Smoking remains one of the most stubborn public health challenges of the modern era. It’s impact extends beyond lung/respiratory and oral disease. Cervical cancer for instance, the fourth most common cancer among women globally, has been linked not only to HPV but also to smoking. The latter can double the risk for this particular cancer by weakening immune responses and introducing toxins directly into cervical tissue. Secondhand smoke exposure adds another layer of risk, often overlooked in prevention strategies.
For years, tobacco control has relied heavily on deterrence: higher taxes, tighter restrictions, social stigma and, increasingly, prohibitionist regulations. These measures can reduce smoking prevalence over time, but they are blunt tools. They frequently ignore individual differences in dependence, mental health, socioeconomic context and access to support. In many cases, they also produce unintended consequences, from illicit markets to disengagement from cessation services.
The COVID-19 pandemic exposed some of these weaknesses. In 2022, Dr. Sanjay Varma of Global Medical Institutes noted a 27 percent decrease in the number of people seeking help to quit smoking. Stress, disrupted healthcare access and reduced face-to-face support all played a role, highlighting how fragile cessation systems can be when they rely on narrow pathways rather than flexible, harm-reduction-oriented support.
Recognizing that addiction is complex and multifaceted
Emerging research increasingly shows that nicotine dependence is not simply a matter of choice or moral failing. Genetic, psychological and social factors all influence who becomes dependent and how difficult quitting will be. A study published in Nicotine & Tobacco Research by psychologists at Emory University introduced a multi-polygenic model to better predict nicotine dependence risk. The findings suggest that genetic traits linked to schizophrenia, depression, neuroticism, risk-taking behaviour, high body mass index and alcohol use disorder, all increase vulnerability to nicotine dependence. Conversely, genetic factors associated with higher educational attainment appear to lower that risk.
This matters because it challenges one-size-fits-all policy. When tobacco control treats all smokers as equally capable of quitting unaided, or equally responsive to punishment, it ignores biological reality. Harm reduction begins with accepting that not everyone can quit easily, quickly, or at all.
Behavioural science offers alternatives to coercion
Rather than doubling down on prohibition, some researchers are exploring behavioural strategies that support change without coercion. At Virginia Tech’s Fralin Biomedical Research Institute, health behaviour scientist Jeff Stein is leading a study funded by the US National Cancer Institute, examining a technique known as episodic future thinking. The method encourages individuals to vividly imagine meaningful, positive moments in their future, helping shift decision-making away from short-term urges and toward long-term benefits.
The study, conducted remotely with participants from both urban and rural areas, combines standard cessation information and nicotine replacement guidance with future-oriented mental exercises. Earlier research suggests this approach can reduce impulsivity across multiple addictive behaviours. If successful, it could offer a low-cost, scalable tool, particularly valuable in rural communities where access to cessation services is limited. This kind of intervention reflects a broader truth: people are more likely to change behaviour when they are supported, not punished.
When tobacco control overreaches
Hong Kong offers a clear example of how public support for tobacco control can coexist with policy overreach. Recent research presented by the Hong Kong Council on Smoking and Health shows overwhelming backing for stricter smoking restrictions, including expanded smoke-free zones and higher tobacco taxes. Nearly nine in ten residents support tougher controls, and more than 90 percent favour banning smoking while walking in public streets.
Modelling by the Chinese University of Hong Kong suggests that aggressive tax increases could reduce smoking prevalence by nearly 10 percent within a decade. On the surface, this appears to validate a hardline approach. Yet Hong Kong’s smoking rate is already just over 9 percent, among the lowest globally. The marginal gains from ever-tighter restrictions come with rising costs: enforcement burdens, social division and the risk of pushing remaining smokers into more marginalised positions.
Notably, Hong Kong is also moving to restrict alternative nicotine products in public spaces, despite growing international evidence that non-combustible products dramatically reduce harm compared to cigarettes. This conflation of smoking with all nicotine use exemplifies the wrong lesson being drawn from declining prevalence.
The limits of prohibition
In the UK, Action on Smoking and Health (ASH) reports that nearly seven in ten smokers aged 11 to 17 regret starting and would choose not to smoke if given the chance again. Many support the government’s proposed “smokefree generation” policy, which will gradually ban tobacco sales to anyone born after 2009.
While youth regret should be taken seriously, it does not automatically justify prohibition. Most adult smokers also regret starting, yet banning tobacco outright has historically failed. Evidence shows that early regret reflects addiction, not approval of coercive policy. Moreover, youth smoking rates are already historically low, raising questions about whether sweeping generational bans address the real drivers of harm or simply offer political symbolism.
Harm reduction does not deny the need to protect young people. It argues that protection is best achieved through education, age enforcement and safer alternatives, not by entrenching cigarettes as the most accessible option for adults.
Can there be “safer” cigarettes?
Few examples better illustrate the dangers of misguided tobacco control than cigarette filters. Public health experts in the UK have called for a nationwide ban on filters, arguing (correctly) that they offer no health benefits and contribute massively to plastic pollution. Filters were designed to make smoking feel safer, not to reduce harm, and may even increase risk by encouraging deeper inhalation. Despite this, most smokers believe filters are protective.
This history matters. It shows how cosmetic harm reduction (changing appearances without addressing combustion) misled consumers for decades. True harm reduction focuses on eliminating smoke, not tinkering with cigarettes.
Research into tobacco plants themselves underscores this distinction. In studies led by De-Yu Xie at North Carolina State University, scientists successfully reduced nicotine, carcinogenic nitrosamines like NNN, and other toxic compounds simultaneously without harming the plant. This work suggests it is technically possible to reduce tobacco toxicity, but also highlights how complex the chemistry of harm really is.
While pharmacological products like cytisinicline, a plant-based compound now in Phase 3 trials, aim to ease nicotine withdrawal while blocking nicotine’s rewarding effects. Yet even widely endorsed cessation drugs like varenicline and bupropion, now listed by the World Health Organization as essential medicines, carry significant psychological side effects. For some users, these risks are unacceptable, which reinforces a core harm reduction insight: no single solution works for everyone. Hence, the more products/ smoking cessation options available, the better.
Ending smoking without ending choice
The consequences of using the wrong tobacco control techniques are clear: persistent smoking among the most vulnerable, growth of illicit markets, disengagement from cessation services and missed opportunities to reduce harm more quickly. As Clive Bates and other harm reduction advocates have long argued, tobacco control’s true purpose is not moral enforcement, but harm minimisation.
Effective policy should weaken the appeal of smoking while strengthening access to safer alternatives, behavioural support and credible information. When control becomes coercion, it risks protecting cigarettes by default.
The future of tobacco control lies not in repeating the same strategies more aggressively, but in adapting to what science, behaviour and lived experience have already taught us: people change best when offered safer choices, not when cornered by ideology.
