Rise of the pragmatists

A new commentary in Nature Health sets out a bold but pragmatic agenda for addressing the global epidemic of smoking and related harms. Meanwhile a cautionary tale explains what can go wrong.

Over 1 billion adults - about 1 in 7 - still smoke. How can we do better?

A bold and pragmatic strategy

One of the best commentaries I have ever seen on the future of tobacco and nicotine has just been published in the prestigious journal, Nature Health.

Beaglehole, R., Bonita, R., & Pang, T. (2026). Smoke-free nicotine products can accelerate the end of the smoking epidemic. Nature Health. 20 April 2026. DOI 10.1038/s44360-026-00121-1 (Access)

Disclosure: I know and admire all three authors, who have each held senior positions in the World Health Organisation earlier in their careers.

A relentless focus on what matters: smoking

The central idea of their commentary is to focus on the primary driver and most modifiable of non-communicable disease, smoking. See: The WHO is a risk factor for cancer, for the consequences of dissipating the focus on smoking.

The authors point out that the globally adopted targets to reduce smoking by 30% and non-communicable diseases (NCDs) by one-third by 2030 are unlikely to be met. They call for a change in strategy to meet a new target based on realising new opportunities:

The rapidly evolving market for smoke-free nicotine products, combined with their increasing uptake among people who smoke, presents an unprecedented opportunity to rethink global tobacco control ambition. We propose a global smoke-free 2040 goal, defined as an adult daily smoking prevalence below 5% by 2040.

I claim this to be the argument of pragmatists. It is clear that the authors are frustrated by dogma and naive idealism that obstruct progress in real-world problem-solving. I share their concern and exasperation.

They make a clear pitch for tobacco harm reduction as the missing global public health strategy:

Achieving the potential of tobacco harm reduction requires regulatory coherence; cigarettes remain widely available, while many less harmful alternatives face greater regulatory constraints. This misalignment risks protecting the most dangerous products while limiting access to safer substitutes.

The authors point towards a pragmatic risk-proportionate approach to regulation:

A risk-proportionate regulatory framework would reverse this logic by recognizing the continuum of risk across nicotine products and aligning regulation, taxation and public communication accordingly5. Combustible tobacco should be subject to the strongest restrictions and highest excise taxes, as a reflection of its uniquely harmful nature. Smoke-free alternatives should be regulated to ensure product safety, restrict marketing to youth, minimize environmental harm and prevent uptake among non-smokers, without undermining their capacity to displace smoking.

They dismiss the idea of achieving the idea of “nicotine-free society” as a pointless pipe-dream and a distraction from doing what works and will make a difference:

In some policy debates, tobacco control objectives are framed increasingly in terms of nicotine elimination rather than eliminating exposure to smoke, and potentially conflate nicotine use with the harms of smoking. Decades of evidence demonstrate that it is exposure to smoke from combustion — not nicotine — that drives tobacco-related disease.

The authors draw on experience from several places, but notably from New Zealand, where pragmatism has prevailed over naive “endgame” idealism and is delivering excellent results:

The New Zealand experience is particularly instructive. Smoking prevalence declined gradually for decades following the introduction of FCTC-aligned measures but the rate of decline accelerated sharply after 2018, which coincided with broader access to regulated vaping products. The steepest declines occurred among Māori and other disadvantaged groups (populations that historically have experienced the highest smoking rates), which suggests that harm reduction also contributed to reducing health inequities.

Attention has been given to legislative ‘endgame’ measures intended to drive prevalence well below low single-digit levels. In New Zealand, legislation passed in 2022 included a smoke-free generation law, mandatory denicotinization of cigarettes and a substantial reduction in tobacco retail outlets. Following a change in government, most of this legislation was repealed before implementation, which reflected concerns about feasibility, equity and unintended consequences.

Note, they are not arguing that nicotine use is good or cool, but that in public health, we have to relentlessly focus on what matters, and that means the drivers of serious disease, debilitation and death - and therefore smoking. Trying to introduce a nicotine-free objective will make ambitious goals to reduce smoking harder or impossible to achieve.

Objections

They are realistic about the genuine public health concerns about tobacco harm reduction, noting worries about youth uptake, gateway effects, dual use and unavoidable uncertainties about unknown long-term risks. But they address these with concise language that embodies great insights from experience and the scientific literature. I will summarise:

• Gateway effects are an illusion, and correlations between vaping and smoking are best explained by shared risk factors: psychosocial characteristics of the individual or their circumstances that incline them to both smoking and vaping. These shared risk factors are the reason vaping is displacing smoking.

• Dual use is a stage in progression to smoke-free status for many and an improvement in its own right for anyone compared to exclusive smoking. Moving to exclusive smoke-free status could be expedited by clearer risk communication. Far too many people have been misled by misinformation and believe that vaping is at least as dangerous as smoking.

