alone. They emerge from discourse, from shared associations, and from images sedimented over time. And smoke carries a historical weight that vapor does not yet bear. Smoke evokes combustion, soot, and the smell that clings. It evokes known harm, decades of accumulated deaths, public campaigns, warning labels on cigarette packs, and darkened lungs. When vapor enters this imaginary by way of analogy, half the dispute has already been won before the comparison even begins.

Sussman’s effort is to interrupt precisely that automatism. His question is not whether vaping should circulate without rules. It is whether it makes sense to apply the same regulatory template designed for cigarettes to vaping and wholesale, without distinguishing risk, dose, context, and the nature of exposure.

Behind this lies a dispute that is less about nicotine than about method. What happens when public policy learns to respond by reflex?

When Science Stripped the Cigarette of Its Glamour

Sussman begins by acknowledging what worked, and rightly so. For much of the twentieth century, the fight against the conventional cigarette was not a hysterical crusade. It was a civilizational correction. There was a powerful adversary: wealthy and, on many occasions, profoundly dishonest. The constellation of interests surrounding tobacco normalized a lethal product through aggressive advertising, cultural capture, and the systematic denial of evidence. Against this, epidemiology, medicine, and public health played a historic role.

The story is familiar, but worth recalling.

Richard Doll and Austin Bradford Hill helped establish, with the growing weight of data (1950–1955), the causal link between smoking and lung cancer. Then came the reports of the Royal College of Physicians (1962) and the U.S. Surgeon General (1964), which helped consolidate the emerging public consensus. What had once been an elegant habit came to be recognized as a massive risk factor for cancer, cardiovascular disease, and respiratory illness.

Decades later, that institutional arc culminated in the Framework Convention on Tobacco Control. The treaty was adopted in 2003 and entered into force in 2005, becoming the first global public-health agreement of its kind.

That history matters because it lends legitimacy to what came next.

The authority earned in that battle was not gratuitous. It was deserved. But as Sussman suggests, every conceptual victory leaves behind an ambiguous inheritance. A cause that wins acquires not only historical vindication but also prestige, institutional apparatus, language, and confidence.

At some point, however, a risk appears. Evidence ceases to function solely as a criterion of correction and begins to operate as a form of identity.

From there, nuance may cease to sound like legitimate scrutiny. It is increasingly seen as infiltration, moral backsliding, or sabotage.

Consider the didactic formulation once promoted by Public Health England, that vaping is “95% less harmful,” which became both a marker of belonging and a target of criticism. Something similar happened with the Royal College of Physicians. Its institutional prestige helped legitimize the war against cigarettes. Later, when it endorsed harm reduction through vaping, the institution itself became the object of criticism, because part of the field rejects that strategy.

At that point, for Sussman, the problem ceases to be merely technical. It becomes a question of intellectual discipline. The question is no longer only what the data show. It is also: what does a field do when it becomes accustomed to being right?

When Virtue Acquires a Machine

In the genealogical reconstruction Sussman proposes, the turning point comes in the late 1990s and early 2000s, particularly in the United States. The political and financial ecosystem surrounding tobacco, once untouchable, had already been discredited and hemmed in by litigation.

Anti-smoking activism, which for many years had operated as a force of resistance, was beginning to move inside the institutional apparatus itself. The cause was shifting from frontal confrontation to the administration of power.

In Sussman’s reading, the 1998 Master Settlement Agreement marks this transition.

The agreement imposed billions of dollars in payments from tobacco companies to the states. It also introduced marketing restrictions and brought a kind of stabilization to the legal conflict. Sussman notes, without romanticism, that money publicly associated with anti-tobacco initiatives often ended up serving other fiscal purposes.

Indeed, reports from the Government Accountability Office indicated that a significant share of those revenues was used to balance state budgets or fund general priorities rather than tobacco-control programs. The point here is less accounting than politics. When virtue acquires a budget, it also acquires incentives to preserve itself.

There is nothing cynical about this observation. It is simply institutional sociology. Public health is not made by saints hovering above history. Institutions and coalitions make it. It is shaped by careers, struggles for influence, agendas, reputations, and resources.

None of this invalidates the cause. But it does prevent its idealization. And for Sussman, this is the blind spot in much of the debate: the belief that good intentions alone are enough to shield a field from the selective use of evidence.

The argument is uncomfortable because it strikes at a narrative the field itself holds dear, the narrative that being on the right side of history automatically protects it from methodological excess. But it does not. No field does.

The Moment the “Other” Enters the Equation

At this point in his reconstruction, Sussman introduces a Mexican recollection. In 1975, he writes, roughly forty percent of men in the country smoked. Among women, the rate hovered around three percent. The figures fit a broader regional pattern: across Latin America in the 1970s, male smoking prevalence often exceeded forty percent, while among women it generally remained below ten.

In popular culture, the association between cigarettes and cancer was already circulating strongly enough to produce a street nickname: “cancer tacos.” The detail matters because it shows that public awareness of tobacco’s risks preceded, to some extent, the tightening of regulations that came later. Science had already begun to exert a real cultural effect.

But the decline in smoking prevalence, Sussman argues, eventually slowed.

Even as Mexican legislation aligned itself with World Health Organization recommendations, smoking rates spent years oscillating around roughly the same levels.

Sussman’s reading is that information alone does part of the work, but not all of it. People do not smoke only out of ignorance. They smoke out of habit, pleasure, context, class, stress, routine, social bonds, and as a precarious form of self-management of distress. Public health speaks in probabilities about the future. The body, more often than not, decides under the pressure of the present.

It is on this terrain that secondhand smoke enters the picture as a decisive political device. As long as the message was that you harm yourself, regulation ran up against an important moral boundary: autonomy. Once the axis shifts to harming others, especially the innocent, the board changes.

Sussman locates a key moment in this shift in 1975, at a World Health Organization conference, recalling remarks by Sir George Godber, a pioneer of anti-smoking policy in the United Kingdom since the 1950s. Godber described smoking as a “preventable epidemic.” He criticized governmental passivity and advocated mass anti-smoking education, investment in primary care, and the need to foster the perception that smokers harm those around them—particularly family members, babies, and young children.

His perspective was embedded within a broader horizon shaped by the idea of “health for all,” which would later be formulated internationally at Alma-Ata.

That horizon combined tobacco control, the reduction of environmental risks, and community integration, and it would help shape the World Health Organization’s early resolutions on noncommunicable diseases.

It is not hard to see the political force of this shift. Once harm ceases to be merely self-imposed and is presented as something inflicted on others, especially vulnerable others, restrictions become more defensible, more intuitive, and more expansive. The smoker ceases to be merely someone who assumes a risk. He becomes someone who distributes it.

Consensus in Armor

At this point, Sussman revisits a study by James Enstrom and Geoffrey Kabat published in the British Medical Journal (BMJ) in 2003. The paper examined exposure to environmental tobacco smoke and mortality in a cohort of couples in California. He recalls the cautious wording of the article itself: the results did not support a robust causal relationship between environmental smoke exposure and tobacco-related mortality, though they also did not exclude the possibility of a small effect.

The point here is not to treat this single study as a refutation of the prevailing consensus. The paper itself must be read with that caution. Major health agencies maintain that, on the basis of a much broader body of evidence, environmental tobacco smoke causes significant harm, including cardiovascular and respiratory effects with meaningful population-level impact. That remains the dominant understanding.

Sussman’s point is different. He asks when a field stops tolerating the reexamination of specific points without interpreting it as heresy.

In his formulation, the subject of secondhand smoke has become “quasi-sacralized.” Not merely a strong consensus, but a consensus transformed into moral identity. And when that happens, disagreement ceases simply to be contested. It becomes suspect.

This may be the most useful passage in the essay, not because it resolves the dispute, but because it identifies a pattern that recurs across many fields: the ease with which public science, when it feels morally besieged, shifts from firmness to insulation.

