Recent developments in the US reveal a growing disconnect between scientific evidence, public perception and regulatory policy—one that could have significant consequences for smoking-related disease worldwide.
The global tobacco harm reduction movement faces pressure from multiple directions. In the United States, online sales channels for vaping products are narrowing as major technology and payment companies distance themselves from nicotine retailers. At the same time, new research suggests public understanding of vaping risks has deteriorated to unprecedented levels, potentially discouraging millions of smokers from switching away from combustible cigarettes.
Shopify ditches vapers
A major shift in the online nicotine marketplace appears imminent after reports that Shopify plans to halt vaping product sales across its platform in the United States. The decision follows sustained pressure from a coalition of bipartisan state attorneys general seeking stronger action against unauthorised vaping products.
The move marks a new phase in tobacco and nicotine regulation. Instead of focusing solely on manufacturers and retailers, regulators increasingly target the infrastructure that enables commerce, including e-commerce platforms, payment processors and financial institutions. And while many believe these actions will help reduce illegal sales, tobacco harm reduction experts rightly highlight that limiting legitimate retail options without tackling consumer demand will actually increase illicit sales even more.
This concern is not just theoretical. Industry estimates indicate that the illicit US vape market is worth around $9 billion each year. The ongoing existence of this market points to a challenge that harm reduction advocates know well: the demand for nicotine doesn’t simply vanish when access becomes tougher.
The regulatory paradox
The United States currently operates one of the world’s most restrictive authorisation systems for vaping products. The Food and Drug Administration has authorised only a small number of products for legal sale, most of them tobacco-flavoured, unintentionally creating a gap between what consumers want and what’s legally available. Even as regulators try to curb unauthorised products, millions of people still buy alternatives that suit their tastes better. This situation has led to a regulatory paradox. Combustible cigarettes, which lead to hundreds of thousands of deaths each year, are still easily accessible, while safer options face increasing restrictions.
Another challenge is widespread misinformation. A recent US study analysing nationally representative PATH data found about 94 per cent of smokers who neither vape nor plan to quit believe vaping is as harmful as or more harmful than smoking. Published in Contributions to Tobacco and Nicotine Research, the findings represent some of the highest levels of vaping risk misperception recorded in recent years. The implications are significant. Public Health England’s widely cited review concluded that vaping is likely to be around 95 per cent less harmful than smoking, while the Royal College of Physicians has repeatedly emphasised that the health risks are unlikely to exceed a small fraction of those associated with cigarettes.
Public opinion goes against evidence
Yet public opinion has sadly moved in the opposite direction, with particularly high levels of misunderstanding among older smokers, Black smokers and those with lower educational attainment. The study focused on smokers with no immediate plans to quit—a group that represents most adult smokers and is likely to benefit from harm reduction approaches.
Evidence shows smokers who believe vaping is as dangerous as smoking are significantly less likely to switch to reduced-risk products. This matters because smoking-related disease is caused mainly by combustion rather than nicotine itself. The toxic by-products produced when tobacco burns cause most smoking-related cancers, cardiovascular disease and respiratory illnesses. More experts argue that correcting misunderstandings about relative risk could become one of the most important public health interventions.
Recent commentary published in Nature Health by former World Health Organisation leaders argued that tobacco harm reduction should play a greater role in global tobacco control if meaningful reductions in smoking-related mortality are to be achieved by 2040. Their conclusion aligns with evidence emerging from countries that have embraced smoke-free alternatives. Sweden’s experience is often cited as a real-world example of harm reduction in action. The widespread use of snus and, more recently, nicotine pouches has helped smoking prevalence fall below 5 per cent.
Who can the public trust?
Harm reduction expert Martin Cullip recently highlighted that among other things, public health organisations are undermining their credibility by opposing tobacco harm reduction strategies despite growing evidence showing their effectiveness. Historically, public health advocates earned moral authority by exposing tobacco industry efforts to obscure the dangers of smoking. However, contends Cullip, some modern tobacco control groups seem instead set on creating uncertainty around safer alternatives.
He points to legislative debates, including a recent proposal in Rhode Island that would have allowed flavoured e-cigarettes to be sold in tightly regulated adult-only stores while funding smoking cessation programs. Despite safeguards designed to protect youth, the measure was opposed by several major health organisations. Cullip argues that this reflects a contradiction in tobacco policy: lower-risk products often face greater restrictions than conventional cigarettes, which remain widely available. According to Cullip, tobacco control now faces a credibility test.
Tobacco control is regressing, not progressing
The result of the current course of tobacco control may be an unintended consequence: smokers aware of the dangers of cigarettes but unaware of the benefits of switching. At a time when online sales channels are tightening, regulatory pressure is increasing, and public misunderstanding is growing, accurately communicating relative risk is more important than ever.
If the goal is reducing smoking-related disease rather than simply restricting nicotine use, policymakers, healthcare professionals and public health organisations must ensure that smokers receive clear, evidence-based information. The greatest danger is not in vaping or the increase in use of any other safer alternative, but in the growing number of smokers who incorrectly believe there is no meaningful health advantage in switching away from cigarettes.