• There is some long-term uncertainty about the effect of smoke-free alternatives to cigarettes. But we must base policy on what we do know, and not allow residual uncertainties to cause policy paralysis. We know with certainty that smoke-free products expose users to toxic burdens one to three orders of magnitude lower than smoking, and we know that long-term smoking is immensely harmful.

I think they could have addressed the youth issue more forcefully. In a world without tobacco harm reduction, young people would continue to use nicotine and initiate smoking. It is better that they use far safer products from the outset. Young people benefit from harm reduction and age into the population without smoking initiation, serving as a critical mechanism in the migration toward a smoke-free population. It’s an uncomfortable argument for some, but smoking uptake was never going to disappear overnight.

Once we accept that there is a demand for nicotine, as there is for other substances like alcohol, caffeine or cannabis, and that nicotine offers its users real or perceived benefits - pleasure, mood modulation, cognitive, and therapeutic benefits, then we can be sure it will continue to be used. The pragmatist will understand this and act accordingly. The aim is to make nicotine legally available in relatively safe forms acceptable to consumers.

The alternative is to try to address nicotine demand through prohibitions, taxes, and other punitive, coercive or stigmatising measures.

We can turn to Australia to see how that plays out.

A cautionary tale: Australia

In a great week for insightful publications, we also have highly credible pragmatists weighing in on what can go wrong with excessive or prohibitionist tobacco control measures. We have an excellent discussion of the lawless mess that has emerged in Australia.

Borland, R., Martin, J., Jegasothy, E., Youdan, B., & Hall, W. (2026). Has Australia lost control of its tobacco and nicotine markets? Addiction. https://doi.org/10.1111/add.70428

A chaotic fiasco has developed:

The rate of decline in tobacco smoking in Australia has slowed in the past decade but may have recently increased. At least half of all tobacco cigarettes and most vapes in Australia are now purchased from an illicit market that exceeds the size of the combined Australian illicit markets for cannabis, cocaine, heroin and ecstasy (MDMA). An estimated $7 billion in tobacco excise and arson attacks on tobacco retailers have prompted large increases in law enforcement funding.

They accept that enforcement or banning harder is unlikely to work…. While it is possible to seize a lot of contraband, that does not diminish demand, the highly lucrative economic incentive, or the illegal adaptability of illegal supply:

Based on the experience from other illicit markets, increased enforcement will at best limit sales but at likely enormous social and economic cost and, specific to nicotine, constraining access to vapes and thus potentially leading to more smoking.

… and the cause is excessive quasi-prohibitionist tobacco control policies colliding with demand for ongoing nicotine, and highly adaptable criminal supply chains.

Punitive taxes on cigarettes and restricted access to lower-risk nicotine products have diverted Australians who use nicotine into illicit markets and may also have increased cigarette smoking among young people. Australia should allow easier consumer access to less harmful alternative nicotine products to help bring the illicit tobacco and nicotine markets under better control.

New Zealand or Australia?

The Tasman Sea Experiment

There is absolutely no question: the pragmatists in New Zealand have won this hands down. These are the headline results… anyone should be happy with that.

: New Zealand Health Survey 2011-25 (chart adapted from Ben Youdan)

The success in New Zealand contrasts with the dogma and naive idealism of Australia’s tobacco control establishment. Being “tough” might make its advocates feel potent and awesome. It might win absurd plaudits from fellow NGOs or the WHO, but the results tell a different story.

In a recent submission to an Australian Senate inquiry into the “Illegal Tobacco Crisis in Australia [my submission here], I commented on the importance of pragmatism:

Consider more diverse advice. For years, there has been a political consensus to follow the tobacco control advice of Australia’s influential public health establishment. The government has faithfully implemented the policy agenda of the most vocal activists, yet the result is a chaotic, lawless fiasco. It is time for the government to be more sceptical about the advice from these groups and individuals, and more open to economically grounded and consumer-focused analysis about the nicotine market and tobacco harm reduction.

Australia’s tobacco control establishment has created an almighty mess and a failure of epic proportions. It’s long past the time to stop listening to their endgame fantasies. The more modest approach of New Zealand, however, has worked well, and it works through consent rather than coercion. So, I suggest that international organisations, global tobacco control activists, academics, medical organisations and the money people at philanthropic foundations look to New Zealand, not Australia, to see the road ahead.

As the authors of the Nature Health commentary put it:

The New Zealand experience suggests that implementation of FCTC measures, complemented by well-regulated smoke-free alternatives, reduces the need for more coercive approaches and offers a more politically sustainable path to rapid smoking declines while controlling the illicit trade in cigarettes and vapes.

Now that is good advice.