Three former WHO officials have published a commentary in Nature Health calling on the global health community to formally integrate tobacco harm reduction into international tobacco control policy. The authors, Robert Beaglehole, Ruth Bonita, and Tikki Pang, spent careers building the global tobacco control architecture. When people with that background say the current approach is failing and that less harmful alternatives are part of the solution, that matters.

Their central argument is straightforward. Smoking still kills more than seven million people every year. The WHO’s own target of a 30% reduction in tobacco use by 2025 is not on track. Neither is the Sustainable Development Goal to cut premature mortality from non-communicable diseases by one third by 2030. Progress has stalled, and the authors are direct about why: current approaches cannot drive smoking rates down fast enough, particularly among older, more dependent smokers who have already tried and failed to quit multiple times.

The authors are also direct about a problem that has crept into tobacco control debates. In some policy circles, the goal has quietly shifted from eliminating combustible tobacco to eliminating nicotine altogether. The commentary pushes back on this. Decades of evidence show it is exposure to smoke from combustion, not nicotine, that drives tobacco-related disease. Conflating the two does not protect public health. It gets in the way of it.

The solution the authors propose is not a departure from existing tobacco control. It is an addition to it. They call for a global smoke-free 2040 goal, defined as adult daily smoking prevalence below 5% by 2040, achieved by combining established measures under the Framework Convention on Tobacco Control with wider access to regulated, smoke-free nicotine alternatives. Crucially, they point out that harm reduction is not a new idea being imported from outside the FCTC framework. It is already explicitly recognised in Article 1(d) of the FCTC as a component of comprehensive tobacco control, alongside supply- and demand-reduction strategies. It has simply been ignored in practice.

The evidence they point to is the same evidence harm reduction advocates have been citing for years. Sweden has the lowest smoking rate in Europe and lung cancer rates less than half the EU average, built on decades of access to snus and nicotine pouches. Japan saw unprecedented declines in cigarette sales after heated tobacco products became widely available. New Zealand accelerated its smoking decline sharply after 2018, when access to regulated vaping products expanded, with the steepest drops among Maori and other historically disadvantaged groups.

On youth, the authors are specific. In New Zealand, regular vaping among never-smokers is rare, experimentation has declined in recent years, and youth smoking prevalence is now around 1%. The gateway concern, the idea that vaping leads young people to smoking, is not supported by population-level data. Strong youth protection and accessible alternatives for adult smokers are not in conflict.

Perhaps the most pointed section of the commentary deals with regulatory misalignment. Cigarettes remain widely available with relatively light restrictions in many markets, while less harmful alternatives face heavier regulatory burdens, flavour bans, and in some cases outright prohibition. The authors describe this as a misalignment that risks protecting the most dangerous products while limiting access to less harmful substitutes. A risk-proportionate framework would do the opposite: apply the strictest restrictions to combustible tobacco and regulate alternatives based on their actual risk.

These conclusions come from people who helped design the global tobacco control system and who have no stake in any commercial outcome. Their conclusion is that the system needs to be updated to include harm reduction, and that failing to do so will cost lives.

The WHO has been resistant to this position. Its meetings under the FCTC have repeatedly failed to engage seriously with the evidence on less harmful alternatives. That resistance has consequences. Every year the WHO delays, more smokers who could have switched do not. The commentary in Nature Health is a direct challenge to that position, from people the WHO cannot easily dismiss.

The evidence is there. The real-world examples are there. What the authors identify as missing is political will. That is the honest conclusion, and it is one the global health community should sit with. 

The full article can be found hemen.