I would like to extend my sincere thanks to Derek Yach for taking the time to answer a few questions about the report he recently published, titled: “Nicotine 2030”. Both the report and his responses below compel us to broaden the scope of our thinking about the situation. The interview discusses synthetic nicotine, how life insurance can help reduce smoking-related mortality, the WHO, the tobacco and nicotine industries, the illicit market, the situation in low- and middle-income countries, cytisine, differences of opinion among experts in the field, and future prospects. It’s food for thought, enjoy the read!
Q: Could you tell us a little about yourself, your past work in tobacco control, and what you’re doing now?
I’ve spent more than four decades in global health, with tobacco control as a constant thread through most of it. That started in South Africa as a medical student. At the Medical Research Council, we published major reviews of the epidemiological, economic and regulatory issues related to smoking that laid the basis for the Mandela government’s focus from the start on ending smoking. In 1993 I co-chaired (with the Minister of Health of Zimbabwe, the All Africa Tobacco Control meeting that had a few firsts: first meeting between tobacco growers and public health, first proposal by Ruth Roemer (UCLA and lead WHO lawyers on regulations) about the need for a Framework Convention on Tobacco Control, and first time that the ANC (represented by the about to be Minister of Health, Nkosazana Zuma) pledged to tackle tobacco use.
I was cabinet director at WHO under Gro Harlem Brundtland, where I led the work that produced the Framework Convention on Tobacco Control — the first treaty ever negotiated under WHO’s auspices. After WHO I worked at the Rockefeller Foundation, PepsiCo, the Vitality Group, and then founded and led the Foundation for a Smoke-Free World with a sharp focus on ending smoking through the use tobacco harm reduction products.
Today I work as an independent global health consultant through Global Health Strategies, and most of my energy goes into tobacco harm reduction: trying to get the science on safer nicotine products taken seriously by the institutions — WHO, finance ministries, insurers — that still treat all nicotine as equally dangerous, and supporting the work of Catholic Medical Mission Board as they establish NCD and cancer programs in LMICs.
Q: You just published a report titled “Nicotine 2030,” can you tell us why you wrote it and who you wrote it for?
I wrote it because the gap between what the evidence shows and what policy assumes has become too wide to ignore. It builds on several related reports I have led or supported over the last decade. Between 2016 and 2025 the nicotine marketplace went through its fastest transformation in history — daily vapers up from 22 million to 114 million, pouch users from 8 million to 35 million — and yet most public health institutions are still operating as if nothing has changed. The report is aimed at the people who set policy and move capital around this issue: regulators, WHO member states, insurers, finance ministries, and the industry and academic researchers who need to fill the evidence gaps that remain, particularly on pouches and heated tobacco in LMICs.
Q: The report was commissioned by a company that manufactures synthetic nicotine — isn’t there a conflict of interest?
It’s a fair question to ask. Zanoprima Lifesciences supported the report financially, and I disclosed that on the cover rather than burying it. But disclosure of funding is different from disclosure of evidence — every claim in the report is backed by peer-reviewed journals, Cochrane reviews, WHO and IMF documents, company SEC filings, and government data, not to anything Zanoprima produced internally. Readers don’t have to trust me; they can check the IMF’s 2026 fiscal analysis, the Cochrane living review, or the EAC-PM gutkha paper themselves. I’d also point out that conflict-of-interest scrutiny in this field is wildly asymmetric: funding from a synthetic-nicotine company gets flagged constantly, while funding from Bloomberg Philanthropies for anti-THR advocacy almost never does, even though both are funders with a stake in the policy outcome. For those who don’t know, Zanoprima Lifesciences was founded by the late Ashok Narasimhan, a visionary in the pharmaceutical industry for 40 years before his death. He was one of the first to produce NRTs in India and often mentioned his passion to do more to end toxic Gutkha and other forms of tobacco use in India. His son, Anand Ashok, continues the journey.
Synthetic Nicotine
Q: What is synthetic nicotine, and why $9–10 billion by 2030 — is that realistic?
