In a recent document, the World Health Organization (WHO) writes:
Governments can best protect health by fully implementing comprehensive tobacco control measures that reduce demand and supply for all tobacco, nicotine and related products. This includes:
• Where countries ban manufacturing, distribution and sale of specific product categories, enforcing those prohibitions rigorously against commercial actors…
Thus, prohibition is now at the heart of WHO policy in this area. Using e-cigarettes is prohibited in several countries, e.g. : Singapore, Thailand and Qatar, where users face heavy fines or prison. Selling e-cigarettes is prohibited in several countries, e.g. : Brazil, Mexico, Ethiopia. Partial bans are ubiquitous, e. g. in Australia, e-cigarettes are available only by prescription; in Japan, nicotine-containing e-liquids are banned; disposable vapes are banned in many countries. In the UK, it will be illegal to sell vapes to people <18 years old, or tobacco to people born after 2009. In many countries, e-liquid flavors other than tobacco are banned.
The ethical question is this: given that most of the harmful effects stem from combustion rather than nicotine, and that some smokers are unable or unwilling to stop using nicotine, is it ethical to deny them access to less harmful alternatives, while cigarettes remain widely available and are not subject to similar bans?
The principles of bioethics can help us answer this question:
- respect for persons and their autonomy,
. beneficence,
- non-maleficence,
- justice.
The principles of public health ethics can also serve as a guide: analyzing issues from a population perspective, with an emphasis on prevention and social justice.
The principle of autonomy:
First, we should acknowledge that nicotine dependence can undermine consumers’ autonomy and their ability to make autonomous decisions. In particular people with mental health issues, who may find it particularly difficult to quit smoking or the deal with nicotine withdrawal symptoms, and vulnerable or marginalized populations with high smoking prevalence.
Also, at the center of this debate is the fact that the availability of nicotine products can lead some young nonsmokers to develop nicotine dependence. It is therefore necessary to protect them through effective, proportionate, and ethical measures.
Autonomy: duty to inform:
People are treated with dignity and respect when they are given choices and accurate information. Therefore, opinion leaders, professionals in this field and decision makers have a duty to provide truthful information about nicotine and tobacco, to inform the public on the specific risks of each product, compared with the risks of smoking and with the risks in non-users.
The problem is that prohibitions are often based on false assumptions and accompanied by misinformation, or information that emphasizes absolute risk rather than relative risk (compared to smoking).
For example, the EU Health Commissionner Olivér Várhelyi said that he is « 100% sure » that e-cigarettes, heated tobacco and nicotine pouches are as harmful as cigarettes.
In the same WHO document, we can read that :
« All tobacco, nicotine and related products pose health risks, including risk of addiction »
The problem with this statement is that it leads the readers to think that all products are equally harfmul, whether or not they burn tobacco, which is obviously wrong.
Withholding information about safer alternatives is a violation of the duty to inform and to provide the best possible options. Users are denied the opportunity to make informed choices based on their preferences and values. Furthermore, this misinformation undermines public trust in health authorities, and this mistrust can then spread to other areas (such as epidemics or vaccines).
A ban is also a form of paternalism, as it assumes that consumers are incapable of making informed and independent choices, and this undermines their dignity. To respect the autonomy of users, the authorithies should use the least restrictive measures to achieve public health goals.
The principles of beneficience and non-maleficience
Primum non nocere : does a ban “do no harm”? Bans give a competitive advantage to cigarettes, which are not subject to similar bans. If the prohibition discourages smokers to switch to non-combustible products, or pushes former smokers back to cigarettes, then it may perpetuate smoking, and cause more harm than good.
The logic of prohibition is quite radical, as it says to smokers: “quit or die”. This approach lacks compassion, to the point that one may suspect that it is not primarily intended to protect public health, but motivated by other objectives (a moral aversion to nicotine, or political, electoral or strategic considerations, or ideology). Bans are not proportionate, in part because their foundation is ideological. Harm reduction is more pragmatic and better serves the smoker’s interests.
The effects of prohibition:
When a product is prohibited, youth uptake may decline, but not always, particularly if illicit products are easily available, or if an innovation replaces the banned product. In any case, strong enforcement is required.
Furthermore, addiction is defined by compulsive use in spite of adverse consequences. Therefore, people will continue to use addictive products despite the prohibition, and demand does not disappear after a product is banned.
