The Report’s Basements and the Bodies That Do Not Grow
A journey through how the WHO turned tobacco into the central enemy of childhood growth delays, shifting attention away from social determinants—poverty, violence, racism, malnutrition—toward a single narrative that moralizes health, places blame on mothers, and erases the complexity of structural causes.
In a hospital in Quetzaltenango—more than 2,300 meters above sea level, where hypoxia steals invisible grams from newborns— a nurse cradles a tiny body that fits entirely in the palm of her hand. It weighs barely more than a pack of Rubios, as if life had been condensed into a fragile cardboard packet. Outside, the father lights another cigarette, and the red dust of the street drives the smoke against the windowpanes.
No Guatemalan doctor needs to consult the latest report from the World Health Organization to intuit the connection. And yet, there it is: the bureaucratic translation of catastrophe, an eight-page document that aspires to the exhaustiveness of synthesis but reduces the vulnerability of that minimal body from Xela to downward curves and unyielding percentages.
The Organization has singled out tobacco as a central enemy in the fight against stunting, that technical term that softens the rawness of childhood growth delays. In the report’s hall of mirrors, all causes appear with equal gravity: smoking a cigarette, drinking contaminated water, suffering recurrent infections, or surviving on an insufficient diet. Poverty and low education levels also appear in the first line of the list. However, while tobacco is granted an accumulation of evidence, as if it held the single key to the problem, the other determinants receive only fleeting mentions—without hierarchy or historical context.
The result is ambiguous: on the one hand, tobacco is magnified; on the other, the rest of the causes are flattened, as if stripped of their own epidemiological weight. Out of this false symmetry emerges a recipe book of abstinences, while childhood keeps shrinking in neighborhoods without sanitation, in villages without harvests, in improvised camps where there is neither roof nor bread. Thus, once again, global health policy seems less oriented toward questioning and transforming structures than toward monitoring and disciplining bodies.
In the report "Tobacco and Stunting" there are no metaphors; figures, symptoms, and abbreviations prevail, aligned with the coldness of a war inventory that exposes an invisible wound in a conflict that was normalized before it was even declared lost.
The document is blunt in stating that smoking during pregnancy poses a critical risk for intrauterine growth restriction, low birth weight, and premature delivery—conditions closely linked to childhood stunting, especially in low- and middle-income countries. That is the core: the highlighted sentence in the summary.
But behind every data point hides a scene statistics can barely brush against: newborn after newborn with almost translucent skin, as if the world had hurled them out too soon, only to strip them afterward.
What the report minimizes is that these curves do not arise from nowhere: behind the figures of malnutrition and poverty stretches the long shadow of centuries of dispossession, of lands seized, of economies designed to serve others.
Colonialism is not a closed chapter. It is a past that endures. It did not end with independence. It rewrites itself in external debt, in dependence on patented raw materials, in unequal trade agreements. It transforms, but it does not vanish. It remains inscribed in the open veins beneath the translucent skin of that newborn.
When Colonization Translates into Curves
The wounds of colonialism are updated today in another language: that of epidemiology. What was once narrated as dispossession and subjugation now appears in medical charts: persistent inequalities that reflect inherited racist structures.
For centuries, public health and biomedicine were shaped to serve colonial interests: segmented systems of care, with colonizing populations receiving resources and treatment while the colonized were left with precarious—or nonexistent—services, discriminatory practices, and the devaluation of their knowledge. That legacy left concrete marks: heavier burdens of infectious and chronic disease, shorter life expectancy, deep mistrust toward medical systems.
Today, those scars can be read in indicators of childhood growth: maternal malnutrition, premature births, and low birth weight. The evidence is solid in the prenatal stage: smoking during pregnancy increases the risk of fetal growth restriction (FGR), low birth weight (LBW), and preterm birth (PTB) by 50 to 100 percent.
These are acronyms that pile up in reports with typographic coldness, yet in hospitals they transform into incubators humming through the night, into mothers with reddened eyes, into doctors silently carrying the certainty that each downward curve also has a face.
Colonialism left scars still inscribed today on the bodies of children.
And yet here opens the first methodological fissure in the document: the uneasy tension between association and causality.
The report asserts with confidence that smoking during pregnancy causes fetal growth restriction, low birth weight, and preterm births. But when it turns to postnatal growth, it concedes that the link with stunting “remains uncertain.” That admission, tucked away in a secondary section of the text, vanishes from the executive summary and the key messages, where the tone returns to one of blunt certainty.
Not so much denied as sidelined, uncertainty is pushed into the footnotes—treated as a minor detail rather than a central point in scientific debate. There, the language sheds its martial tone and becomes hesitant, almost timid, as if doubt—precisely what should illuminate scientific discussion—were being managed like a nuisance best kept out of sight.