From Chemistry to Political Reflex

This history matters because, for Sussman, it prepares the ground for the expansion of the smoke-free concept to contexts where the basis for comparison is far less obvious.

By the time e-cigarettes and heated tobacco products entered the scene more visibly—particularly over the past decade—an institutional repertoire was already in place: maximum precaution, absolute language, denormalization as a cultural strategy, and the protection of children as a highly resonant political justification.

The problem is that the object has changed. Conventional cigarettes involve combustion. Vaping does not. That does not make vapor harmless, nor “just water,” a caricature as simplistic as the one offered by the opposite side. But it does change the physics and chemistry of what is exhaled. And if the phenomenon changes, the yardstick should change with it.

It is in this context that Sussman also discusses so-called third-hand smoke, the residues from tobacco smoke that settle on surfaces and can react with compounds in the surrounding environment. He does not deny the phenomenon's chemistry. What he questions is the leap that turns laboratory plausibility into a sense of ubiquitous threat, without passing through the harder work of measuring dose, frequency, context, real exposure, clinical relevance, and the magnitude of risk.

Chemistry does not legislate on its own. What should guide regulation is the relationship between exposure and harm under real-world conditions.

In the same vein, Sussman criticizes the totalizing use of formulas such as “there is no safe level of exposure to ETS,” which functions less as scientific precision than as a language of political authorization.

The problem with absolutes is well known. They erase gradations and turn any residual presence into a potential justification for prohibition. Instead of governing risk, policy begins to govern through aversion.

It is in this climate that Sussman situates the expansion of bans to open areas and a variety of public spaces, often justified in the same terms used for conventional cigarettes.

His criticism is not that children do not deserve protection, nor that public life should be left unregulated. It is that protection can become a catch-all word. Once invoked, it seems to dispense with the need for more careful demonstration.

When Science Enters Campaign Mode

Sussman chooses an emblematic case: the study that linked the smoking ban in Helena, Montana, to an abrupt drop in the number of heart attacks treated at the local hospital.

The paper circulated quickly in the press and came to be presented, in many contexts, as a kind of portable proof of the immediate effects of smoke-free policies. The problem, he notes, is that the study design was far too small to sustain such sweeping conclusions without considerable caution. Statistical variability, temporal coincidence, and simple noise may have carried more weight than the narrative allowed.

Critics pointed to the small sample size, the high statistical variability, and the fact that a similar fluctuation had already occurred in 1998, when no smoking ban was in place. Subsequent commentary questioned the strength of the causal inference and the biological plausibility of such a large decline in so short a time, without accusing the authors of misconduct. Broader reviews later treated Helena as an early study with a striking effect but low precision, assigning greater weight to larger datasets and subsequent meta-analyses.

It is worth avoiding excessive accusatory language here. Terms such as “fraud” or “hoax,” used by Sussman, attribute intent and require a level of caution that serious journalism cannot abandon. A study does not have to be fraudulent to be absorbed into a narrative machine. But the broader point remains. When a public agenda enters campaign mode, studies with strong communicative impact tend to receive a selective advantage.

Not because they are necessarily false, but because they fit the story better.

This may be the most unsettling core of the genealogy Sussman proposes. What consolidates itself, he suggests, is not merely a body of results about environmental tobacco smoke, but an institutional style: one marked by a preference for maximalist language, a low tolerance for inconvenient contestation, the use of denormalization as a form of cultural engineering, and a readiness to convert uncertainty into an argument for tightening restrictions.

When this style encounters a new target—vaping—the transfer is swift. Sussman summarizes the operation almost verbatim: e-cigarettes and heated tobacco products come to be banned “in all public spaces, even open outdoor spaces, where smoking is prohibited,” under the justification of “health protection,” despite the “enormous differences between the environmental emissions.” His point is not that these differences eliminate every concern. It is that they make the problem, in comparative terms, more complex than policy tends to admit.

Taking the Other Side Seriously

At this point, it is necessary to resist any temptation to turn this critique into a pro-vape pamphlet. Bad science has no fixed side. If there are biases, overinterpretations, and shortcuts in the more orthodox wing of tobacco control, there are also conflicts of interest, indulgent formulations, and convenient framings in harm reduction. Studies funded by corporations, or linked directly or indirectly to their interests, deserve heightened scrutiny. That does not automatically invalidate them. It simply raises the standard of caution.

Taking the other side seriously does not weaken Sussman’s critique. On the contrary, it puts that critique under pressure.

The strongest arguments from the restrictive camp tend to organize themselves along two lines. The first is renormalization. Allowing vaping in spaces where smoking is prohibited could reintroduce into public space the visual choreography of the cigarette: the gesture, the pause, the cloud, the familiar aesthetic of the act. The second concerns the protection of children and adolescents. The aim is to reduce exposure, limit indirect advertising, and prevent certain behaviors from acquiring an aura of social normality.

None of these arguments is absurd. The problem lies in treating them as sufficient grounds for full regulatory equivalence. Because at that point, appearance and substance begin to blur. One thing is to debate public etiquette, contextual limits, marketing practices, and coexistence in enclosed or shared spaces. Another is to treat exhaled vapor as if it were, by definition, the same problem as cigarette smoke.

There is another point that the rhetoric of renormalization often sidesteps. If what becomes more visible in public space is not the combustible cigarette but an alternative of comparatively lower risk, that normalization should not automatically be read as a threat. In some contexts, it may represent precisely the kind of displacement that an evidence-oriented public health policy ought to recognize. To reduce it to a symbolic relapse may be a way of confusing cultural memory with the real hierarchy of harms.

A proportional response may lie less in general slogans than in contextual arrangements: where, when, under what conditions, with what standards of public information, and with what clear distinction between products of very different levels of risk. The key question isn't whether vaping is risk-free, but whether public policy has the right to overlook the relative scale of risks.

The Tragedy of Virtue

This is where Sussman’s essay touches a problem larger than vaping itself. Public policies can fail not only through omission but also through poorly calibrated moral excess. A rule designed to protect may end up protecting less than it imagines—or protecting the wrong target.

The study by Saffer and colleagues offers one example of this possibility. But it is not alone. Similar patterns have been observed in Abigail Friedman’s analysis of San Francisco, in recent studies of state-level flavor restrictions, and in research using large panels of young adults in the United States.

The designs vary. So does the scope. And the magnitude of the effects is far from uniform.

Even so, the convergence is enough to counsel caution toward any policy that treats sweeping flavor bans as an automatic benefit. When consumption migrates toward the more lethal product, the language of protection can no longer dispense with comparative accounting.

That is the difficult irony. A policy designed to steer young people away from nicotine may push some of them toward the form of consumption that kills the most. The good intention does not disappear. What disappears is its innocence.

Once policy begins to produce side effects of its own—some quiet, others cruel—the question changes. It is no longer enough to know which side someone is on. The question becomes another: how does one govern without becoming intoxicated by one’s own argument?

Sussman brings that question to the center. When does protecting become delegitimizing? When does prudence become standardization? When does uncertainty, which ought to call for measurement, monitoring, and revision, become the engine of total prohibition? These are not questions opposing regulation. They are questions about effective regulation.

In today’s communication environment, absolutes travel better than proportions. “Zero tolerance” is simple, marketable, and morally photogenic. Nuance sounds defensive. Revision looks like a weakness. But serious public policy cannot be designed to fit neatly into headlines. It has to fit the real world.

Ultimately, this highlights the value of Sussman's proposed genealogy. It doesn't settle the debate over vaping by itself. However, it offers a key institutional lesson. When fear is effective, it tends to be reused. When the word 'protection' is used to shield a policy from criticism, it often makes that policy more rigid. And when a field forgets that flawed science can come from all sides, it begins to lose the right to claim that rigor is a core principle.