Adverse consequences of prohibition:
In the field of addictions, decades of experience show that bans have predictable, largely negative consequences. The first one is that the prohibition hands the market over to criminal groups. The creation of a black market fuels criminality and violence,
e.g. in Australia and Brazil. In the USA, 86% of retail sales of e-cigarettes are for illegal products. And a ban puts consumers in contact with drug dealers and criminal organizations.
If a product is banned, there can be no regulatory oversight, no quality control, no safety standards, and the products may contain iIlicit ingredients or be of inferior quality. In addition, the most vulnerable and marginalized groups are disproportionately affected by criminality and by enforcement and over-policing by authorities. Is it ethical to create conditions that foster the emergence of illicit markets when there are other solutions, safer and more effective ?
If a product is banned, the protection of minors is compromised, as manufacturers and distributors are no longer subject to any restrictions regarding packaging, advertising, content, flavors, etc. This outcome runs completely counter to the original intention, which was to protect young people.
Also, the development of illicit markets and the ubiquitous availability of illicit products that are designed to attract young people comes with a reputational cost for the field: regulators and health professionals cannot trust products that are so wildely uncontrolled.
Furthermore, a banned product cannot be taxed, which results in a loss of revenue for the government, in addition to increased costs for enforcement. Ideally, products should be taxed according to their level of risk: cigarettes should be taxed the most, followed by heated tobacco products, then e-cigarettes, while nicotine pouches should be taxed the least.
Other innovations in harm reduction initially sparked controversy, facing opposition based on moral and ideological considerations, before proving their effectiveness and being accepted as a pragmatic approach, for example needle exchange, supervised injection sites, medical prescription for heroin. In my country, Switzerland, these measures have been approved in referendums on several occasions over the past 35 years. A prohibition stifles innovation and favors cigarettes over the reduced-risk innovations
Also, banning innovations is a misinterpretation of the precautionary principle, this principle does not imply that innovations should be banned. The European Union has a systematic approach to the precautionary principle, based on the following principles :
Fullest possible scientific examination of the degree of uncertainty,
Examination of the costs and benefits of action or inaction,
Participation of all interested parties,
Proportionality between measures and the chosen level of protection
Non-discrimination: comparable situations should not be treated differently
Consistency with actions already taken in similar situations
Reversibility: measures should be subject to review based on new data
Burden of proof: should be assigned (to the consumers or the producers)
A ban runs counter to these principles, as well as to the rules of good legislative practice and good governance.
Young people:
Young people require special protection and should not use nicotine or tobacco. They may be immature or inexperienced and may not be able to make decisions as adults do. Their ability and their right to independence and autonomy are limited. Therefore, as in other contexts, young people should be afforded stronger protection than adults, since they cannot exercise their rights and make choices in the same way. However, there are less restrictive and more ethical measures to protect young people, including:
•Education and information: school-based prevention, mass media and social media campaigns (as long as these interventions do not spread misinformation…),
•Economic and financial measures: taxation proportional to risk, minimum prices,
•Marketing and commercial restrictions: advertising and sponsorship restrictions, packaging restrictions,
•Environmental and social measures: smoke-free and vape-free environments, denormalization, interventions using peer influence,
•Product regulation: limits on nicotine content and flavors, quality control, pre-market authorization,
•Access measures: age verification, retail licensing,
•Structural measures that reduce the risk factors, like reducing vulnerability and poverty, better healthcare,
•Research and surveillance, monitoring of the patterns of use, the new products, the industry’s behavior and marketing practices, the health effects, the illicit trade.
Implemented together, these measures can produce the desired outcome, while being less restrictive and more ethical than a ban.
The gateway theory:
This theory is at the core of the dispute on new tobacco and nicotine products. It states that young non-users who start using a non-combustible product will become addicted to nicotine, and then will start smoking. This theory has an enormous influence, perhaps because of its simplicity. It is a causal theory, and is therefore difficult to prove or disprove in the absence of experimentation. It is a controversial theory, also in the case of cannabis causing or not causing heroin use, in particular because the available data are also compatible with a common liability model, which states that the same risk factors cause both smoking and vaping (e.g. social, or psychological, or genetic factors). Vaping may increase the risk of smoking in some some teens and decrease it in others, this depends on the product, the social context, the individual vulnerability. Time trends are often cited to support or to reject the gateway theory, but they do not prove causality, and they vary across countries: e.g. the time trends for vaping and smoking differ in the USA, the UK, and Switzerland.
