Tobacco Harm Reduction
A positive alternative to combustible tobacco or merely a perpetuation of a highly profitable nicotine pipeline?
Dr. Nevin Zablotsky
To help understand the recent success of e-cigarettes and nicotine pouches, the latest nicotine delivery systems, one needs to review the history of tobacco and how it generated an industry that continues to be exceptionally profitable as well as cause tremendous harm. Tobacco was first grown in the Americas about 18,000 years ago.Tobacco was chewed, sniffed, eaten, drunk and smoked, and used as a medicinal salve as its uses evolved over those thousands of years.
In the early 1600’s the first successful commercialization of tobacco was developed in Virginia by John Rolfe and exported to England.
By the early twentieth century tobacco products were seen on every continent with the exception of Antarctica, It was used in pipes, cigars, snuff, chew and newly commercialized cigarettes. In 1890 Buck Duke formed the American Tobacco Company (ATC) with estimates of his company producing 9,800,000 cigarettes in its first operational year. By 1902 , ATC dominated about 90% of the U.S cigarette manufacturing market.
Twentieth Century
Over the years the tobacco companies from the U.S and other countries continued to flourish despite having internal proof in the late 1940’s to the early 1950’s, that their products were literally killing or maiming millions of people every year throughout the world.
In 1964, Luther Terry M.D, the Surgeon General of the U.S Public Health Service, based on 7,000 research articles concluded that cigarette smoking caused lung cancer and laryngeal cancer in men, and likely in women as well. It became clear to the industry that they needed new strategies to continue to promote and sell cigarettes.
That same year the ATC introduced the Carlton cigarette stating that it was ”low tar”, “light” and filtered making it a “safer alternative”, which it was not.They also increased their marketing to women, teens and less regulated markets in other countries. In addition, on April 14th, 1994 the leading companies’ C.E.O’s appeared before Congress and stated that nicotine was not addictive despite their internal memos showing that their scientists knew that it was. Which brings us to the era of tobacco harm reduction, and the advent of snus, e-cigarettes, heated tobacco products, and most recently non-tobacco synthetic nicotine products made in laboratories such as nicotine pouches.
Harm Reduction
In the 1960’s the U.S helped lead the world in developing forms of harm reduction when it tried to tackle the problem of addiction to heroin and other opiates. Researchers introduced the use of methadone, an addictive opiate, which introduced the possibility of helping substitute less harmful drugs for the more dangerous opiates with the understanding that addicts would be substituting one addiction for a “safer” one. Harm reduction was also employed when drug users were allowed to exchange their old needles for new ones in attempt to prevent them from getting hepatitis B, which was then expanded to prevent the spread of HIV/Aids. Both of these policies met with significant resistance in the general public as the perception was that these individuals should be strong enough to break these behaviors on their own. Over the years scientists have recognized that addiction is a disease and that a more pragmatic approach that respected those who were unable to quit their addiction was needed.
Tobacco Harm Reduction
The claims of tobacco harm reduction advocates are that the new non combustible products create a “safer” nicotine delivery system which enables a nicotine addicted individual to continue to use nicotine if they are unable to quit smoking cigarettes. They argue that products like e-cigarettes, heated tobacco, and now nicotine pouches are an effective “safer” approach to smoking cessation. Given the tobacco industry’s history of obfuscation and the endless pursuit of profits as their main goal, one has to question whether their true motive is switching nicotine addiction to other very profitable products or trying to protect users from the harms they have placed them in for hundreds of years.
The Latest Products
E-cigarettes were introduced in China in 2003 by Hon Lin, a pharmacist. They were electronic nicotine delivery systems that created an aerosol of propylene glycol, nicotine, and a nicotine solution with flavorings. Initially they mimicked the form of a cigarette but then evolved to many other shapes with some being disposable and others with refillable cartridges. In addition, by modifying the nicotine molecule the concentrations of nicotine in these products has dramatically risen, and has made its use non-irritating to the throat. The flavored additives have also made it more pleasant for children to experiment with as it tastes better and has a pleasant aroma, setting them up for disaster.
There is agreement that e-cigarettes are highly addictive and can harm the developing brain of teens, kids and fetuses. There is also ample research showing that its use can negatively affect the lungs and heart and other systems of the body. Advocates for its use argue that if adults are unable to quit cigarette smoking “vapes” are “safer to use as a nicotine substitute. Only time will tell how dangerous they truly are.
Heated tobacco products such as IQOS are tobacco sticks that are heated to 350 degrees Celsius which emit an aerosol cloud. Given that this product uses tobacco its aerosol releases the same cancer causing chemicals as cigarettes. The FDA has not said it is an effective cessation tool nor is it considered a safe product.
Nicotine pouches were created in the early 2000s but reached the mainstream consumer market in 2014 when the Swedish Match company introduced ZYN which was purchased by Phillip Morris International in 2022 for $16 billion dollars and has become the market leader in pouch sales. Overall nicotine pouch revenue in the U.S was $2.8 billion dollars in 2024, $3.8 billion dollars in 2025, and it is projected that sales worldwide will reach $25 billion dollars by 2028.