How Doubt Becomes Dogma
When it comes to smoked tobacco—and, by extrapolation, nicotine—some sectors of the WHO seem to need certainties the way an army needs slogans. Doubt nearly evaporates and, in the body of the report, is subordinated: a linear, almost didactic narrative is erected, a storyline designed less to reflect the cracks in an uncertain link than to drive taxation, justify prohibitions, and promote shock campaigns.
The operation is anything but innocent: documents aimed at delegitimizing and stigmatizing nicotine use—whatever the form—tend to transform scientific uncertainties into political certainties.
Ambiguity is erased because the WHO requires a seamless narrative to sustain its arsenal of global policies. And in that erasure, another strategic silence becomes visible: the denial of harm reduction.
A table of definitions in the report describes in meticulous detail the risks of alternative products, but avoids contextualizing differences in toxicity levels. Thus, on the very same page, combustible cigarettes—with more than 7,000 chemical substances, 69 of them carcinogenic—are placed alongside electronic devices (HTPs and ENDS), described simply as aerosol generators “with nicotine and toxic substances.” No reference is offered to toxicity gradients or to evidence on relative reductions in exposure.
In this way, a cigarette and an electronic device appear on the same plane, as equivalents, when the scientific literature suggests clear risk differentials. That strategic silence—the systematic omission of harm reduction—sustains a binary narrative: everything is equally harmful. And an electronic device whose aerosol is, in fact, a troubling reminder: in the terrain of nicotine, shades of gray exist, though international policy, for its own reasons, prefers to ignore them.
The effect is that of a hall of distorted mirrors: in the same highlighted box of definitions, everything reflects with equal gravity, everything appears equally lethal. Combustible cigarettes, heated tobacco products (HTPs), and Electronic Nicotine Delivery Systems (ENDS) are described in the same language of risk, with no nuance of magnitude or toxicological difference.
The document, which should illuminate contrasts, describe nuances, spark questions, and broaden evidence, instead becomes a machinery of simplification. Its absolutist narrative not only constrains understanding: it misinforms, feeds fear, and with it, blocks any policy of transition toward lower-risk options for the general population.
In the printed text resounds a brutal paradox: the smoker is condemned to an impossible binary—total abstinence, or perpetual bondage to combustible cigarettes—as if nuance itself were a heresy.
The Causes That Don’t Fit in a PowerPoint
And in that erasure, what vanishes as well is the essential: the discussion of the social determinants that make stunting a tragedy repeated, anonymized, and centuries old. Poverty, inequality, structural racism, food insecurity—all are pushed into the background, as if the problem could be solved with prohibitions and numbers, without attending to the historical conditions that incubate it.
The report mentions poverty, low education, malnutrition, and infections, but displaces them from the core and reduces them to secondary notes beside the central space granted to tobacco.
By contrast, structural racism, gender violence, and chronic food insecurity—decisive factors—do not appear at all. The result is a flattened picture: poverty that suffocates; land lost that no longer feeds; hunger that shrinks bodies before they are born, all blurred into invisibility.
The document that should illuminate cracks instead covers them with a coat of uniform paint. And in that antiseptic whiteness, voices, bodies, and stories fade away. What is lost is precisely what gives meaning to the struggle against stunting: the truncated lives of those who never reach the height they were promised.
The Possibility of a Bridge
Beyond this particular report, the WHO’s global nicotine policy systematically omits the perspective of harm reduction.
In the general population, the accumulated evidence suggests that non-combustible devices are substantially less harmful than conventional cigarettes and can even double the quit rates compared with traditional substitution therapies, according to a 2022 Cochrane review.
Within that difference lies a possibility that, while not risk-free, could become a bridge out: a stairway toward renunciation, a crack widening into a solution.
By minimizing this emerging literature, the WHO subordinates a growing body of evidence to an abstentionist bias that operates as dogma. The paradox becomes visible in everyday life: in places where non-combustible nicotine products have been restricted or stigmatized, sales of conventional cigarettes have risen again.
It is as if, in the name of sanitary purity, the smoker were being pushed back into the flames, denied the right to a possible bridge. For the cruelest paradox is this: by demonizing transition, the original enemy is protected.
The Bodies That Bear the Blame
And here emerges the fundamental fault line: biomedical reductionism. The report lists, with the neatness of a table, factors such as malnutrition, low education, recurrent infections, or poor sanitation—but presents them as background scenery, while placing tobacco at center stage. In doing so, it casts the cigarette as the visible culprit and leaves in shadow the true set designers of growth delays: poverty, social inequality, food insecurity, violence against women, and structural racism.
It is the difference between peering through a microscope and opening one’s gaze to the whole landscape.
The bodies that carry the blame are, above all, those of poor mothers, who appear as individual culprits in what is, in truth, a structural tragedy.
The scene takes shape outside the PDF.
In a refugee camp, the tents smell of hot canvas and chlorine; water arrives by truck and is never enough. A pregnant, anemic woman rations food among three children and lights a cigarette as if granting herself one minute of control over something.