The dilemma, therefore, is not about simply “to ban or to allow.” It is more complex and less satisfying than that. It involves creating regulations that are proportional to the risk, transparent in their criteria, and adaptable as new evidence emerges. Rules that protect without defaulting to automatic equivalence. Rules that differentiate without humiliation. Rules that don’t, out of rhetorical habit, turn vapor into smoke before understanding what is actually in the air.

Maybe the debate over vapor-free policies needs to move beyond its deadlock and focus on a simpler question: what exactly is public health willing to compare? And who answers when it chooses not to make that comparison?

Roberto’s Substack

On the global intensification of "vapor-free" policies (Part 1)

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3 months ago · 11 likes · Roberto Sussman

When a smoker lights a cigarette, the body has no choice; it complies. Within seconds, a cocktail of thousands of compounds moves through the airways and spills into the bloodstream, reaching the lungs, the brain, the heart.

Yes, there are carcinogens. But there are also irritants and toxins that begin sabotaging the organism long before any tumor announces itself: chronic inflammation, vascular dysfunction, emphysema, and acute events.

Some of the names sound almost didactic in their cruelty, as if chemistry, with a professor’s composure, had drafted a pedagogical script for catastrophe. Benzene, associated with hematologic damage, is no stranger: it also appears in gasoline, and when it enters the body through smoke, it travels through the bloodstream to the bone marrow. Acrolein, a fierce respiratory irritant that history has seen deployed in chemical weapons during the First World War, arrives in the lungs with the familiarity of something that knows the way. And NNAL, a metabolite linked to tobacco-specific nitrosamines, lingers as a signature of exposure, a stubborn mark that does not vanish overnight.

Now imagine that same smoker trading fire for a small white pouch tucked between lip and gum: a discreet envelope of nicotine and excipients dissolving in silence. There is no flame, no smoke, no ash in the tray. Thirty minutes later, plasma nicotine rises enough to blunt the craving, like turning down the volume on an internal alarm.

And the rest?

This is where the narrative begins to lose its sharp edges. When combustion exits the scene, the body no longer “signs off” on easy theses. Without tar, without carbon monoxide, without the toxic choreography of burning, some of the most familiar accusations lose their immediate target. What remains—and in what magnitude—demands a different vocabulary: less moralism, more pharmacology; less menacing smoke in the air, more dose in the blood; more molecule, stripped bare and insistent.

Among available biomarkers, benzene appears nearly absent. Acrolein declines sharply: by 78.8 percent in the biomarker 3-HPMA compared with smokers. And NNAL, the most feared trace of tobacco-specific nitrosamines, falls further still: roughly 91 percent lower in exclusive pouch users, with levels similar to those observed in former smokers who use no nicotine product at all. Here is the sentence politics, on its worst days, prefers to avoid: this is not “feeling” or a “hypothesis.” It is a fact.

This is not a promise printed on a package. It is the kind of story biomarkers tell: molecules that record exposure with the coldness of a lab report and, at times, with the quiet eloquence of a lie detector.

That is one of the keys to the review by Greek cardiologist Konstantinos Farsalinos, “Nicotine pouches: an aid in smoking cessation, or a new public health hazard?” (February 2026).

The axis of the argument is neither “trust the industry” nor “trust the panic.” It is a different imperative, less comfortable and more verifiable: observe what the body records when the smoke stops passing through it. At the same time, accept the gray zone, because biomarkers do not replace decades of epidemiology; at best, they light up the dashboard.

In the real world, this matters because smoking still exacts an obscene toll. Tobacco remains a machine of death on an industrial scale: more than eight million deaths each year, with a disproportionate burden that falls on low- and middle-income countries.

Decades of campaigns, laws, restrictions, and prohibitions were designed to squeeze both supply and demand. And yet a vast contingent of people remains who cannot—or do not wish to—stop consuming nicotine. It is in that gap between the ideal (“total abstinence”) and the real (life, with its shortcuts and relapses) that harm reduction enters not as a slogan but as a persistent tension.

The human body is a biochemical registry office: it stamps exposures. Some of those stamps are so specific to cigarette smoke that they approach testimonial evidence: was here, passed through, remained. The most famous bears a name that sounds lifted from science fiction: NNAL, shorthand for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol.

NNAL is a metabolite linked to tobacco-specific nitrosamines, particularly NNK, and it has a quality that makes it an inconvenient witness: it is slow to leave. Put simply, the body metabolizes NNK and produces NNAL, and it is this end product that keeps “signing in” long after the cigarette exits the stage. Its trace can be detected 6 to 12 weeks after exposure ceases, because its terminal half-life ranges from 10 to 18 days. In street terms, it is not fooled by an “I quit yesterday.” It is the chemical equivalent of the smell of smoke on a coat: you leave the room, but it stays, and gives you away for weeks.

When a smoker switches from cigarettes to a nicotine pouch, that “tobacco-free” product that, in some places, has become a trend and, in others, a moral panic or a regulatory problem, the body enters an involuntary experiment.

And the first results tend to appear where politics has the least reach (or the least patience): in the laboratory.

It is precisely this kind of data, which shows up in the lab before it shows up in statistics, that structures the central question of Dr. Farsalinos’s review, simple and incendiary: are we looking at a cessation and harm-reduction tool, or at a new public-health risk?

Biomarkers do not answer everything. But they address what most unsettles the debate: what does the body register when combustion is no longer in the equation?

The Body Rewritten: What Changes When Smoke Exits the Scene

The classic promise of tobacco control has always carried a certain moral elegance—heroic, even, in its simplicity: “quit.” But human biology rarely cooperates with such elegance. Dependence is a repeated pharmacology—routine, immediate relief, a daily negotiation with discomfort, and daily life. The review makes a clear and useful distinction: nicotine sustains the bond; combustion carries the damage.

The most direct way to see that difference is not to debate “toxins” in the abstract, wholesale sense, but to follow—almost in real time—the shifts inside the body when someone switches from cigarettes to pouches.

A cross-sectional study of exclusive pouch users (Velo) compared biomarkers of exposure—and some markers of “potential harm”—with those of smokers. The figure that unsettles intuition is NNAL: roughly 91 percent lower among pouch users than among smokers, with levels approaching those of former smokers who use no nicotine product at all.

But the “lie detector” does not reside in a single number; it lives in the coherence of the whole. In the same study, markers tied to classic smoke toxins move in concert: the acrolein signal (3-HPMA) drops by 78.8 percent; benzene (S-PMA), by 97.2 percent; and 1,3-butadiene (MHBMA), by 93.5 percent.

These figures do something the public debate rarely tolerates: they pull “harm reduction” out of the territory of slogan and place it on the cold, impersonal ruler of measurement.

But the story does not end with toxins. Among markers of potential harm, carboxyhemoglobin declines by 46 percent in pouch users; white blood cell counts fall by 19 percent; and fractional exhaled nitric oxide—suppressed in smokers because smoke alters the airway epithelium—rises by 107 percent, approaching the levels observed in non-smokers.

Here, uncomfortable honesty is required: this study was conducted by researchers affiliated with British American Tobacco. That does not make biomarkers “false,” nor does it make scientists pamphleteers—laboratories measure molecules, not motives—but it changes how the findings must be interpreted. It demands transparency, independent replication, and vigilance.

When the switch is tested under controlled conditions, the pattern returns, with greater discipline. In a randomized study, smokers who switched to pouches (on!®) for seven days had significantly lower total urinary NNAL (creatinine-adjusted) and 18 of 19 exposure biomarkers than those who continued smoking, with reductions ranging from approximately 42 to 96 percent. In magnitude, the review notes, these declines align with those observed in the short term under complete cessation.

Yes, that trial, too, carries political economy on its back cover: it was conducted by researchers affiliated with Altria. And here the paradox that public conversation often prefers to soften becomes unavoidable: the industry that helped feed the fire now wants to sell the extinguisher. That does not absolve anyone. But neither does it erase the biological fact that the markers repeatedly suggest: when combustion is removed from the equation, exposure to toxicants plummets.