Synthetic nicotine is chemically identical to the nicotine in tobacco leaf, but it’s made either through chemical synthesis from small precursor molecules or through engineered bacterial or yeast pathways, with no tobacco plant involved at all. Both routes now reach 99.9 per cent purity with no detectable tobacco-specific nitrosamines, which is a real manufacturing achievement. As for the $9–10 billion projection — it comes from Goldman Sachs’ market sizing work, and given that the US, EU and UK have all moved in the last couple of years to define “nicotine-containing product” by chemical composition rather than plant origin, the regulatory plumbing for that growth is being put in place. I’d treat any ten-year market projection with the usual humility, but the regulatory direction of travel supports it.
Q: Are there disadvantages to synthetic nicotine — the R-nicotine isomer, unknown long-term effects, lost revenue for tobacco farmers?
Yes. On R-nicotine: natural nicotine is almost entirely the S-isomer, and depending on the synthesis route, synthetic nicotine can contain a small fraction of the R-isomer, whose pharmacology and toxicology are less well characterized. Manufacturers using chiral resolution can get this down close to natural ratios, but not every producer does, and that’s a legitimate area for regulators to set purity standards rather than take on faith. Zanoprima uses an enzymatic route that produces S-Nicotine directly. On long-term effects: synthetic nicotine itself isn’t new chemistry, but its use at scale in consumer products is recent enough that we don’t have multi-decade epidemiological data — we’re relying on toxicology and on the fact that nicotine itself, as opposed to combustion products, has a fairly well-understood risk profile. Recall though that NRTs have been on the market for over 40 years and retain an extremely high safety profile.
And on farmers: this is real and I don’t think the field talks about it enough. Smallholder tobacco farmers in Africa and Asia have legitimate cause for concern, and I’ve argued elsewhere that FAO, WHO and the World Bank have largely ignored their FCTC Article 17 obligations to help these farmers transition. That’s a gap industry and donors both need to close, not something synthetic nicotine’s advocates should minimize. And its why I supported a multimillion dollar grant to Malawi to establish the Agricultural Transformation Agency that after 8 years has shown that alternative livelihoods are possible and profitable.
Q: Can synthetic nicotine be used or recommended without long-term clinical studies first?
Anyone watching progress in innovations underway in oncology prevention and treatment might ask the same question. The reality is that today we can get a strong view of future health risks by using a growing range of biomarkers predictive of health outcomes and these are being used led by PMI and BAT.
Pharmaceutical-grade nicotine-replacement uses goes through the same regulatory pathway as any NRT product, and several agencies already prefer synthetic sources precisely because GMP certification is cleaner without agricultural variability. For consumer vapes and pouches using synthetic nicotine, the honest answer is that we’re in the same position we were in with tobacco-derived nicotine in those same products a decade ago: relying on short- and medium-term biomarker and toxicology data while longer-run cohort data accumulates.
Life Insurance
Q: Can you explain how life insurance can be used to reduce smoking-related mortality?
Insurers price risk, and right now most of them price all nicotine use as if it were cigarette smoking, even though we can now distinguish a smoker from a vaper or pouch user with two to five biomarkers. Once an insurer can verify that someone has switched completely to a low-risk product, there’s an actuarial basis to charge them a lower premium than a smoker — not the same as a never-user, but meaningfully lower. That premium gap becomes a direct financial incentive to switch, on top of the health incentive, and Swiss Re’s 2025 modelling shows it operates at serious scale: full adoption of risk-proportionate underwriting in the $2,525 billion global life market would rebalance roughly $71 billion in annual premium and unlock a new $35–50 billion cessation-linked insurance product category.
Q: Should public health officials get more involved here and encourage insurers to adopt similar reforms?
I think they should, yes, but carefully. Public health officials aren’t insurance regulators, so the lever isn’t to dictate underwriting practice — it’s to make sure the biomarker science Swiss Re is relying on gets validated and adopted as a public good, and to remove any regulatory ambiguity that might make insurers cautious about reclassifying nicotine users. The most useful thing a health ministry can do is support the kind of biomarker database work that groups like Knowledge·Action·Change have called for, so that insurers in lower-income markets aren’t stuck waiting for European or American actuarial data to trickle down to them.