In a flooded suburb, children splash through gray-yellow puddles; the buzz of mosquitoes competes with the motors of pumps that never suffice. There, diarrhea—one of the factors listed by the WHO—is as seasonal as the rain.
In a drought-stricken village, crops have turned to dust; water has an owner, as do the seeds. The smoke filling lungs comes as much from tobacco as from the wood-fired stove, another exposure recognized in public health. And almost anything can serve as wood.
In all these settings, smoking is less a “consumer choice” than a symptom of exposure: a minimal ritual to numb hunger, fear, and insomnia.
The problem is not that biomedicine observes smoking and nicotine; the problem begins when its lens displaces everything else.
Scientific literature describes stunting as a multifactorial phenomenon (some factors acknowledged in the WHO’s own report, others only hinted at) and profoundly contextual: repeated infections, environmental enteropathy—the silent inflammation of the intestine caused by chronic exposure to pathogens—diets poor in micronutrients, maternal toxic stress, anemia, homes that colonize the body with mold and bacteria.
A map of causes that insists on reminding us that growth delay is not an isolated effect but the expression of intertwined historical and socio-environmental conditions.
Fetal hypoxia does not come only from cigarettes. The report itself acknowledges factors such as malnutrition, severe anemia, and exposure to solid-fuel smoke in closed kitchens. But it leaves out others just as decisive: precarious working conditions that exhaust mothers and expose them to toxic environments, or daily violence and psychosocial stress that raise cortisol and restrict placental flow.
Reducing that map of causes to a thick arrow pointing in a single direction inside an epidemiological chart is, above all, a narrative convenience: a political act of simplification that turns the complexity of millions of lives into a manageable story, though brutally incomplete.
There is, moreover, a political effect: when the story concentrates on individual behavior—stop smoking and your child will grow—responsibility becomes moralized and the burden shifts onto mothers.
Public health becomes catechism: forbid, tax, monitor. Anti-tobacco patrols and shock campaigns are funded, while what is slow, expensive, and structural—clean water, sanitation, girls’ education, income transfers, protection from domestic violence—is hidden and deferred.
This is biopolitics in its most economical form: regulating eligible bodies and governing individual behaviors proves cheaper—and less threatening—than fixing the broken pipe that sickens everyone.
Thus, public health preaches abstinence aloud, while in a low voice, it tolerates and normalizes the structural poverty that shrinks bones and chisels futures.
Quit Smoking and Your Child Will Grow
What does it mean to care? The report acknowledges it—it does not ignore it; it states it. It mentions poverty, low education, malnutrition, and poor sanitation. But it relegates them to secondary graphs; it does not place them at the center or confront them.
In those figures, tobacco always appears with thick arrows; social determinants in faint gray. Almost a palimpsest. The reader is left convinced that the correct solution is to raise taxes and ban, even if a block from the hospital, the open ditch still breeds mosquitoes.
The arithmetic of the best buys (raising tobacco taxes, restricting alcohol advertising, promoting healthy diets) pays off quickly in clean figures and neat charts that fit onto a slide.
The social engineering of causes, by contrast, takes years, resists Excel, defies short-term metrics, and refuses to produce instant images. Yet it is in that delay—in that dead time of politics without electoral returns or fast funding—where children’s bones stop growing.
If protecting childhood is the goal, the script should be inverted in the hierarchy of priorities: first, guarantee the conditions that make a growing body possible—food security, water, sanitation, decent housing, income, education, and women’s autonomy, direct determinants of maternal and child health. And only then, simultaneously but subordinately, intervene with honesty on the uncertainties of behavioral risks.
That should be the script of a public health policy that truly aspires to protect childhood.
Otherwise, health policy risks confirming itself in what it already seems to be: a pedagogy of fear and discipline that confuses symptom with cause. The cigarette appears as the main enemy when, in many cases, it is nothing more than an expression of poverty and exclusion.
And so, with good intentions, those punished are the very ones with the least room for choice: mothers who smoke to dull hunger, children growing up in homes without water, families whose daily lives are marked more by the smoke of wood fires than by tobacco.
The final image should not be a confiscated pack of cigarettes, but a measuring tape that rises a centimeter because, upstream, someone opened a safe water tap, sealed a latrine, filled a plate with iron and protein, and guaranteed a mother she could sleep without violence.
The other measures—taxes, warnings, smoke-free spaces—are necessary, but secondary and insufficient if structural conditions are not addressed first. None of them can reverse the social drought that, if left unchecked, will continue to wither bones and futures, turning fire from possibility into certainty.
By privileging a single agenda and institutional dogmatism, the WHO risks imposing a global hygienist morality that disciplines bodies without transforming the realities that weigh upon them.
What does it mean to care in public health? To repeat an abstract slogan of abstinence, or to accept the world’s complexity and save possible lives with the measures that are possible?
Until the WHO incorporates this question, many of its policies will remain what they too often are: less a realistic strategy of protection than a global catechism, a manual of discipline that orders bodies without touching the roots of the world that sickens them.