There is a physiological reality that public policy will have to confront, even when moral revulsion would prefer to look away.

A third layer—perhaps the most “real-world” of all—comes from population data.

An analysis of the PATH Study (Wave 7, 2022–2023) finds that exclusive pouch users have high nicotine exposure but sharply reduced levels of minor tobacco alkaloids—anabasine and anatabine—94 percent and 97 percent lower, respectively—and lower lead levels than smokers. In a nationally representative dataset, the practical separation between “nicotine” and “smoke” begins to take statistical form.

If caution remains necessary, it serves to sharpen the question: not “is this good?” but “where, exactly, does combustion still leave its signature?”

If exclusive pouch users show such large declines in the canonical markers of smoke, the debate must abandon the convenience of treating everything as a variation on the same harm.

Where, then, would an “equivalent” harm to cigarettes reside, and through what mechanisms would it operate if smoke no longer passes through the body?

Farsalinos’s review does not sell the fantasy of zero risk. What it argues—with the caution of someone who knows “safe” is an expensive word—is that, along the continuum of toxicological risk, pouches tend to occupy the lowest end and may approach nicotine-replacement therapies. One condition, however, changes everything: the dominant pattern must be substitution, not the opening of a new pathway to initiation.

The Ghost of Combustion

Combustion is the invisible character in this story. The presence that never appears in the frame yet ruins the film. Nicotine explains why the smoker returns; combustion explains why he gets sick.

What biomarkers do, quietly, is separate these characters. COHb falls because carbon monoxide is produced by the act of burning and by drawing that burn into the lungs. NNAL falls because the chain of tobacco-specific nitrosamines is no longer fed by smoke. And markers linked to benzene, acrolein, and butadiene plunge because they belong to the world of fire, not to that of an oral matrix without combustion.

The review also underscores a practical detail: pouches deliver nicotine efficiently, generally more slowly than cigarettes, yet fast enough to compete with cravings. In harm reduction, the goal is almost never to purify behavior; it is to remove the fire from the mechanism, reduce suffering, and divert from greater harm.

Here, the review reaches for a bridge: the Swedish experience with snus as proof of concept. Not because snus and pouches are identical, but because they share what matters for this story: oral use, nicotine absorbed through the mucosa, and the absence of smoke passing through the lungs.

Farsalinos crosses that bridge through a “worst-case” argument: if snus, which still contains tobacco, has not been associated with lung cancer and does not exhibit the respiratory-damage pattern typical of cigarettes, then a derivative product without processed tobacco leaf, with far lower levels of harmful constituents, appears plausibly even less risky.

“Plausible,” here, is a scientific term: it asks not for faith, but for confirmation.

But bridges develop cracks. And it is in those cracks—not in the span itself—that public policy tends to lose its footing.

What We Still Don’t Know

Two nearly symmetrical errors circle this debate. The marketing error is to turn biomarkers into a seal of “safety.” The panic error is to treat the absence of twenty years of epidemiology as if it nullified, by decree, robust evidence of reduced exposure.

“Biomarkers are powerful, but they are surrogates: they measure the pathway of harm, not the final outcome.” Lowering NNAL does not “prove” that cancer rates will decline decades from now. Yet, from a biological standpoint, it is difficult to argue that large, sustained reductions in exposure would not, over time, alter risk, as one toxicologist who requested anonymity told me.

Scientific honesty resides in gray zones. And here, those zones have names. Long-term epidemiology does not yet exist for pouches because the category is new, and the review calls for research and surveillance. Local effects and oral health: reports of irritation and lesions exist; long-term studies and well-designed comparisons remain limited. At the same time, technical refinements are emerging with increasingly strong supportive evidence—such as Stingfree—awaiting less proof than broader acceptance, large-scale replication, and investment. Dose and standardization: labeling, additives and flavors, and maximum nicotine limits remain rough terrain for regulators.

And then there is the herd of moral elephants in the room: addiction, dependence, habit, need, and pleasure.

Biomarkers do not measure autonomy; they measure molecules. A world with less combustion may, at the same time, be one with more people using nicotine, and that unsettles the debate because it shifts the frame from “absolute evil” to the slipperier ground of “relative harm.”

The review attempts to frame that tension as a public health equation: benefit when use reflects substitution and cessation, versus potential harm when uptake shifts to non-smokers—especially young people—and the still-disputed, never conclusively demonstrated hypothesis of a “gateway” effect.

Youth data, for example, is an alarm that should never be silenced. In the United States, the CDC estimated a 1.8 percent current-use rate of nicotine pouches among middle and high school students in 2024, with a meaningful share reporting frequent or daily use.

That does not prove a gateway to cigarettes—it may even point in the opposite direction—but it proves something simpler, perhaps older: nicotine has always found ways to circulate, adapting to the times by changing containers, rituals, and language. What changes now is not the human impulse, but how it is packaged, marketed, and diffused.

At the same time, regulators are signaling how they intend to treat the category. In January 2025, the FDA authorized the marketing of twenty ZYN products through the PMTA pathway, the first such authorization for nicotine pouches, according to the agency.

This enters the global storyline: countries will oscillate between prohibition and permission, taxation and tolerance, nicotine caps and flavor restrictions. And each decision rearranges the “dopamine market”: who enters, who exits, and who migrates between products, in ways biomarkers alone cannot see.

The Lie Detector of the Public Debate

Why do these kinds of findings so rarely make headlines with the force they might? Because nicotine is a political object. It carries the stigma of tobacco and the muscle memory of decades of industrial deception.

In the public imagination, “nicotine” and “cigarette” have become moral synonyms. But the body does not work with synonyms; it works with metabolic pathways, combustion byproducts, nitrosamines, and COHb.

Biomarkers function as lie detectors precisely because they do not participate in cultural theater. They sign no manifestos, neither for harm reduction nor for condemnation. They record. And so far, the record has been stubbornly consistent: when combustion disappears, the markers associated with smoke decline significantly.

At the same time, public distrust is not gratuitous; it has a history. And it has a present: the fear that discreet, palatable, potent products may expand the consumer base along the same track that ultimately leads to disease. This is the point at which science and politics face one another without recognition: one measures molecules; the other attempts to anticipate mass behavior.

Here is where Farsalinos’s review proves more useful to a reporter than to a pamphleteer: it does not resolve the moral dilemma. It shifts the terrain to where the evidence is hardest to assess: exposure. And it suggests that public impact will depend less on “basic chemistry” than on the social architecture of use: full substitution versus dual use; adult smokers versus curious adolescents; clear labeling versus confusion.

The human body is an implacable archivist. It keeps traces of what has passed through it, of what irritated what did not need to be irritated, of what ignited inflammation without necessity.

When a smoker switches from cigarettes to a pouch, that archive does not become a certificate of virtue; it begins to be rewritten in measurable terms, not as moral redemption but as a change in exposure.

The lie detector absolves no one. But neither does it allow combustion to masquerade as opinion.

• Farsalinos, K. Nicotine pouches: an aid in smoking cessation, or a new public health hazard?. Intern Emerg Med (2026). https://doi.org/10.1007/s11739-026-04278-1

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In empirical science, these choices are referred to by other names, such as variables, samples, specifications, and models, but they perform the same function. They decide how the world becomes legible as evidence.

“Ideological bias in the production of research findings,” a paper published in Science Advances, argues that in politically charged subjects, preferences (what researchers, in more technical language, call priors and expectations) can latch onto decisions that, from the outside, look like mere matters of craft: how a concept is operationalized, which cases make it into the sample, which controls are deemed necessary, and which family of models comes to feel “appropriate.”

And through that path, different empirical results can emerge from the same dataset, without fraud, without invented numbers, without anyone stepping outside what the discipline itself would call a defensible method.