WHO
Q: Where does the problem stem from — WHO leadership, the FCTC, Bloomberg funding, or the General Assembly (e.g. India)?
It’s all four, and they reinforce each other. WHO leadership has taken a precautionary, undifferentiated stance toward all nicotine products for years, which filters down into how the FCTC Secretariat frames issues for the Conference of the Parties. Bloomberg Philanthropies funds a very large share of the global tobacco-control advocacy ecosystem, and that funding has consistently favored prohibition over harm reduction, which shapes the civil-society voices in the room. And at the Conference of the Parties itself, a bloc of member states — India prominent among them — has pushed hard for restricting or banning new products rather than regulating them, partly out of genuine concern about market expansion and partly, in India’s case, while overseeing a domestic market where banned e-cigarettes coexist with an exploding, unregulated gutkha market. None of these four factors is sufficient on their own to explain the institutional position, but together they’ve made it very hard for harder evidence to break through.
Q: What would be the best strategy to get the WHO to change its attitude?
I think the single highest-leverage moment is the Director-General election in May 2027 — we set that out as recommendation six of the ten in the report. Beyond that, I’d point to three things: getting member states that have already adopted harm reduction domestically (the UK, Sweden, New Zealand, the Philippines, Japan) to advocate for it collectively at COP rather than individually; activating FCTC Article 1(d), which already provides for harm reduction but has sat dormant since 2005; and commissioning an independent scientific review that isn’t run through the same advocacy networks that have shaped WHO’s current position. None of this is fast. But COP12 is a real near-term juncture for movement on Article 1(d), and the DG transition is the structural opportunity behind it.
Q: How can advocates ensure WHO selects the next Director-General who supports tobacco harm reduction, and what strategy should they adopt?
Civil society and member states need to treat this election the way other global health constituencies treat DG elections — organized, early, and substantive rather than symbolic. Practically, that means engaging candidates directly on their FCTC Article 1(d) position well before the formal nomination process, building a coalition of member-state health ministries that will ask the question publicly during candidate forums, and making sure the consumer organizations — INNCO, ETHRA, CASAA, the African Harm Reduction Alliance — have a seat at those forums rather than just industry and traditional tobacco-control NGOs. The HIV/AIDS movement’s “nothing for us without us” principle is the model: it wasn’t only scientists who changed that policy landscape, it was organized people with a direct stake in the outcome.
Q: Are MPOWER’s other policy actions not sufficient — why is Article 1(d) “the most consequential policy action available”?
MPOWER has done real work — it helped take global adult smoking prevalence from roughly 33 per cent in 2000 to 20 per cent by 2022. But its pace has slowed sharply since 2015, and WHO’s own estimate is that fully implementing MPOWER going forward would cost over $400 billion, a figure nobody believes is achievable. Conventional cessation interventions still only produce about a 7 per cent annual quit rate and reach a small percent of smokers in most LMICs, meaning over nine in ten smokers who try to quit with approved methods relapse within a year. MPOWER was built for an era before vaping, pouches and heated tobacco existed at scale; it has no real mechanism for engaging the people who won’t quit cold but will switch. That’s precisely the gap Article 1(d) is positioned to close, and it’s why I’d call it more consequential right now — not because MPOWER doesn’t matter, but because it’s running into diminishing returns.
Q: What would you say to people in LMICs who fear THR will undermine traditional tobacco control?
I’d say look at what prohibition has produced rather than what it promises. India banned e-cigarettes in 2019, and since then rural gutkha use — a Class-I carcinogen combination — has risen more than fivefold, now accounting for 41 per cent of rural tobacco spending. That’s not a hypothetical trade-off; it’s what happened. My report provides other examples from South Africa and Australia worth reading. Harm reduction isn’t a replacement for taxation, advertising bans, and smoke-free air laws — it’s meant to sit alongside them as an option for the smoker or user of toxic forms of oral tobacco who isn’t going to quit through those measures alone. The fear that THR “undermines” control measures assumes those measures are working well enough on their own that introducing alternatives would distract from them. In the countries with the highest remaining smoking burden, that assumption isn’t holding up.
