Part III — What To Do With the Smoke (or With Ourselves)

After decades of war on tobacco, perhaps the next frontier of public health lies not in purity — but in proportion.

From a realistic, bioethical standpoint, there are at least six moves that can help nations and health systems confront nicotine without reproducing moral panic. This is not about absolving a molecule, but about reducing harm while preserving autonomy, equity, and truth.

1. Separate nicotine from tobacco, vapor from smoke, combustion from non-combustion.

• In every official communication, the distinction must be explicit. Tell the whole truth: vaporizing or heating tobacco is not without risk, but its harm is a fraction of that caused by smoke. Transparency does not legitimize youth marketing; it empowers informed clinical decisions. Bioethics begins with language: to name precisely is to care honestly.

2. Treat children and adolescents as the highest legal and ethical good — not as scarecrows.

• Regulate advertising and influencer activities, product design, and point-of-sale licensing, and enforce strict age verification. And at the same time, facilitate access for adult smokers, steering their use toward less harmful alternatives.

• The goal is not to spark moral panic, but to organize availability and appeal. The finding that teenagers are nine times more likely than adults to vape should translate into policy, not hysteria.

• Prevention is an act of care, not of fear.

3. Cessation without puritanism.

• Integrate e-cigarettes, nicotine pouches, heated tobacco, and nicotine replacement therapies into treatment lines for highly dependent smokers. The more options, the better.

• Utilize clear, flexible clinical protocols that are based on dialogue, gradual reduction goals, and biomarker monitoring. Each 1% increase in cessation saves thousands of lives and millions in costs.

• Protecting youth does not require punishing adults.

• The ethics of care allows for gradations: not every step forward has to be pure to be good.

4. Tax with technique and conscience.

• Keep taxes high on combustible products, but design fiscal structures that don’t push dependents toward the illegal market. Non-combustible products should always be more accessible.

• Regulate price without ignoring social context.

• Invest the bulk of the revenue in free cessation services, independent scientific research, and clear, evidence-based education.

• A tax without purpose is punishment; a tax with purpose is public health.

5. Measure better.

• Differentiate between experimental, occasional, and daily use among adolescents.

• Assess the intensity and trajectories of cessation among adults.

• Invest in long-term, transparent, open-access research on vaping’s effects — especially cardiovascular and respiratory — without losing sight of the counterfactual: combustion remains the true benchmark of risk

• To measure well is an ethical act: without sound measurement, policy becomes belief.

6. And above all: treat the determinants.

• Policies on income, housing, labor, leisure, and education are also tobacco-control policies.

• Where despair and hopelessness exist, any substance finds a social function.

• Bringing psychological support, pain management, leisure spaces, and harm-reduction practices into the public health network does more for equity than any moral campaign ever will.

• Because systemic exploitation — the engine of inequality — is, in the end, the most persistent drug of all.

• Understanding that harm reduction is not a concession but a form of maturity means recognizing that public health deals with humans, not ideals.

• At its simplest, bioethics is an exercise in proportion: to do good without promising purity, to reduce harm without pretending eradication.

• It is on that human, imperfect, concrete scale that intelligent policies can finally become just.

The WHO’s Challenge in the 21st Century: A Return to Human Concreteness

The WHO’s Global Report fulfills its function — selectively — of taking the pulse of the world. People smoke less today than in 2000, especially in South and Southeast Asia — and, notably, in Sweden. Women have made more progress in quitting; Europe now has the highest prevalence; and new products have transformed the ecosystem of risk, communication, and desire. A global map of partial progress and persistent dilemmas.

Does the communiqué exaggerate? Not necessarily. It simply foregrounds what the organization’s leadership believes deserves priority. By emphasizing youth risk and urging governments to “close gaps,” the WHO plays the safest side of precaution — the rule that keeps the board under the control of those who write it, and those who fund it. As the saying goes, those who pay choose the tune.

The danger lies elsewhere: in implying that there is no legitimate space for harm-reduction strategies. That omission is more than rhetorical — it is political. And every policy, in the end, is also economic.

Ignoring solid evidence — from the Cochrane Tobacco Addiction Group’s reviews demonstrating e-cig effectiveness, to Sweden’s and Japan’s experiences with pouches and heated tobacco — reduces a complex phenomenon to a moral dispute.

And moralizing risk is the surest way to miss the point of care.

It would also be crucial to place greater emphasis on the social determinants of health: to redistribute income, easing poverty and improving quality of life; to invest in education, deepening our understanding of human complexity; to secure housing, so that a basic need does not consume vital energy; to shorten working hours, recovering leisure, social connection, and family time; and to advance gender policies that relieve the disproportionate burden placed on women.

Because technological shifts alone don’t correct historical asymmetries — they merely rebrand them in the language of progress. And if 80 percent of the world’s tobacco users live in low- and middle-income countries, it is because markets, governments, and living conditions shape epidemics as much as molecules do.

Reducing smoking without reducing misery is like drying ice with statistics.

Ultimately, the report seeks to reaffirm its instruments — the MPOWER package and the Framework Convention — but it does so more to preserve its own bureaucratic ecosystem than to reckon with the impact of its actions on real lives.

In today’s complex landscape, measuring better, regulating better, and caring better are verbs of a new grammar — one that demands investment without profit, intelligence without prejudice, and a living public imagination. And perhaps hardest of all, institutional empathy.

Somewhere between graphs and goals, the WHO appears to have drifted away from its focus on people. It’s understandable: numbers are more docile than lives. But public health begins and ends in somebody’s body — a tired body, a curious body, one that coughs in the morning, works six days a week, and finds comfort in the sweet taste of an imperfect habit.

Somewhere between graphs and goals, the WHO seems to have drifted from the people it serves. It’s understandable: numbers are more docile than lives. Yet public health begins and ends in somebody’s body — a tired body, a curious body, one that coughs in the morning, works six days a week, and finds comfort in the sweet taste of an imperfect habit.

A report is not just statistics; it is biography itself.

And perhaps what the WHO needs, more than new reports, is to relearn how to listen to the coughs behind the numbers.

The problem of tobacco, in 2025, is no longer merely chemical — it is civilizational.

What Does It Mean to “Win” This Epidemic?

It depends on what we mean by victory. If winning means reducing combustion to a rarity and protecting children and adolescents from any harmful exposure, then the path is clear — though long.

It operates through well-designed excise taxes, smart and non-punitive enforcement, objective, non-moralistic, and non-manichean campaigns, accessible cessation services, and modern, equitable regulation for new products.

But if winning means eradicating nicotine from human life altogether, we have mistaken public health for a moral project — and risk failing precisely those most in need of practical care.

In Beauchamp’s understanding of bioethics, the task is to balance conflicting principles; in public policy, it is to manage imperfection. Science has already given us a few fixed points: combustion kills; protecting minors is non-negotiable; and non-combustible nicotine products can help smokers quit. The rest is implementation — with people, in real contexts.

At the end of the press conference in Geneva, the numbers always return to their tables.

Outside, in every city in the world, a smoker decides whether to buy a pack; a father decides whether to scold his son for a colored pod; a doctor decides whether to offer a therapeutic vape to a cardiac patient who has failed with patches and bupropion.

It is there — in that narrow space between policy and biography — that reports become life: when they inform without humiliating, guide without punishing, and care without demonizing.

To win may not mean eliminating vice, dependence, or use, but learning to treat desire with responsibility — and suffering with compassion.

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