Friction is not necessarily a matter of scientific integrity. It is a matter of process: the sequence of legitimate choices that turns a dataset into “evidence” and sometimes turns evidence into a mirror.

The study reanalyzes a collaborative experiment known as BRW, in which independent teams were given the same dataset and the same question. Its conclusion is unsettling because it shifts attention away from the result and onto the path.

Ideology doesn’t appear only as an interpretive gloss at the end of a paper; it can enter earlier, in the engineering of analysis in what is measured and named a variable, in what is controlled (and why), in what is excluded as “noise,” in what comes to count as the right model.

It is there, in that chain of defensible choices, that a common base begins to yield divergent findings.

So what does it mean to “produce evidence” in a world saturated with biases, algorithms, beliefs, and narrative disputes that compete for attention as if oxygen were scarce?

If every study entails choices, the urgent question may not be whether bias exists, but how it organizes itself; what methodological, institutional, and rhetorical filters make some results seem more robust, more publishable, more citable, and therefore more real than others. In other words: not only what the statue “shows,” but which photographs of it we learn to call evidence.

Before the First Regression

In photography, the difference between two images often says less about the statue than about the photographer’s hand and eye on the camera. One lens pulls you closer and flattens the background; another widens the field and bends the edges. One frame focuses on a detail of the protagonist; another allows the context to dissolve into the periphery. The rest falls into shadow. None of this implies deceit; it implies choice. And choices, even when defensible, have consequences.

In science, the gesture is similar. A dataset, like the statue, doesn’t offer a single angle; it opens a constellation of defensible paths: how to measure a concept, which units make it into the sample, which controls count as pertinent, which family of models comes to feel most appropriate.

What Borjas and Breznau do is make that path visible under rare, quasi-laboratory conditions: a large collaborative experiment in which independent teams answer the same question using the same data.

In the reanalysis published on January 1, 2026, George J. Borjas and Nate Breznau return to BRW, which placed 71 teams (158 researchers) before the same dataset and the same question: Does immigration affect public support for social programs and the welfare state?

The teams worked independently, without coordinating with one another. After reproducing an earlier result, they were invited to extend the analysis “in whatever way they thought best,” with broad latitude to define variables, samples, operationalizations, and models.

The raw material was the same: five waves of the ISSP (International Social Survey Programme), from 1985 to 2016, with updated measures of immigration. But the path to evidence was left open like a square where the statue is singular, and the viewpoints are, inevitably, plural.

Before the first regression, before the spreadsheet could even begin to “answer,” participants were asked to state their starting point: in the country where they lived, should immigration laws be tightened or relaxed?

The metascientific question then ceases to be just a curiosity and becomes a mechanism: do these prior positions align with the results each team produces? And if they do, through which intermediate choices, through which samples, controls, and operationalizations does that alignment become evidence?

The study suggests that this association doesn’t appear as “opinion” pasted onto the footnote of interpretation. It appears to be a regularity in the architecture of design: teams with different priors tend to adopt different combinations of methodological decisions, each defensible in isolation, that, taken together, bias the estimate in one direction or another.

It isn’t that “the data change.” It’s that the path deemed acceptable for reading them changes, and with it, the kind of result that reaches the reader.

A second metaphor clarifies why this matters. Think of map projections: the planet is the same, but each projection (Mercator, Gall–Peters, others) redistributes it, distorting areas, compressing shapes, deciding what looks “large” and what looks “peripheral.”

If someone insists there is “no distortion” because they statistically controlled for the projection, they may be making precisely the error Borjas and Breznau identify in the BRW debate: treating as mere noise what is, in fact, part of the mechanism.

Specification choices are not an external “adjustment” to the result. They are endogenous to the process. They compose the path through which evidence is produced.

This discussion doesn’t call for cynicism; it calls for light. When the path is hidden, a single “click”, a modeling choice, a sampling decision, a package of controls, can acquire the aura of universal evidence.

When the path is shown, the alternatives considered, specification curves, and reanalyses by different teams are presented, science moves closer to what it promises to be: not a definitive portrait of the world, but a public method for turning disagreement into measurement and reducing uncertainty step by step.

When Seventy-One Teams Answer the Same Question —and Disagree

BRW was built to expose that distance: what happens when many competent hands take the same data and follow it down different paths. In BRW, the “statue in the square” is almost literal: the same dataset, handed to dozens of teams, with the same analytical brief.

The experiment was designed to shed light on what the published paper typically leaves in the shadows: the distance between data and conclusion, the zone where routine choices begin to determine what will be called a result.

In science, that zone goes by technical names—operationalization, sampling, specification, and model—but its function is old and human: to turn the world into evidence.

This is the material George J. Borjas and Nate Breznau return to in their January 2026 paper in Science Advances. The question—thorny, and unmistakably contemporary—is easy to phrase and hard to face: can researchers’ preferences and priors be associated with the kind of estimate that reaches the reader even when there is no fraud, no gross error, no visible hand bending the number?

To observe that mechanism from the inside, they rely on a rare opportunity: BRW, in which 71 teams (158 researchers) received the same data and the same hypothesis to test whether immigration reduces public support for the policies that constitute the welfare state.

The teams worked independently, with wide latitude to decide how the world would be represented in the model: how to measure concepts, which countries and survey waves to include, which controls to adopt, and what statistical structure to use. In short, how to choose the “design of the photo.”

Before any modeling, participants recorded their stance on immigration policy in their country of residence: whether immigration laws should be tightened or relaxed.

At first glance, it appears to be a side variable, almost a demographic detail. In Borjas and Breznau’s design, it becomes a key for mapping a pattern more unsettling than the psychology of any single team: not what someone “wanted” to prove, but how prior beliefs can line up with final specification choices. The point at which the technical path tilts the estimate before it becomes a public conclusion.

The result is an analytical multiverse. As the teams extended the analysis, they estimated 1,253 regression models, which BRW translated into a common metric: the AME (Average Marginal Effect), the change in the probability of supporting social policies associated with a one–percentage-point increase in the share of immigrants.

Instead of a single number, a distribution emerged. The AMEs cluster around zero, but they don’t end there; the spread includes numerically large and statistically significant values.

At the extremes, the paper itself gives a sense of scale: the 10th percentile is −0.071 and the 90th is 0.052—which, in the language of public debate, means that a shift from 10% to 11% in the share of immigrants could be associated with something like a seven-point drop or a five-point rise in support for social programs, depending on the analytical path chosen.

But the study’s most provocative point isn’t merely that the estimates vary. It’s the shape of that variation, the pattern that emerges when you look at the whole constellation rather than a single, isolated star.

Where the Results Tilt

Variation alone isn’t the story. The question is whether the variation has a signature: whether it aligns, in a repeatable way, with something the researchers brought with them before they opened the spreadsheet.

The central finding is straightforward: researchers’ ideological positions were systematically associated with the direction of the estimates. Teams composed of more pro-immigration participants tended to report more positive effects of immigration on support for social programs, whereas anti-immigration teams reported more negative effects.

What makes this association intellectually unsettling and journalistically combustible is its manner of occurrence. The authors argue that the difference arises because teams adopt different specifications and follow different paths within what the discipline still recognizes as a defensible method.

The most important and intellectually honest note is negative: the paper does not need to posit bad faith to explain the phenomenon. What it describes is a subtler mechanism, and therefore a harder one to police. Ideology does not appear only in the final paragraph, when a coefficient is “interpreted”; it can slip in earlier, in the design of the analysis itself: how immigration is measured, which countries and survey waves are included, and what statistical structure is adopted.

“In sum: research design is endogenous,” the authors write: design is part of the process, not external noise. It is through that channel, through choices that look merely technical, that prior beliefs can align with the kind of result that reaches the reader.

There is a decisive limit, one that the authors themselves emphasize: the experiment captures the final specification, not the full path that led to it.