Industry
Q: Couldn’t we just rely on consumer demand and corporate strategy to drive the transition — are they strong enough to overcome over-regulation and misinformation?
They’re powerful, but no, I don’t think they’re sufficient on their own, and the report doesn’t argue they are. Consumer demand and margin incentives explain why PMI now gets 41.5 per cent of revenue from smoke-free products and why the industry-wide crossover could happen by 2028–2030 in advanced economies. But those same forces have made essentially no progress in markets where regulation blocks them outright — China, Indonesia, India. Market forces can’t overcome a legal ban; they just get diverted into illicit channels, which is exactly what’s happened with roughly 48 per cent of vape sales in Europe being irregular, and with Australia’s $3 billion-plus black market. So, the two forces are necessary but not sufficient — they need a regulatory environment that lets them operate, which is a policy choice, not a market outcome.
Q: Does that mean we shouldn’t worry too much about divisions in the field and misinformation, because the market will bring change anyway?
No. Misinformation is precisely one of the headwinds slowing the market-driven transition — nearly 80 per cent of physicians worldwide believe nicotine itself causes cancer, and that misperception measurably suppresses switching even where products are legally available. Note that misinformation has increased over the last 5 years exactly at a time when evidence of benefits has accumulated. Division among experts feeds directly into the regulatory uncertainty that blocks market forces from operating in the first place. So, it’s the opposite of complacency-inducing: misinformation and division are part of why the market hasn’t already finished this transition in places like the US and Europe despite favorable economics.
Illicit Market
Q: 48 per cent of vape sales in Europe are irregular — can this be changed without lifting bans on non-combustible products?
Where there’s an outright ban, no — a ban is what creates the irregular market in the first place. But the European case is more specific than that: most EU countries don’t ban vapes, they regulate them inconsistently, with gaps in enforcement, flavor restrictions that push demand underground, and weak customs controls on imports. The fix there isn’t necessarily lifting bans — it’s tighter, more consistent enforcement of existing legal frameworks, ISO-accredited testing requirements, and closing the price gap between legal and illicit products through sensible taxation. Where bans are the actual mechanism, as in India or pre-2026 Argentina, the evidence is unambiguous: prohibition didn’t suppress demand, it just relocated it to gutkha or grey-market imports.
LMIC
Q: Are LMIC fears about THR expanding the nicotine market justified, and can a model built in high-income countries apply to LMICs?
The fear deserves to be taken seriously rather than dismissed. Countries with low smoking prevalence, a young population, and a large informal market genuinely have less to gain and more theoretical exposure to new-market creation than a country like the UK or Sweden with a large, entrenched adult smoking population. That’s a real asymmetry, and I think the report’s own Box on Africa’s low-smoking nations — Nigeria, Ethiopia, and others with rates under 5 per cent maintained through cultural and religious factors rather than switching — makes the same point: prevention is easier than cure, and aggressive marketing into those markets would be a mistake. Where I’d push back is on lumping all LMICs together. China, India, Indonesia and Russia have enormous existing smoker populations — over half the world’s smokers — and for those countries, THR isn’t about creating new demand, it’s about giving existing smokers an off-ramp. The Swedish, Japanese or UK model doesn’t transplant wholesale anywhere, but the underlying logic — give addicted users a less harmful alternative — isn’t culturally or economically bound to high-income settings.
Q: Over half the world’s smokers live in China, India, Indonesia and Russia, and all four regulate vapes and pouches tightly. How can this change?
The report’s own modelling on this is instructive: applying the IMF’s risk-proportionate tax framework to just China, India and Indonesia — a 30-point cigarette tax increase paired with an 80 per cent cut in taxes on verified reduced-risk products — could mean over 140 million fewer smokers across the three countries within a decade, conditional in India’s case on lifting the vape ban entirely. Realistically, change in these four markets will come country by country and for different reasons: India’s path likely runs through domestic recognition of the gutkha-ban failure documented by its own Economic Advisory Council; China’s monopoly structure makes this a state decision rather than a market one; Indonesia faces cultural resistance despite already-high taxes; and Russia’s path is harder to predict given the broader regulatory environment there. There’s no single lever — it’s largely a matter of each government weighing its own fiscal and public-health evidence.
