Can Smokeless Nicotine Alternatives Deliver a Smoke-Free World by 2040?
Global public health experts are calling for a decisive shift in tobacco policy, urging the formal integration of tobacco harm reduction (THR) into international frameworks. Despite two decades of coordinated efforts under the WHO Framework Convention on Tobacco Control (FCTC), combustible smoking remains the leading cause of preventable death worldwide, prompting demands for a modernized approach to achieve a smoke-free world by 2040.
While traditional tobacco control measures have made notable progress, the rate of decline in smoking prevalence has slowed dramatically in many high-burden nations. With population growth, aging demographics, and uneven policy implementation, current strategies are unlikely to meet global non-communicable disease (NCD) targets. The rapid rise of smokeless nicotine products offers an unprecedented opportunity to accelerate the end of the smoking epidemic.
The Stagnating Global Burden of Smoking
Today, approximately 1 billion people worldwide still smoke cigarettes—the most lethal method of consuming nicotine. Combustible tobacco use remains the primary driver of chronic diseases, placing an immense, long-term strain on healthcare systems already burdened by aging populations and rising multi-morbidity rates.
This burden is highly unequal. Over one-third of the world’s adult smokers live in China and India alone, reflecting both massive populations and stubbornly high smoking rates, particularly among men. In most other regions, smoking rates are declining slowly and remain heavily concentrated among socioeconomically vulnerable groups, worsening existing health disparities.
Since entering into force in 2005, the WHO FCTC has served as the cornerstone of global tobacco control, encouraging smoke-free public spaces, advertising bans, graphic health warnings, and higher taxes. However, progress has hit a plateau. Nearly 50 countries have yet to implement a single high-level WHO-recommended demand-reduction measure, leaving nearly 2 billion people unprotected from tobacco-related harm.
Consequently, the world is on track to miss both the WHO’s voluntary target of a 30% reduction in tobacco use by 2025 and the UN Sustainable Development Goal of reducing premature NCD mortality by one-third by 2030. Even the UN’s latest target of reducing the number of tobacco users to under 150 million by 2030 would leave the global disease burden largely unchanged if combustion is not directly addressed.
Why Traditional Approaches Are Stalling
Public health priorities must shift to eliminate the inhalation of toxic tobacco smoke rather than waging a war on nicotine itself. Traditional policies rely heavily on demand-reduction strategies, such as aggressive taxation and advertising bans. While these measures remain vital, their ability to rapidly lower smoking rates is reaching its limit.
As smoking prevalence declines, the remaining pool of smokers increasingly consists of older individuals, highly dependent users, and marginalized populations who have tried and failed to quit multiple times. Treating nicotine use and cigarette smoking as identical evils ignores decades of scientific consensus: the primary driver of tobacco-related disease is the toxic smoke produced by combustion, not the nicotine itself.
Tobacco Harm Reduction: The Missing Strategy
Harm reduction is a core public health principle. When completely eliminating a risky behavior is unrealistic, the priority must shift to minimizing its adverse consequences. In the context of tobacco, this means providing smokers with access to significantly less harmful, non-combustible nicotine alternatives.
Importantly, harm reduction is explicitly recognized in Article 1(d) of the WHO FCTC as a component of comprehensive tobacco control. Yet, in practice, it remains underutilized and politically polarized. Rather than viewing harm reduction as an opponent of traditional tobacco control, policymakers should leverage it as a powerful accelerant.
The rapid evolution of smokeless products—including nicotine replacement therapy (NRT), oral snus, e-cigarettes, heated tobacco products (HTPs), and nicotine pouches—has transformed the landscape. By eliminating combustion, these products deliver nicotine with a fraction of the toxicants found in cigarette smoke. While no nicotine product is entirely risk-free, the relative risk of smokeless alternatives is dramatically lower than smoking.
Real-World Evidence: Country Case Studies
Several countries that have embraced tobacco harm reduction as part of their public health strategies demonstrate its profound impact on a population level:
| Country | Primary Alternative Adopted | Public Health Outcome |
|---|---|---|
| Sweden | Oral Snus & Nicotine Pouches | Achieved the lowest smoking rate in Europe; lung cancer and tobacco-related mortality rates are less than half of the EU average. |
| Japan | Heated Tobacco Products (HTPs) | Experienced an unprecedented 30%+ decline in domestic cigarette sales within five years of HTP introduction in 2016. |
| New Zealand | Regulated Nicotine Vaping | Accelerated its smoke-free transition post-2018, reducing adult smoking to historic lows, particularly among indigenous Māori populations. |
| United States | E-cigarettes / Vapor Products | Rapid declines in adult and youth smoking rates coincided directly with the widespread adoption of vapor technology. |
New Zealand’s experience is particularly telling. After decades of gradual progress using standard FCTC measures, the country saw its smoking rates plummet after legalizing and regulating vaping in 2018. Crucially, the steepest declines occurred among indigenous Māori and low-income communities, demonstrating that harm reduction can actively reduce health inequalities.