The data do not allow us to observe how many alternatives each team tested, when it abandoned one path for another, or why; the garden of forking paths of empirical work, where hypotheses branch and some versions of the world die quietly. Nor can we determine whether researchers, consciously or unconsciously, gravitated toward models more compatible with their preferred conclusions, a question the paper deems crucial and one the BRW design cannot address.

What they can show, given the available data, is an association: final specification decisions correlate with ideological priors measured before any analysis, in the first wave of the questionnaire. That supports the thesis of bias-by-path, but it does not license strong causal inference (ideology was not randomized as a treatment).

To make this path less abstract, Borjas and Breznau perform a surgical cut. From a universe of 103 specification decisions recorded in BRW, they single out five crossroads. Choices that, in combination, explain much of how the same dataset can generate estimates that contradict one another without anyone “forcing” anything.

1. How to scale the outcome: Do responses about different government responsibilities (health care, housing, unemployment, etc.) become a composite index (by averaging or factor analysis), or remain as separate items?

2. How to measure immigration: as stock (% foreign-born/foreign nationals) or as flow (net migration)?

3. What statistical structure to use: whether or not to use multilevel modeling to capture variation in country–year units.

4. Which countries to include: all available countries in the dataset, or a subset.

5. Which survey waves to include: whether to include the 2016 wave—beyond the waves anchoring the original analysis—and thereby shift the historical window being observed.

In combination, these five decisions generate 58 “non-empty” alternative specifications. An atlas of possible paths to the same question.

The point is not that any one choice, in isolation, “determines” the result. The authors insist on the plural: what matters are combinations, second-order interactions, and paths that make sense only once decisions lock into one another.

When Borjas and Breznau compress this space into a comparable set of recurring specifications, 58 “non-empty” paths are ranked by the expected AME (the mean of the AMEs within each specification), and the pattern appears. Anti-immigration teams were the only ones to adopt the combinations that produce the smallest expected effects; pro-immigration teams, the only ones to use those that produce the largest.

And this five-decision package, taken together, explains a substantive share of the distance between the extremes: about 68% of the average gap between pro- and anti-immigration teams in the experiment, according to their decomposition between “observed” AME and “expected” AME.

The Numbers That Travel

Not every estimate has the same afterlife. In public debate, the center of the distribution rarely gets the microphone; the edges do. Estimates cluster near zero. But they don’t end there. Borjas and Breznau describe a landscape in which the histogram clings to the null and still yields numerically large, statistically significant results at the extremes.

In percentile terms, the contrast is almost pedagogical: the 10th percentile is −0.071, and the 90th is 0.052. In the language of public debate, this suggests that a shift from 10% to 11% in the share of immigrants could be associated with a seven-point drop or a five-point rise in support for social programs, depending on the analytical path taken.

This is where the tails matter. Not because they represent the majority, but because they are legible, publishable, politically reusable. Two antagonistic readings can be drawn from the same dataset, and both can sit, with some comfort, inside the universe of plausible choices the experiment makes visible.

The invitation, here, is to treat the tails as a social phenomenon, not merely a statistical one. Extreme results travel better: they become headlines, slogans, policy “evidence” with a speed the null effect, shy, conditional, thick with footnotes, rarely achieves.

The paper does not measure headlines. But it measures something that feeds them: the production of extremes is not randomly distributed across teams. In models that ask who ends up in the tails with large, significant effects, anti-immigration teams are less likely to appear in the positive tail, while pro-immigration teams are less likely to appear in the negative tail; the odds of landing in a tail aligned with one’s orientation differ substantively across groups.

Hence, a sentence that should unsettle any hurried reader: given that all teams began by replicating the same null reference result, the most ideological teams tend to move away from it, adopting specifications that push the estimate toward one extreme or the other. Toward the kind of number that crosses, more easily, the border between academia and public argument.

The implication is double, and uncomfortable at both ends.

First: even a science conducted through technically defensible choices can inadvertently become a vector of polarization when different analytical paths generate “ammunition” in opposite directions, each stamped with methodological plausibility.

Second, the study underscores the need for infrastructures of transparency that can reveal the full distribution, not only the most photogenic spikes, the easiest results to circulate, so that public debate does not mistake the tail for the rule.

And if this is what happens under quasi-laboratory conditions, it’s worth asking what the same mechanism does in the open air, where incentives, institutions, and moral stakes are louder.

A Stress Test Outside the Lab

From here, the piece shifts terrain. We are no longer within Borjas and Breznau’s study, nor within its immediate object: immigration and the welfare state.

What follows is an editorial extrapolation: applying the mechanism they describe—the idea that legitimate design choices, compounded by institutional filters, can steer what circulates as “evidence”—to an analogous, highly politicized domain. This is not a substitute for reporting. Any specific claim here would require its own legwork: independent sources and point-by-point verification.

If metascience insists that data do not speak for themselves, what remains is a political question in the broad sense: who is authorized to speak for them, and under what rules does that speech become valid?

Tobacco control, science, public health, and industry meet on ground where the dispute is rarely limited to toxicology or epidemiology. It also intersects with moral grammars and political and economic ends: abstinence as the sole regulatory ideal, or harm reduction as a pragmatic strategy for those who cannot—or do not wish to—quit entirely.

In this environment, “method” and “moral” often intersect. Not because one side invents science, but because science is always filtered through the rules of passage.

Evidentiary standards, publication norms, outcome priorities, and the language of guidelines themselves can operate as gates: they determine which questions enter the agenda, which comparisons seem acceptable, which risks become tolerable, and which are treated as politically unassimilable.

The literature on non-combustible nicotine products puts this tension in sharp relief.

On one side, studies suggest that for smokers who move from cigarettes to devices such as vaping, exposure to certain toxic substances tends to be lower than under tobacco combustion, and that for some users these products can function as tools for cessation or substitution.

On the other side, none of this amounts to innocence. These products are not risk-free, and use by non-smokers, especially very young people, is treated by many policymakers as a public-health crisis: a reopened gateway and a normalization of nicotine.

Some countries—the United Kingdom is often cited as the leading example—have taken a relatively more pragmatic stance, incorporating such devices into cessation repertoires, with caveats and a focus on adult smokers.

In some multilateral forums, the tone tends to be more cautious. Alongside calls for draconian regulation, these bodies warn of a risk less chemical than rhetorical: narrative capture, when the language of “harm reduction” becomes an instrument of commercial strategy, with possible side effects such as the initiation of new users and the erosion of controls.

In some regulatory debates, concern has also drifted toward non-combustible products that are less conspicuous than vaping: nicotine pouches—small sachets of nicotine—are frequently raised as a point of worry, particularly because of high concentrations and their perceived appeal among adolescents.

The case of snus—and, by extension, oral nicotine products—functions as a laboratory of controversy. Sweden is often cited for historically low smoking prevalence in certain strata and for enviable indicators linked to the burden of mortality and disease attributed to cigarettes.

Part of the literature reads this picture as, at least in part, an effect of substitution: less combustion, more nicotine in oral forms. At the same time, the ground is contested. Critics point to the risk of simplifying narratives, conflicts of interest, and hasty extrapolations from one national context to others.

And the clinical literature is not a single block: for many researchers, some outcomes, especially cardiovascular and population-level ones, remain surrounded by uncertainty, methodological heterogeneity, and interpretive dispute.

The point here is not to arbitrate a winner. It is to watch the mechanism.

Before it becomes consensus, evidence passes through filters: editorial rules, guideline committees, norms about what counts as a “good question,” reputational barriers, legitimate fears of regulatory capture, real conflicts of interest, and, beneath it all, societal values about what a society decides to tolerate.

In fields like this, the mirror doesn’t merely distort. At times, it legislates: it decides which reflections are allowed to exist.