Q: Why does China National Tobacco Corporation remain so reliant on combustibles — fear of losing tax revenue, or other reasons?
Tax revenue is certainly part of it with about 7/8 of general revenues coming from tobacco— CNTC is a state monopoly, so its commercial incentives and the government’s fiscal incentives are the same thing, unlike PMI or BAT, which answer to shareholders who reward the shift toward higher-margin smoke-free products. But I’d add a structural point: China legalized e-cigarettes through the state monopoly in 2022 but restricted flavors in 2023, and a draft regulation from the State Tobacco Monopoly Administration in late 2025 moved to prohibit new production licenses — signaling Beijing wants to consolidate control over the domestic vaping industry rather than let it grow independently of the state tobacco structure. That looks less like pure revenue protection and more like a state preferring to manage the pace and shape of transition on its own terms, rather than ceding the category to market competition the way PMI or BAT have had to. I have hope that before long China will address the combustible cigarettes as it addresses the combustible car engine-through innovation, clean technologies and the potential for global leadership. I write this from Shenzhen. An incredibly quiet, clean, and environmentally sustainable city built on those principles and of course, home to 500 000 workers in the vape and related sectors.
Impact
Q: The Cochrane review found 4 additional quitters per 100 over NRT, which itself only adds a few percentage points. Isn’t that disappointing? Is it realistic to expect non-combustibles to meaningfully cut mortality?
Taken purely as a head-to-head cessation trial number, it can look modest, and I understand why that reads as underwhelming. But two things matter here that the raw number doesn’t capture. First, the Cochrane figure of roughly four additional quitters per hundred is a relative-risk comparison against NRT specifically — the 2025 update found e-cigarettes increase cessation by about 59 per cent over NRT, and a 2026 overview in Addiction found 20 to 40 per cent gains over NRT and at least 46 per cent over non-nicotine placebo devices. Second, and more importantly, full cessation isn’t the only outcome that matters for mortality. Real-world cohort data in the report shows the dominant pattern isn’t 10 to 15 per cent quitting outright — it’s 30 to 50 per cent of users cutting cigarette consumption by half or more, which still meaningfully reduces toxicant exposure even without complete quitting. At population scale, applied across a billion smokers, even a 20 per cent switching rate over 15 years is modelled to avert roughly 100 million premature deaths by 2060. Modest individual-level effect sizes can still be enormous in aggregate when the starting population is this large.
Q: In the report’s hypothetical scenario, 20 per cent switching could prevent 100 million premature deaths. What are the main obstacles to this scenario?
Three, mainly. The first is regulatory: outright bans on vapes or pouches in countries holding thirty-some per cent of the world’s smokers — India, Vietnam, Turkey, Mexico, and until last month Argentina — close off the off-ramp before it can be used. The second is misperception: with close to 80 per cent of physicians worldwide believing nicotine itself causes cancer, the clinical and public messaging environment actively discourages the switching the scenario depends on. The third is access and affordability in the countries that carry 80 per cent of the global smoking burden but currently see only about 3 per cent of reduced-risk product sales — LMICs need both regulatory permission and commercially viable, affordable products, and right now they mostly have neither. Colleagues and I have written about the serious underinvestment by Bloomberg, WHO, tobacco companies in building the capacity of scientists in LMICs to innovate, evaluate programs, and shape interventions to meet their highest risk smokers. That hampers science and policy development.
Cytisine
Q: How could we accelerate acceptance, uptake and regulatory approval of cytisine, especially in LMICs where varenicline and bupropion may be too expensive?
Let me first acknowledge with admiration your incredible work in this field over decades.
