Smoke, Not Nicotine: The Fatal Error of Tobacco Policy
Decades of public health strategy failed to distinguish between what kills — and what doesn’t.
For half a century, the image of harm was clear: a glowing cigarette, a rising plume of smoke, a pair of blackened lungs in a medical textbook. We learned to fear it. To teach others to fear it. And for good reason. Smoking is still one of the leading preventable causes of death and disease around the world.
But something was lost somewhere in that righteous war — in the slogans, the posters, the policies.
The nuance.
The distinction between what kills and what doesn’t. Between what burns and what binds. Between smoke and the molecule carried within it: nicotine.
Nicotine was never the fire. But we made it the flame.
The Unlikely Heretic
From a quiet office at the University of Louisville, in the tobacco heartland state of Kentucky, a physician has spent the last two decades trying to undo a mistake most of the world refuses to see.
Dr. Brad Rodu is not a radical. He is a professor of medicine, holds an endowed chair in tobacco harm reduction research, and is a member of the James Graham Brown Cancer Center. But what he says disturbs the orthodoxy.
“Conflating all nicotine or tobacco use with smoking is not just a scientific mistake,” he tells me. “It’s an ethical one.”
This confusion — between combustion and substance, between behavior and chemical — continues to shape public health policy. The Centers for Disease Control and Prevention (CDC) counts with precision the number of lives lost to smoking. But it refuses to separate deaths caused by cigarettes from those associated with non-combustible forms of tobacco.
It’s not just an oversight. It’s a form of institutional silence. A refusal to admit that not all tobacco use is equal. That not all nicotine use is deadly.
Not all tobacco kills. Not all nicotine harms. The real danger is fire.
The Data We Choose to Ignore
A large, federally funded study found that traditional smokeless tobacco — the kind chewed or dipped — carries only minimal risk for cancers of the head and neck. Rodu’s research, based on retrospective national survey data, went further: American men who used these products but did not smoke showed no excess mortality from diseases typically linked to tobacco.
In other words, not all tobacco kills. Not all nicotine harms.
The real danger is the flame.
Still, the myth of universal harm persists.
The Chemical We Chose to Hate
Nowhere is this confusion more visible than in the case of e-cigarettes. For years, public discourse has blurred the line between vaping and smoking — as if all forms of inhaling nicotine were equally deadly. But science tells a different story.
Most vapers are current or former smokers. That complicates population-level data on mortality. But one fact is not in dispute: vapes do not burn. They do not produce tar, carbon monoxide, or the cocktail of combustion byproducts found in cigarette smoke.
“Equating vaping with smoking is not just incorrect,” Rodu says. “It institutionalizes misinformation.”
Sweden offers a revealing contrast. There, a form of pasteurized oral tobacco known as snus has long been used instead of cigarettes. As a result, Sweden now has the lowest smoking-related disease rates in Europe. The U.S. Food and Drug Administration, acknowledging similar data, has approved the sale of heated tobacco devices, e-cigarettes, and nicotine pouches as “appropriate for the protection of public health.”
Still, the stigma lingers.
The Nicotine Panic
Perhaps the most enduring myth is that nicotine — in and of itself — causes cancer, heart disease, and COPD. Over 80% of American physicians still believe this.⁽³⁾ Rodu calls it “medical folklore,” passed down unexamined, reinforced by policy rather than evidence.
“There is no credible evidence that nicotine, on its own, causes these diseases,” he insists. “The harm comes from the smoke. From combustion. Nicotine may be addictive — but it is not lethal.”
When confronted with this data, many officials retreat to caution: “We don’t know enough.” However, according to Rodu, the MEDLINE database contains over 28,000 studies on nicotine. The issue, he says, is not ignorance — but institutional fear.
“We keep saying we don’t know enough about nicotine,” he tells me.
“But the truth is, we do. We just don’t want to admit it.”
Children, Brains, and the Seduction of Certainty
No fear is more politically potent than the fear for our children. The CDC warns that nicotine can “harm brain development up to age 25.” This statement is repeated with such frequency that it has become doctrine. However, it is mainly based on animal studies, not human epidemiology.
To date, there is no measurable cognitive deficit found among the millions of Americans who began smoking in adolescence. Nor among Swedish snus users. That silence — like so many in this debate — is telling.
Caution is wise. But fear, weaponized, becomes its own kind of harm.
The Gateway We Pretend Is a Wall
Another fear-based narrative is the so-called gateway theory, which claims that vaping among teens inevitably leads to cigarette smoking. But Rodu’s team recently published a study showing the opposite: as youth vaping increased, teen smoking rates fell sharply.⁽⁴⁾
“If there’s a doorway,” he says, “it swings both ways.
For many young people, vaping has been a way out of smoking — not into it.”
Addiction Isn’t a Sentence
Of all the myths, perhaps none is as quietly insidious as this: that nicotine addiction is lifelong. Dr. Brian King, now director of the FDA’s Center for Tobacco Products, has stated that adolescent nicotine use leads to “lifelong addiction.”
But the data resists that conclusion. Over 56 million Americans have quit smoking.⁽⁵⁾ Addiction exists, yes. But permanence is a myth. What may be irreversible, Rodu argues, is not the chemical dependence — but the damage done by misinformation.
Abstinence or Nothing: The Cruel Choice
For nearly 30 million Americans who still smoke, the official advice is to quit using FDA-approved therapies: patches, gums, and pills. But these options — despite decades of endorsement — have a success rate of just 7%.⁽⁶⁾
Meanwhile, many are denied access to safer alternatives that don’t require total abstinence. That denial is not neutral.
“To offer ineffective options while outlawing the effective ones,” Rodu says,
“is a form of institutional cruelty.”
A Call for Inaction
As leadership shifts in Washington and regulatory priorities realign at the FDA and CDC, speculation mounts about the future of tobacco control. But for Rodu, the most radical act may be the simplest:
Stop. Step back. Let the evidence speak.
“Killing myths doesn’t require more government action,” he says.
“If anything, it requires inaction — stepping aside so that people and physicians can educate themselves.”
Sometimes, the real danger isn’t chemical.
It’s narrative.
Not the substance — but the lie we tell about it.