Implementing Risk-Proportionate Regulation
To fully realize the benefits of harm reduction, regulatory frameworks must be aligned with scientific evidence. Currently, highly lethal combustible cigarettes remain widely available and sold in almost every convenience store, while safer smokeless alternatives often face disproportionately harsh bans or restrictions.
A risk-proportionate regulatory model would correct this imbalance by aligning taxation, marketing restrictions, and public communication with a product’s position on the continuum of risk:
- Combustible Cigarettes: Should face the highest taxes, strictest packaging laws, and severe retail restrictions to reflect their extreme lethality.
- Smokeless Alternatives: Should be taxed at significantly lower rates and regulated to ensure product safety, prevent youth access, and minimize environmental impact—without destroying their appeal to adult smokers looking to switch.
Accurate public communication is vital. Misconceptions about the relative risks of nicotine products are widespread, often fueled by sensationalized media reports. Clear, evidence-based messaging from organizations like the WHO—clarifying that the toxins in tobacco smoke, not nicotine, cause the vast majority of cardiovascular diseases and cancers—is essential to help smokers make informed choices.
Addressing Youth Prevention and Policy Concerns
Opponents of harm reduction frequently raise concerns regarding youth uptake, long-term health uncertainties, and “dual use” (using both cigarettes and smokeless products simultaneously). While these issues require careful monitoring, they must be evaluated against the massive, immediate harms of ongoing smoking.
The “gateway hypothesis”—the idea that vaping funnels youth into smoking—has largely been debunked by population-level data. In countries where vaping has risen, youth smoking rates have continued to decline to historic lows. In New Zealand, regular vaping among youth who have never smoked remains rare, and overall youth smoking has dropped to approximately 1%.
Similarly, concerns over dual use often overlook the dynamic nature of smoking cessation. Many dual users are in the process of transitioning, gradually reducing their cigarette consumption before quitting entirely. Biomarker studies consistently show that dual users who significantly cut down on cigarettes experience lower exposure to harmful toxicants compared to exclusive smokers.
The Path to “Smoke-Free 2040”
The global “Smoke-free 2040” target—defined as reducing adult daily smoking prevalence to less than 5%—is highly achievable if policymakers embrace pragmatic, science-based strategies. If current trends continue under traditional policies, global smoking prevalence will only drop to about 10% by 2040. Reaching the 5% threshold requires doubling the current rate of decline, a feat already proven possible by nations utilizing THR.
While some countries have attempted coercive “endgame” legislations—such as generational smoking bans—these policies often face severe political, legal, and practical hurdles. New Zealand’s recent repeal of its generational ban highlights the fragility of coercive approaches. In contrast, providing regulated, safer alternatives offers a politically stable, consumer-driven path that naturally dismantles the illicit cigarette market.
For low- and middle-income countries (LMICs), where healthcare budgets are constrained and smoking cessation services are virtually non-existent, risk-proportionate taxation is the most viable tool. By keeping smokeless alternatives more affordable than cigarettes, LMICs can motivate millions of smokers to switch, saving countless lives and reducing future healthcare costs.
The scientific data, regulatory blueprints, and real-world case studies exist to end the global smoking epidemic. The only remaining obstacle is the political will to integrate tobacco harm reduction into the global public health agenda.
Reference:
- WHO. WHO Report on the Global Tobacco Epidemic, 2025: Warning About the Dangers of Tobacco (WHO, 2025).
- McHardy, J., Blanco Marquizo, A., Bettcher, D. & Gakidou, E. Lancet Respir. Med. 13, 756-768 (2025).
- NCD Countdown 2030 Collaborators. Lancet 406, 1255-1282 (2025).
- United Nations General Assembly. Political Declaration of the Fourth High-Level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases and the Promotion of Mental Health and Well-Being (United Nations, 2025).
- Royal College of Physicians. E-Cigarettes and Harm Reduction: An Evidence Review (RCP, 2024).
- Clarke, E. et al. Harm Reduct. J. 16, 62 (2019).
- Cummings, K. M. et al. Tob. Control 35, 79-82 (2024).
- Foxon, F., Selya, A., Gitchell, J. & Shiffman, S. Harm Reduct. J. 21, 136 (2024).
- Ministry of Health NZ. New Zealand Health Survey 2024/25 (Ministry of Health NZ, 2025).
- Jackson, S. E. et al. JAMA Netw. Open 7, e240582 (2024).
- Selya, A. Harm Reduct. J. 21, 113 (2024).
- ASH New Zealand. ASH Year 10 Snapshot Survey 2025 (ASH New Zealand, 2025).
- Warner, K. E. Am. J. Public Health 114, 1191-1194 (2024).
- Office for Health Improvement and Disparities. Nicotine Vaping in England: Evidence Update (OHID, 2022).
- Hartmann-Boyce, J. et al. Addiction 118, 539-545 (2023).
Beaglehole R., Bonita R. & Pang T. Smoke-free nicotine products can accelerate the end of the smoking epidemic. Nat. Health (2026). https://doi.org/10.1038/s44360-026-00121-1
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