When Controls Swallow the Mechanism

If this is what the mechanism looks like in the open air, what happens when the debate returns to the lab, where reassurance can come in the form of a regression, and where “controlling for everything” may end up controlling away the very channel at issue?

Borjas and Breznau’s paper doesn’t merely reexamine a rare trove of evidence; it also challenges BRW’s more soothing reading of its own experiment. In the original study, the organizers concluded that “researcher characteristics do not explain outcome variance”; that is, researchers’ characteristics did not account for the variation in results.

Borjas and Breznau argue that this peace is illusory. It may be purchased at the price of a classic statistical move—controlling for almost everything—which, in this setting, risks controlling away the very mechanism producing the divergence.

Their reanalysis identifies a substantive reason for the disagreement.

BRW privileged a kitchen-sink strategy: it regressed each team’s final estimate (the effect of immigration on an indicator of “social cohesion,” operationalized as support for social policies) on ideology, along with a broad vector of controls that included, among other things, descriptors of the team’s own specification (for instance, logit versus OLS; the inclusion of country and year fixed effects). In that expanded setup, the coefficient for ideology was not statistically significant.

Here is the critique that changes the game: if modeling choices are endogenous, if they are part of the mechanism by which beliefs and priors become estimates, then “controlling” for those choices may mean controlling the very channel through which ideology operates.

This is not a technical quibble; it is a causal inversion. That is why, they write, their result conflicts with BRW’s: the reanalysis “takes into account the possibility that variables that indicate design choices are endogenous to the process.” Put differently, when a kitchen-sink regression throws specification descriptors into the bundle, it risks neutralizing what it set out to test because “the variables that indicate aspects of the specification are endogenous and are the mechanism by which ideology influences the estimates.”

Intuitively, a kitchen-sink regression can be useful for describing how much variation is associated with a broad bundle of observable features. But when some of those “controls” are not noise—when they are the mechanism itself—the model can erase the effect it is meant to detect.

In the language of causal inference (offered here as an editorial translation, not as the paper’s own label), this is the classic mistake of controlling for a mediator: you neutralize the channel, and then conclude the channel never existed.

The implication is epistemological.

If bias in the weak sense—inclinations, intuitions, priorities—can be inscribed in the decisions between data and model, then “who controls what” stops being a technical detail and becomes an architecture of knowledge.

At the same time, the authors underscore a limitation inherent in what BRW can show: the experiment records the final specification, not the full workflow. We do not know how many alternatives were tried, when and why certain routes were abandoned, or whether researchers, “consciously or unconsciously,” gravitated toward models that supported preferred conclusions.

What remains observable, with some confidence, is a temporally ordered association: final specification choices correlate with ideological priors measured before any analysis, in the first wave of the questionnaire, and it is this fit (not proof of intention) that sustains the bias-by-path hypothesis.

Between Method and World

Once the possibility of “controlling away” the channel is on the table, the argument ceases to be a dispute over models and becomes a dispute over what evidence is and what we ask it to do.

There is something deeply unsettling about Borjas and Breznau’s reanalysis, not because it uncovers scientific misconduct, but precisely because it doesn’t need to. What it puts on stage is more disturbing: the possibility that legitimate, technical, defensible decisions can produce distinct analytical worlds, and that part of this divergence aligns, systematically, with prior beliefs about the subject.

The paper itself, however, taps the brakes. Ideology was not a randomized “treatment”; it was a measured characteristic across a moderate number of teams, which limits the strength of causal inference.

In other words, the study does not claim, with the rigidity of a classic experiment, that “ideology causes X.” It shows a persistent association between priors and the choices that culminate in estimates, and it acknowledges uncertainty, including wide confidence intervals.

Still, the finding returns empirical science—especially in politically sensitive topics—to a stubborn tension: data do not speak for themselves. Not because “anything goes,” but because there is a labyrinth of plausible choices between the spreadsheet and the result. And if research design is endogenous, that labyrinth is not neutral: the final specification can correlate with beliefs that predate the analysis.

Here, metascience ceases to be a debate about robustness and becomes a debate about process. The authors themselves acknowledge a decisive gap: the experiment does not record the full path. It does not indicate how many alternatives were tried and discarded, when they were tried, or why. Hence, the agenda they gesture toward: observing and documenting workflows tracking the garden of forking paths that still remains, largely, outside the published paper.

There is another uncomfortable detail in any discussion of what counts as “valid evidence.” Within the experiment, each modeling strategy underwent randomized, double-blind peer review, yielding a referee score for each model.

Under that filter, moderate teams earned the highest mean score (0.35), above anti-immigration teams (0.03) and pro-immigration teams (−0.33). This doesn’t decide who is “right.” The authors themselves warn that the run-of-the-mill may be merely the most comfortable, not necessarily the most true. But it does suggest something structural: filters of quality—or of conventionality—also participate in selecting what rises to the status of an “acceptable” result, especially when “non-traditional” choices produce outliers and are, for that reason, penalized in peer judgment.

None of this has to curdle into cynicism. The authors insist on an exit that is, at once, more laborious and more honest: treating robustness as aggregated evidence, not as an anointed coefficient.

To that end, they run an “agnostic” robustness test: they estimate the effect of ideology across 883 models, covering all combinations of specifications used in the main tables and supplementary material, and display a specification curve.

The result is eloquent in scale: ideology appears with a statistically significant effect (P < 0.10) in 88.2% of models, a share that rises to 92.4% when models potentially affected by omitted-variable bias are excluded (those that do not include disciplinary fixed effects).

In other words, the association between ideological position and the estimate produced does not hinge on a single way of modeling, nor on a particular sampling choice that could be dismissed as a special case.

As the authors traverse the multiverse of specifications—swapping, combining, recombining defensible decisions—the signal returns along the overwhelming majority of paths: you change the lens, you change the frame, you change the bundle of controls, and ideology still shows up as a factor associated with the result.

And when a subset of models more vulnerable to distortion by omission is removed, the pattern becomes more frequent, suggesting, in plain terms, that this is not a fragile artifact of specification, but a feature that persists precisely when the test becomes more demanding.

After hundreds of models and a curve that refuses to settle into a single story, the argument widens. It’s no longer only about robustness; it’s about who gets to see the path, and who benefits when it stays hidden.

The Mirror, the Angle, and the Invisible Reader

Ultimately, Borjas and Breznau’s reanalysis may say less about immigration and social policy than about the nature of scientific evidence in charged domains. Those in which empirical reality arrives at the lab are already accompanied by dispute.

It suggests that “statistical truth,” like an image in a curved mirror, shifts with the angle of the viewer—or, more precisely, with the sequence of choices that determine what will be measured, compared, controlled, and published.

And there is a third vertex, almost always outside the frame: the invisible reader (the institution, the newsroom, the court of public opinion) for whom certain images circulate more easily than others.

There are no heretics in this story.

Each team adhered to established protocols, applied methods taught in graduate programs, and used tools accepted by disciplinary tradition. The problem is not bad faith; it is the invisibility of the route: the decisions that don’t fit in the final paper, the models tried and abandoned, the alternatives that disappear without leaving a trace, and that, taken together, determine what the reader will receive as evidence.

Like a newsroom in which everyone is handed the same raw material but only one story makes the cover, scientific production is also a process of selection and disappearance. Some forks close without a sound; others, through repetition and reputation, become the norm. What remains, the final coefficient, the “clean” figure, the number that becomes an argument, is only one among many possible versions of the same world.

So the challenge ahead may not be to insulate science from bias—an impossible task—but to build institutions capable of living with it without naturalizing it.

That calls for less fetishizing of neutrality and more transparency about choices; less idolatry of a single result and more attention to distributions; less worship of the closed paper and more openness of process.

If there is an antidote—one I learned from Borjas and Breznau—it doesn’t look like censorship, but like its opposite: pluralism.