What sort of studies do we need to progress in the debate on the gatewa theory? First, there is no need for more studies of antecedence (vaping first, then smoking) combined with increased relative risk of subsequent smoking, because there are many such studies already, and they cannot establish causality. Rather, we need:
- experimental intervention studies,
- studies of the effects of regulations,
- large, specific longitudinal studies, with frequent repeated measures, that measure all confounders,
- studies using propensity scoring,
- monitoring and surveillance,
- behavior genetic studies.
(See my 2018 article in Addiction for an in-depth discussion of the gateway theory).
The principles of justice and social justice:
Who bears the cost of prohibition? First, the smokers who continue to use cigarettes, the most dangerous product. Also the consumers who are exposed to unregulated, unsafe products and to drug dealers. Then the populations that are victims of criminal gangs (Australia, Brazil, Mexico, etc.), in particular the disadvantaged social groups, because they have the highest smoking prevalence, carry the highest burden of disease, and are the most affected by enforcement and over-policing. And finally the legitimate manufacturers, who are pushed out by illicit providers.
Is it acceptable to sacrifice them in the (ideological) fight against nicotine ?
Who bears the moral and legal responsibility for the negative, yet often accepted, consequences of prohibitions, in particular if its proponents are aware of the negative consequences, have been warned about them, but choose to proceed anyway
(e.g. the Australian Government). Will anyone ever be held accountable, and if so, who, and by whom ?
Why do these prohibitions persist ?
Why do these bans persist, even though the “cure” is often more harmful to society than the products themselves? I see the following reasons for the rejection of new non-combustible products and for the division that prevails in the field of tobacco harm reduction. I will elaborate on these points in another article:
The fear that young people will start smoking and our collective inability to protect them, even though it is inevitable that some young people will eventually use nicotine.
Historical conflict with the tobacco industry (the “light” cigarettes), the industry is the traditional enemy.
Differences in goals (reducing the mortality vs. reducing nicotine use).
Differences in perceptions of nicotine, moral discomfort with nicotine use.
Misinformation.
Rejecting the new products is the easiest choice: to be well-informed and to understand the intricacies of tobacco harm reduction, you need to work hard.
Conformism, groupthink, institutional inertia in tobacco control.
Social media and tribalization.
Misguided leadership (e.g. WHO, EU).
Funding of WHO and of several NGOs by Bloomberg.
Conflicts of interest (exist on both sides).
Electoral or political strategy (e.g. Trump vs. FDA commissioner Makary). Governments may try to avoid responsibility by claiming they by banning vapes, they did everything bthey could.
Differences between countries (LMIC have different smoking prevalence, demographics, informal sector, etc.).
Conclusions:
Bans run counter to the core principles of bioethics and public health ethics. A better approach would prioritize reducing disease and death (versus targeting nicotine), be pragmatic rather than ideological, respect the principles of autonomy and justice, provide accurate information, use the least repressive measures that are effective to obtain outcomes, remain open to innovation, apply the precautionary principle correctly, and evaluate policies based on results, not on ideals or unrealistic intentions.
What should we do now ?
First of all, we should protect children and adolescents, who should not use these products.
It is also crucial to provide accurate and honest information.
We should also select leaders who prioritize health and pragmatic, evidence-based solutions.
There is a need for greater transparency regarding conflicts of interest, on both sides of the debate.
We should limit the influence of private funding on public policy.
We should also recognize the differences that exist between and within countries, and produce better science, particularly in LMIC.
We should engage in dialogue with the users and involve them in policy-making and research.
Capacity building is essential, as misconceptions lead to disagreements. Healthcare professionals should be required to undergo continuing education in order to provide their patients with proper advice.
We should encourage open, inclusive debate, to prevent factional mindsets and behaviors.
And we should seek compromises, which often are the only feasible policy option.
(This article is based on a presentation that I gave at the Global Forum on Nicotine in Warsaw on June 4, 2026).
I agree that too many education or mass media campaigns spread misinformation. I have no solution for this except perhaps capacity building (educators, health professionals, public health professionals etc. ).
Terrific analysis. I think prohibitions are often a way for authorities to avoid responsibility and accountability. They can claim they are taking the strongest possible measures and therefore cannot have done more to avoid harmful consequences. Not true, of course, given the wide range of foreseeable harms that arise from illegal trade that follows, compounded in the case of bans on far safer products than the legal market norm.