The WHO is a risk-factor for cancer
In a new Code Against Cancer, the World Health Organisation opposes the most effective and popular way to reduce the most important modifiable cancer risk, smoking. So, what does that make WHO?
The European Code Against Cancer
The revised European Code Against Cancer, 5th edition (“the Code”) was launched on 2nd February by the WHO, the International Agency for Research on Cancer (IARC) and the European Commission, which funded the work. The updated Code asserts that “Four in ten cancer cases could be prevented globally” and proposes 14 ways people can help prevent cancer, each backed by a policy package that would encourage the Code’s intended behaviour changes. Sitting behind the Code is a special edition of the journal Molecular Oncology, and within that, a paper (Feliu et al. 2026) that purportedly underpins the recommendations on smoking, nicotine, and alcohol. Finally, there is a series of fact sheets and policy briefs, including a smoking fact sheet and a smoking policy brief.
A lot of work has gone into the Code: according to the project overview, 60 European experts and five working groups have toiled for 4 years to produce this update.
What could possibly go wrong? A lot has gone wrong.
Smoking is by far the most important part of the Code
First, the most important section of the Code is whatever it says about smoking. That is because smoking is the most important modifiable risk factor for cancer.
An excellent recent paper (Fink, H., Langselius, O., Vignat, J. et al. Global and regional cancer burden attributable to modifiable risk factors to inform prevention. Nature Medicine, February 2026) showed that smoking accounts for by far the largest share of modifiable (preventable) cancer risk.
Smoking (15.1%), infections (10.2%) and alcohol consumption (3.2%) were the leading contributors to cancer burden.
Smoking is the biggest overall risk factor. Smoking is a bigger risk factor among men than women globally. This is because male smoking prevalence is globally about six times higher. Men are at a greater risk of cancer overall and at a greater risk of cancers of the lung and respiratory tract that are most strongly associated with smoking.
Here is the Economist graphic from its report of the Fink et al. paper - the bright red is smoking.
If you’d prefer to frame the costs in monetary terms, they’re gigantic. One estimate (Chen, S., et al (2023 JAMA Oncology) puts the global labour market and healthcare cost of cancer at $25 trillion from 2020-2050. Yes, trillion. The cancers most directly associated with smoking, lung and respiratory tract, form the largest category at $3.89 trillion in 2017 international dollars.
Smoking is also the risk factor for which there have been game-changing technological advances over the past 15 years. People who use the recreational drug nicotine can easily use it with a small fraction of the risk of smoking by using vapes, pouches, heated tobacco or smokeless tobacco.
There is no reasonable doubt that these products expose users to vastly lower intake of carcinogens. In the case of vaping, studies suggest differences in cancer risks for primary and secondhand exposure of two orders of magnitude (<1%) and five orders of magnitude, respectively, compared to smoking. So this should be an opportunity for a game-changing update to the Code.
Given the scale of the preventable risks, the costs of failure, and advances in technology, the ONE THING the Code really must get right is its advice on smoking.
And that’s where this all goes wrong.
What is wrong with the Code?
This is a Code Against Cancer. But is it really against cancer? Or just a bit against cancer: just as much against cancer as its authors feel comfortable with? Or worse, does it do things that cause cancer?
Most of the code is exhortation to live a more cautious, virtuous life (“avoid alcohol”), which will likely have little effect on anyone.
However, when it comes to smoking and nicotine, the Code moves away from mere forgettable exhortation into the role of an aggressive risk factor for cancer. This is driven by crude misdirection away from clearly established options to reduce cancer risks - namely, switching from smoking to low-risk, smoke-free nicotine products.
My comments on the Code headlines are below: the WHO text is in bold; my comments are in italics, marked CB.
The smoking advice
Do not smoke. Do not use any form of tobacco or vaping products. If you smoke, you should quit.
CB: This is cancer-promoting advice. So people should not quit smoking by vaping, the most popular and successful way to quit (e.g. see Jackson et al, 2025), or by using HTP or snus as an alternative? Really? The cancer problem is dominated by smoking: the exhortation should stop after the first three words; the rest is in conflict with this simple, actionable idea. It blocks a route to reduced cancer risk, and so the advice is a risk factor for cancer. We have to be blunt here: they are doing things with the foreseeable effect of causing death by cancer.
What the Code should say:
Do not smoke, and do whatever works to stop smoking.
If more elaboration would be helpful, this message could be emphasised:
That includes quitting completely or switching to exclusive use of any smoke-free nicotine product including vapes, pouches, heated tobacco and smokeless tobacco.
This is what the Code should say if its authors were serious about the most important cause of cancer. But they shut this idea down in favour of promoting nicotine abstinence - a far more demanding ask and less likely to succeed. In doing so, they loftily ignore why so many people use nicotine (clue: they want to experience the mild psychoactive effects of this drug, whether or not we approve - see my briefing: Nicotine for Policymakers).
To see the weird self-exempting sophistry that these scientists are capable of, we turn to the Molecular Oncology paper to find a strange attempt to have their cake and eat it:
In view of the above, the ECAC4 recommendation, ‘Do not smoke. Do not use any form of tobacco’ was updated to:
Do not smoke. Do not use any form of tobacco, or vaping products. If you smoke, you should quit. (Fig. 1).