Nicotine pouches’ components include a powder of synthetic or tobacco derived nicotine, flavorings, sweeteners which are enclosed in a permeable pouch made of plant based fibers. For comparison’s sake, one cigarette delivers 1-2 mg of nicotine to the body, whereas the common nicotine pouch dose in the U.S ranges from 2-12 mg with some as high as 47 mg. Most light users go through 3-4 pouches per day, while those who are heavier users might use 8-10 pouches. These levels of nicotine exposure clearly increase ones’ addiction to the product and may increase harm to the developing brain up to the age of 25. In addition it can damage the heart, cause heart arrhythmias, elevate one’s blood pressure and delay wound healing. The increase in nicotine exposure can also hurt the developing fetus. We are now also seeing a compromise to oral health with the pouches as well as vapes as they irritate oral tissues, causing periodontal disease and developing oral mucosal lesions . Only time will tell whether these lesions become cancerous.
The use of tobacco harm reduction products has exponentially grown. The prevalence of the use of e-cigarettes is approximately 5.2% of middle and high school students who report use in the last 30 days with more than 1 in 4 using them daily. Over 45% of youth who vape also use other products like nicotine pouches.
In 2024, the CDC reported that approximately 480,000 youth reported using nicotine pouches making them the second most used tobacco product. This number continues to grow. It is not surprising that children are attracted to these products as they are exposed to them via ads on the internet, television, streaming services, movies, or in print media. Young influencers online appeal to the adventurous, exciting, rebellious nature of using these products and continue to capture and create a new generation of nicotine addicts. In addition, those with intellectual disabilities who are particularly vulnerable to the influence of others, can be caught up in the web of exposures to these products from various sources.
In May 2026 the FDA decided to allow more flavored e-cigarettes and nicotine pouches to be sold in the U.S. with flavors that are known to appeal to children, and in August of 2026, the FDA allowed 11 more flavored nicotine pouches including mint and menthol to be marketed. This goes against its former policy which acknowledged that flavored nicotine products, especially those that were fruit flavored, appealed to kids. This comes at a time when the federal funding and enforcement programs to monitor and prevent the sale of vaping and other nicotine products to minors has been heavily cut.
Over the past twenty five years I have worked to help patients who became addicted to smoking cigarettes break their nicotine addiction. I have seen many of them fail in this effort and suffer horrific consequences. Some lost their effective ability to breathe from COPD, some had strokes or heart attacks, and some were terribly disfigured from head and neck cancer. I have seen the numbers of minors who smoked cigarettes radically decrease only to now seem to become addicted to these newer harm reduction products.
In 1965 Congress passed a law requiring a small text warning label be placed on the side of a pack of cigarettes. Fast forward to 2009 when Congress passed another law giving the Food and Drug Administration (FDA) authority over tobacco and ordering graphic warnings covering the top half of packs. In 2011, The FDA created nine graphic images (diseased lungs, a tracheotomy patient) to be placed on a pack. In 2013 the major tobacco companies sued the FDA and were able to delay the placement of these images until 2024 when the U.S Supreme Court declined to hear Big Tobacco’s appeal creating a major breakthrough for those in public health.
Now, in August of this year, a new appeals court has affirmed a preliminary block on enforcing the expanded 11-label rule, agreeing with the Tobacco appeal that the FDA only had the authority to place the original 9 they had asked for. For an industry that states , "To be very frank, nothing and nobody will stop us in our transformation to leave cigarettes behind. "We can see the world without cigarettes. And actually, the sooner it happens, the better it is for everyone.” CEO Jacek Olczak ( CEO of Philip Morris International), it is hard to understand why they continue to block the placement of these images as studies have shown they effectively increase public awareness of health risks, lower the overall appeal of tobacco products, and encourage quitting intentions.
Over 480,000 Americans have died annually from smoking since the late 20th century, with 8 million people dying worldwide every year from tobacco use. Society needs to once again recognize that these products are highly addictive and not “safe”. There needs to be a concerted effort by everyone to find a better way to protect children from ever using these products while at the same time helping those presently addicted to break their addiction. History has shown us that we cannot trust the Tobacco industry to help us in this effort.
Enough is Enough.
About the Author
Dr. Zablotsky received his dental and postgraduate degree in
periodontology from the Tufts School of Dental Medicine. He has lectured
throughout the US and internationally on tobacco related issues. He has
lectured and written courses for the American Dental Association, and
developed a curriculum covering all things related to tobacco and nicotine
usage for Nova Southeastern University School of Dental Medicine
integrating it with their School of Medicine where he continues to lecture.
He has written a chapter for the American Academy of Developmental
Medicine and Dentistry on nicotine and tobacco related issues that can
offer curriculum options for medical and dental schools.
He received the Vermont Advocate of the Year award from the American
Cancer Society and a lifetime achievement award for the Vermont Special
Olympics after 40 years of service.