With prohibition strategies failing smokers and all the existant evidence in favour of tobacco harm reduction, educating doctors about what actually works could save millions of lives.
For more than a century, smoking has been a leading driver of preventable death worldwide. In India alone, it claims over a million lives every year. In the United States, it kills nearly half a million annually. And across Europe, youth nicotine use is becoming entangled in black markets and online loopholes. Despite the clear human cost, policies in many countries continue to treat harm reduction with suspicion—or ignore it altogether. Increasingly, doctors and health professionals are stepping forward to challenge this approach, arguing that science and compassion must guide how governments respond.
India illustrates the stakes. In 2019, the government passed the Prohibition of Electronic Cigarettes Act, outlawing the manufacture, sale, and even storage of vaping products. Six years later, smoking rates remain stubbornly high and more than 253 million Indians still use tobacco—often in its most dangerous forms, such as bidis and gutkha. Far from curbing demand, prohibition has spawned a thriving illicit market where unregulated devices are sold openly in shops or through online networks.
Some doctors are challenging the status quo
Recently, two physicians from the All India Institute of Medical Sciences (AIIMS), Dr. Vaibhav Sahni and Dr. Abhishek Shankar, broke ranks with their institution’s official stance. Drawing on international evidence, they argued that electronic nicotine delivery systems (ENDS) have proven potential to help smokers transition away from combustible tobacco and should be reconsidered as part of a regulated harm reduction strategy. Their commentary emphasized that evidence-based regulation, not blanket prohibition, would better serve public health.
The response was swift. AIIMS distanced itself from the doctors, reaffirming its opposition to all forms of nicotine use and reiterating its full support for the 2019 ban. Yet the fact that respected clinicians are openly questioning policy marks a shift in India’s debate. These voices—drawn from daily experience treating cancer patients—highlight the urgent need to align tobacco control with scientific realities rather than moral absolutes.
Internationally, examples abound where harm reduction has been integrated into policy with positive results. The United Kingdom, for instance, actively promotes smoke-free alternatives under strict regulation, allowing adult smokers access to safer products while keeping youth protections in place. Advocates argue India could adopt similar frameworks, acknowledging that while quitting entirely is always best, safer alternatives should be available for those who cannot or will not stop smoking.
The public deserves better informed doctors
A similar conversation is unfolding in the United States, where a recent white paper from Philip Morris International’s U.S. businesses spotlighted a major gap: doctors themselves are under-informed about tobacco harm reduction. Based on a national survey of more than 1,500 healthcare providers, the paper revealed that 93 percent of professionals believe the U.S. Food and Drug Administration (FDA) has a duty to share findings when a smoke-free product is proven less harmful than cigarettes. Almost all said they would pass that information along to patients. Yet the FDA has been largely silent, and most clinicians remain unaware of which products have been authorized after regulatory review.
This silence fuels dangerous misconceptions. Nearly two-thirds of surveyed providers either mistakenly believed or were unsure whether nicotine causes cancer. In reality, nicotine is addictive but not the main driver of smoking-related disease. The harm comes from combustion—the toxins created when tobacco burns. By conflating nicotine with smoke, many doctors unintentionally deprive patients of accurate information and perpetuate an “all-or-nothing” model: either quit entirely or continue smoking.
The consequences are profound. Thirty million Americans still smoke, many of them unreached by cessation-only approaches. Harm reduction could help reduce this toll, cut healthcare costs, and ease the burden on Medicaid populations disproportionately affected by smoking. But progress requires more than scientific consensus—it demands education for health professionals, regulatory clarity from the FDA, and policies that differentiate between combustible and non-combustible products. Tax structures that treat smoke-free products the same as cigarettes only undermine incentives to switch.
Prohibition fuels black markets
Europe, meanwhile, faces its own challenges. Clearing the Air has just reported that in the Netherlands, doctors have filed a complaint against Snapchat, accusing the platform of enabling illegal vape sales to teenagers. The complaint, lodged with the Authority for Consumers and Markets under the EU’s Digital Services Act, highlights how unregulated access is fueling youth addiction. Despite Snapchat’s promises of tighter controls, underage users continue to find sellers through slang and coded terms. Surveys show one in four Dutch teenagers aged 12 to 16 has already tried vaping, with daily use among a growing minority.
Here again, prohibitionist instincts may be making matters worse. Flavoured disposable vapes were banned in early 2024, but they remain widely available on the black market—often with far higher nicotine levels than legal products. Dutch doctors warn that without better regulation and enforcement, young people will continue to access unsafe devices, undermining public health while fueling organized crime.
Across these diverse contexts, the pattern is the same: prohibition breeds black markets, misinformation leaves doctors unprepared, and patients are left with few real choices. What unites India’s cancer wards, America’s under-informed clinics, and Europe’s struggling regulators is the urgent need for a shift in approach.
Equipping odctors, empowering smokers
Doctors—those who witness the devastation of smoking firsthand—are increasingly at the center of this call. Whether in Delhi, Washington, or Amsterdam, many are no longer content with abstinence-only strategies that have failed millions. Instead, they are pushing for pragmatic, science-based harm reduction: policies that recognize a continuum of risk, empower clinicians with accurate knowledge, and give adult smokers access to safer alternatives.
The path forward is clear. Quitting all tobacco and nicotine will always be the best option, but for those who cannot quit, denying safer choices is not protection—it is neglect. If governments are serious about reducing preventable deaths, they must equip doctors with the truth, regulate alternatives responsibly, and dismantle the false binary of “quit or die.” Only then can the global fight against smoking shift from managing tragedy to preventing it.