Cytisine’s addition to WHO’s Essential Medicines List was an important step, but listing isn’t the same as access. I’d prioritize three things: getting national essential-medicines lists in LMICs to follow WHO’s lead quickly, since that’s what unlocks public procurement and insurance coverage; funding generic manufacturing and distribution in the markets where cost is the binding constraint, since cytisine’s main appeal versus varenicline and bupropion is that it can be produced cheaply; and continuing medical education, because a large part of the uptake problem isn’t regulatory at all — it’s that most physicians, even in countries where cytisine is approved, simply don’t know it exists or haven’t been taught to prescribe it. That last gap is probably the cheapest one to close and the most neglected. I work with health ministries in LMICs and they have no knowledge about cytisine and incidentally give extremely low priority to equipping their PHC facilities with NRTs.
Division
Q: How can we surmount the divisions among experts in this field?
I don’t think full consensus is coming soon, and I’m not sure it should be the goal. What would help more is separating the empirical disagreements from the values disagreements. A lot of what looks like scientific division is actually a disagreement about acceptable risk, about how much weight to give to industry involvement in research, or about whether harm reduction distracts from abstinence-focused public health — those are legitimate value questions, not data questions, and treating them as if better evidence alone will resolve them hasn’t worked. Where I do think progress is achievable is on the genuinely empirical gaps: more RCTs on pouches and heated tobacco specifically, more research in LMIC populations, more inclusion of older, heavier smokers and people with serious mental illness in trials. Closing those gaps won’t end the disagreement, but it would at least narrow the part of it that’s about evidence. Readers would do well to read through the Morven Dialogue output on this topic. It was driven for years by Scott Ballin- a truly rare advocate for ending smoking who spent his career reaching out to those with differing views.
Q: How can we reduce opposition to innovation and tobacco harm reduction?
Partly through the financial and actuarial validation the report documents — when the IMF and Swiss Re, institutions with no stake in the tobacco-control debate, independently arrive at risk-proportionate conclusions, that’s harder to dismiss as industry talking points than when the same argument comes from a company-funded report. Partly through consumer voice: when organized users with no commercial ties — INNCO, ETHRA, the New Nicotine Alliance — make the case for risk-proportionate regulation, policymakers can’t wave it away as corporate lobbying the way they sometimes can with industry submissions. And partly, I’ll be candid, through time and generational turnover in institutions — some of the entrenched opposition is generational as much as evidentiary.
Q: Is it reasonable to assume that opponents of THR will become obsolete and irrelevant as the pace of change accelerates?
I’d be careful with that framing. Market and technological change can absolutely outpace institutional resistance — that’s effectively what’s happening in the UK, Japan, Korea, Iceland and Sweden, where the market and the regulator moved together. But in markets where opposition controls the regulatory lever directly — India’s vape and nicotine pouch ban, Australia’s prescription-only regime — opposition doesn’t become irrelevant just because the technology keeps improving; it can actively suppress the legal market while pushing demand into illicit channels, which is the Australian story over the last few years almost exactly. I wouldn’t bet on obsolescence solving this on its own. The places where opposition holds formal regulatory power are precisely the places where it can keep mattering for a long time, technology notwithstanding.
Future Prospects
Q: Should we expect new disruptive technologies, and what kind of products will they be?
I’d watch three areas. First, precision-dosing devices — programmable vapes and inhalers with dose feedback, moving cessation science toward delivering just enough nicotine to suppress withdrawal without reinforcing dependence. Second, further growth and refinement of synthetic nicotine, including micro-encapsulated formulations for targeted, non-systemic delivery in therapeutic contexts well beyond smoking cessation — there’s real, if early, science on nicotine’s anti-inflammatory and neuroprotective properties in conditions like ulcerative colitis and Parkinson’s disease that synthetic formulations could eventually serve. Third, regionally adapted products like electronic shisha for the Middle East and North Africa, which could do for hookah-culture markets what heated tobacco did in Japan — offering a culturally familiar format without the combustion. None of these are guaranteed to scale the way vaping did, but they’re directions where I see genuine innovation pressure building.
A real privilege to share my views and insights about ending smoking with you. Look forward to comments and feedback.
Thanks and agree that more on cessation would be helpful- but great you filled that gap!