More teams, more angles, more models, more cross-examination, not to turn every conclusion into opinion, but to make the route visible, light up the forks, and reduce the quiet power of a single tilted mirror.

• Borjas, G. J., & Breznau, N. (2026). Ideological bias in the production of research findings. Science Advances, 12(1), eadz7173. https://doi.org/10.1126/sciadv.adz7173

About the Researchers:

George J. Borjas is affiliated with the Harvard Kennedy School and the National Bureau of Economic Research (NBER).

Nate Breznau is affiliated with the German Institute for Adult Education—the Leibniz Centre for Lifelong Learning in Bonn (Department of Organization and Program Planning).

An Annotated Interview / Backstage Notebook

In the Multiverse’s Editing Room, with Borjas and Breznau

On the screen, science looks like a calm object. A specification curve, a row of models, arranges chaos into something like a landscape. From a distance, it’s easy to believe the debate is about numbers. But in my exchange with Borjas and Breznau on February 6, the subject kept returning to the same place: before the number, there is a path. And that path is where evidence acquires direction.

I. Endogeneity of Design: Unconscious or Deliberate?

I began with the phrase that, in their paper, works like a hinge: endogeneity of design. Is this process mostly unconscious—the researcher’s quiet drift—or is there room for more deliberate (yet still legitimate) alignments between theoretical expectations and modeling choices?

They didn’t answer with psychology. They answered with architecture:

“The process of conducting empirical research has many steps: How to frame the question? Which data to analyze? How to measure the variables to be used? Which methodological technique to use? And so on.

Each of these decisions opens a fork in the road, and the combination of all the different decisions leads to very specific results that differ from what would have been obtained with another set of decisions.

Everyone who does empirical research knows this and ‘sees’ the specific impact of a set of decisions during the research process.

Unfortunately, the decisions can be manipulated by someone who wishes to reach a particular endpoint. That is why it is extremely important for the researcher to be totally transparent in what research design choices were made.”

Here, transparency doesn’t read as a decorative virtue; it reads as an institutional counterweight to a banal, explosive fact: there are many plausible routes, and some routes make the world look like something else.

II. Learning What “Pushes” Results

The next question presses on a more delicate point: in contexts of high analytical flexibility, do researchers inevitably learn which decisions “push” results in one direction or another?

Their reply arrives without padding:

“If, during the research process, a researcher does not learn that certain research design choices tend to push results in a particular direction, that researcher is not very competent to begin with.”

It’s a sentence that invites slow reading. It doesn’t merely say that learning is inevitable; it defines competence as the ability to see, in real time, what choices do to the estimate.

The problem, then, is not discovering that choices tilt outcomes. It’s what one does with that discovery, and how much of it stays outside the final paper, invisible to the reader who receives the coefficient already cleaned up, already edited, already converted into a conclusion.

III. Ideological Asymmetry: A Dominant Bias in the Social Sciences?

BRW’s ideological asymmetry—few anti-immigration teams—raises a question that is hard to keep purely technical. Does it suggest a dominant ideological bias in certain fields?

They answer with a conjecture anchored in an American backdrop:

“Given the widely publicized data in the US of how nearly all the money donated to political parties by faculty in universities goes in a single direction (left), it is difficult to dispute the conjecture that ‘social sciences today operate under a dominant ideological bias’.”

Editorial cut: they call it a conjecture, not a result of the experiment. But the line carries an infrastructural implication: if a field is asymmetric, then the plurality of routes (and of questions) may be filtered from the start, not only by method, but by the sociology of who gets into the lab.

IV. An Epistemological Problem—or a Sociological One?

If the asymmetry is real, I ask, what is it an epistemological problem in itself, or a reflection of the scientific community’s composition?

They step back into terrain where metascience still lacks a firm footing:

“We don’t know.”

Then a hypothesis:

“There’s probably a lot of ‘ideological bias’ in faculty hiring in universities.”

And from there, a research agenda:

“We need more research into how ideology shapes the entire research process from epistemology through methods onto results.”

The arc is clear: from recruitment to method, from method to result, a whole chain of selection in which what we call “evidence” is also an institutional photograph of what was permitted to be asked.

V. Tails, Extremes, and Polarization

When the conversation returns to the tails, the extreme, statistically significant results that travel most easily into policy and public argument, I ask what this does to polarization.

The answer comes as an avowed prior:

“Our prior is always to be skeptical of evidence in highly contentious and politicized fields.”

Then the critique shifts from the dataset to the ecosystem:

“Unfortunately, the hiring process in universities and the peer review process are also contaminated by ideological bias, so what one gets to read is already heavily filtered.”

And then comes the line that lands with the force of an accusation, even if it’s offered as a diagnosis:

“So it would not be too far-fetched to say that a lot of the distrust in science has probably been ‘earned’ through the years of scientists selling results that might have been manipulated to reach specific conclusions.”

Editorial cut: the paper measures associations and patterns; here, the conversation brushes up against public trust and the way a “result” becomes a political commodity. The line is not a statistic. It is a moral reading of an ecosystem of filters.

VI. Mitigating Selective Circulation—Without Censorship

If extremes travel, can anything be done about selective circulation without sliding into censorship or neutralizing dissent?

They don’t offer a simple solution, but they point in a direction:

“Although we don’t see a simple solution, we would say that the answer (if it exists) is exactly the opposite of censorship. Let a question be analyzed by many researchers from many different angles.”

Pluralism as an antidote, not to say that “anything goes,” but to insist that when there are many plausible routes, intellectual honesty is not choosing one and pretending the others never existed; it is making the forks visible.

VII. If Many Results Are Possible, Does Replicability Collapse?

If “the” empirical result is only one realization among many, does the classical ideal of replicability fall apart?

They resist the clean answer:

“We don’t know.”

But an ethos appears:

“But the scientific method involves checking and re-checking results, and paying attention to robustness.”

And with it, a criterion for discomfort:

“If there are many results in many different directions, then we either have no clear effect of something, or we need to do more work to identify the correct test.”

Replicability, here, isn’t a stamp. It’s repeated labor, and a diagnosis: either the effect isn’t there, or the test has not yet found its proper form.

VIII. Controlled Pluralism: Multiverses, Curves, Radical Transparency?

Instead of replication in the strict sense, should the field move toward controlled pluralism, multiverse analyses, specification curves, and radical transparency?

They don’t pick a side. They pick both:

“Both. We should perform replication and reanalyses—where we adjust previous models.”

This isn’t methodological fashion; it’s discipline: replicate and reanalyze and, in reanalysis, adjust earlier models, making choices and consequences explicit.

IX. Does This Apply to Public Health—Nicotine, Tobacco, Drugs?

I push the mechanism outside the lab and into domains where method and moral judgment knot together —public health, tobacco control, drug policy, etc. Is this a special case?

They refuse the comfort of the exception:

“Show me a field of science where evidence and moral judgments do not intertwine. This is not a problem unique to any one area.”

If the entanglement is structural, then the question isn’t where it happens, but under what rules it is governed.

X. When the Risk Is Epistemic Hegemony—Without Falling into Relativism

Finally, I ask whether, in areas of strong institutional consensus, the main risk may not be individual bias but the epistemic hegemony of certain frameworks, and how science can address that without sliding into relativism.

The answer ends at a limit:

“No idea.”

That last sentence functions like a window. It suggests that when the conversation reaches its hardest point—not the ideology of individuals but the hegemony of structures—the language we have remains insufficient.

The paper measures what it can measure. The interview, at times, brushes up against what we do not yet even know how to ask.

And that is where this notebook finds its purpose: to show that behind every coefficient there is a system of choices; behind every choice, a set of filters; and behind the filters, an invisible reader: the institution, the editor, the guideline, public policy, us; waiting for the number that travels best.

Editor’s note: Quotations have been lightly edited for spelling and punctuation, with wording and meaning otherwise preserved. Illustrations by GR.