Recent events indicate that harm reduction, a concept that is so widely used in multiple contexts, is not only oftentimes not applied to smoking, but even worse, to pregnant smokers, a vulnerable group which for obvious reasons needs it more than most.
Merseyside and Cheshire NHS services have recently introduced sweeping restrictions on publicly funded in vitro fertilisation (IVF). Among the new rules is one that excludes anyone who vapes from accessing treatment. This policy, which aims to reduce costs and supposedly improve success rates, raises serious questions about evidence, ethics, and fairness—especially for people who turn to vaping as a safer alternative to cigarettes.
IVF is already tightly rationed across the UK because of high costs and modest success rates. Eligibility has long depended on maternal age, body mass index, smoking status, whether applicants already have children, and other medical indicators. The Merseyside and Cheshire region has historically operated under ten different subfertility policies, creating inequities in access. In the summer of 2025, local health leaders launched a consultation to harmonise the system. As part of that exercise, they announced new restrictions, including the vaping ban, alongside a proposal to reduce funding to a single NHS cycle per eligible person.
Authorities argue that lifestyle exclusions help ensure limited resources are used where outcomes are most promising. The region spends more than £5 million annually on IVF, and standardising access while limiting cycles is projected to save around £1.3 million a year. Yet critics question whether including vaping in the ban is based on solid science or simply reflects cost-cutting disguised as health policy.
For harm reduction advocates, the move is troubling because it blurs an important distinction between smoking and smoke-free nicotine alternatives. While cigarette use has long been a reason for reduced access to IVF, vaping is not smoking. Treating them as equivalent is ridiculous, ignoring both the growing evidence base and the lived reality of many adults who turn to safer nicotine products in order to reduce risks.
A misguided experiment in pregnancy
This policy controversy comes at the same time as new research is shining a light on pregnancy, smoking, and the ethics of harm reduction. A recent U.S. trial, published in Preventive Medicine, tested very low-nicotine cigarettes (VLNCs) in pregnant women who smoked. The study enrolled 30 women who did not intend to quit and split them into two groups: one continued smoking their usual brands, while the other switched to federally supplied VLNCs for 12 weeks.
The results were mixed. VLNCs did not significantly reduce overall cigarette consumption, but neither did they cause compensatory smoking or severe withdrawal symptoms. In fact, the VLNC group recorded a slight decline in daily cigarette use. On the surface, the trial suggested that lowering nicotine might modestly reduce smoking without increasing harm.
Yet the ethics of the study have become more controversial than the findings themselves. Public health scholar Dr. Michael Siegel criticised the trial for instructing pregnant women to continue smoking rather than offering them cessation support, calling it a violation of basic research ethics and national medical guidelines. He argued that participants were denied the standard of care and exposed to unnecessary risk. Calls were even made for the study’s retraction.
The researchers defended their work, stressing that it was not a cessation study but an effort to understand how a national nicotine-reduction mandate might play out for pregnant smokers who cannot or will not quit. They pointed out that the trial had cleared multiple layers of ethical and scientific review and was monitored by an independent safety board.
Very low-nicotine cigarettes vs. safer alternatives
Whatever one’s view, the study highlights a fundamental problem with the VLNC approach: it leaves people—pregnant women included—stuck with the most dangerous form of nicotine delivery, combustible cigarettes. At best, they are the slower and longer route to achieving abstinence from smoking, a longer route which pregnant women, who need to get off cigarettes at once, cannot afford to take.
By contrast, smoke-free alternatives like vapes, nicotine pouches, or heated tobacco are demonstrably less harmful and offer real opportunities for transition, and most importantly, the fastest route to stop inhaling the deadly chemicals caused by combustion.
For people who struggle to quit, denying them access to safer products or excluding them from essential services, as seen in Merseyside and Cheshire, can amount to punishing them for not achieving abstinence.
This is where policy and practice collide. Both the IVF restrictions in the UK and the VLNC trial in the U.S. reflect an abstinence-only mindset that prioritises purity over pragmatism. These approaches ignore decades of evidence from harm reduction in other fields, from sexual health to drug use, showing that safer alternatives can save lives even when abstinence is not achievable.
Beyond abstinence-only: what women deserve in prenatal care
For pregnant women, the stakes are especially high. Smoking during pregnancy carries well-established risks for both mother and child. Yet policies that exclude vapers from IVF or clinical trials that keep women tied to cigarettes fail to recognise the role of safer alternatives. Instead of equating all nicotine use with smoking, healthcare systems should be educating providers about the continuum of risk and supporting patients with realistic, compassionate strategies.
The NHS ban on vapers seeking IVF and the ongoing debates over VLNCs both illustrate the same blind spot: a refusal to acknowledge that safer nicotine products exist and can be part of a harm reduction toolkit. As long as public health clings to abstinence-only approaches, patients—especially those in vulnerable situations like infertility or pregnancy—will bear the cost.
If the ultimate goal is healthier pregnancies, healthier families, and fewer lives lost to smoking, then the evidence points to regulation and education, not prohibition and punishment. A harm reduction framework that distinguishes between combustible tobacco and smoke-free alternatives offers a path forward—one that can better serve both individual patients and public health as a whole.