The WG (working group) decided to keep the final statement on cessation sufficiently broad to ensure that people who smoke were not discouraged from using e-cigarettes as a cessation aid.
CB. Eh? What? In one breath, the authors tell people not to vape, without qualification or ambiguity. In the next, they claim their language will not discourage people who smoke from vaping to quit smoking. This is pure back-covering sophistry. How is anyone at risk of cancer supposed to figure that out? What about the health professionals and bureaucrats?
The problem here is that the authors are not giving the actionable, life-saving advice that the people at greatest risk need to hear; they are primarily concerned with how they appear and finding a consensus they are comfortable with.
The Smoking Policy Recommendations
The following policy recommendations are aligned with existing international policies:
CB: The problem is smoking, and the policy package below does not focus on smoking, but on ‘tobacco’, which in smoke-free form can be a low-risk alternative to smoking. We know that there is virtually no mortality risk associated with snus, and as a result of using nicotine in a smoke-free form (a tobacco product), Sweden has led to about half the male lung cancer mortality of Germany. Germany has similar nicotine use to Sweden, but all in the form of smoking.
Tobacco and nicotine-containing products
Adopt, implement, and enforce comprehensive tobacco control policies, as per the WHO Framework Convention on Tobacco Control, including:
CB: In a characteristic bureaucratic, clarity-obscuring muddle, we learn from a later clause that the list of FCTC policies that follows directly below should also be applied to “all tobacco products, electronic cigarettes, and all novel tobacco and nicotine-containing products”, which is going well beyond the scope of the FCTC.
Measures to raise tobacco taxes to at least 75% of tobacco’s retail price and significantly increase tobacco taxes every year. All tobacco products should be taxed in a comparable way as appropriate, in particular where the risk of substitution exists.
Measures to restrict the availability and accessibility of tobacco products. This includes increasing the age of sale and allowing the sale of tobacco products only in licensed stores.
Measures to ban tobacco advertising, promotion, and sponsorship, including display bans at the point of sale.
Provision of smoking cessation services. Identify and allocate sustainable funding for tobacco cessation and tobacco dependence treatment programmes.
Large graphic health warnings, labelling, and plain, standardized packaging for tobacco products.
CB: This isn’t an especially bad list to apply to smoking products, but there is no case to apply it to non-combustible tobacco or non-tobacco nicotine-containing products. I doubt it would do that much. But also not that much harm, if restricted to smoking.
And that’s where it all goes wrong. The authors intend this policy advice to be applied to all nicotine products (other than NRT, of course)
Extend such regulations to apply to all tobacco products, electronic cigarettes, and all novel tobacco and nicotine-containing products.
CB: This clause means the taxes and regulations above should be applied to all tobacco and nicotine products indiscriminately and without any regard for a spectrum of risk that spans two orders of magnitude. So here are the problems:
Raise taxes? The concept of ‘behavioural taxation’ or ‘economic instruments’ means using risk proportionate taxation to shift from high risk to low risk behaviour using an economic incentive - substitution is not a ‘risk’, it’s the point. And please don’t argue that the principle of equal treatment or non-discrimination requires it. The EU non-discrimination regime does NOT require equal treatment, but something more nuanced: “comparable situations must not be treated differently and that different situations must not be treated in the same way unless such treatment is objectively justified“ [see ECJ case 340/1]. Why treat safer products as though they are the same as dangerous products?
Restrict the availability and accessibility of safer alternatives? This makes it harder for people to quit smoking and stay off cigarettes. Why do that?
Ban advertising of safer alternatives? This type of advertising is a form of anti-smoking promotion and supports the harm-reduction strategy. It is a challenge to the incumbent (cigarettes), and without it, the entrants (safer products) will be less effective at displacing smoking. Why protect the cigarette trade in this way?
Vape cessation services? No, this is a distraction from the primary public health imperative of stopping smoking. It’s almost as though the authors don’t understand opportunity cost or that budgets are limited. Because the harms of vaping are so much lower, the benefits of quitting are so much less, and the cost-effectiveness of investment in vaping cessation will always be unattractive compared to smoking cessation.
Graphic warning labels and plain packaging for vapes, etc.? Across society, these measures are, so far, exceptional to smoking products. Applying them to smoke-free products would reinforce the radically false perception of risk (implying equivalence with smoking) and degrade the “offer” to smokers. What would graphic warning labels actually display?
Establish and work towards achieving a goal for a tobacco-free generation in your country.
CB: Despite all this work, they haven’t even said what a tobacco-free generation means. The European Union has a “tobacco-free generation” aim:
Europe's Beating Cancer Plan sets the goal of creating a ‘Tobacco-Free Generation' by 2040, where less than 5% of the population uses tobacco.
This is the wrong goal for a Code Against Cancer. The population most at risk of cancer is already smoking and advancing towards middle age. If the Code were serious about cancer, it would be directing focus towards older (already over 35) people who smoke.
And why “tobacco products” rather than smoking products? If the Code were serious about cancer, then the most important goal is to stop smoking by any possible means, including the use of smokeless or heated tobacco products. But the Code drafters apparently believe that this stops smoking the wrong way, as if they are too prim to let someone else combat cancer in a way they disapprove of.
But the Code is not even clear what “tobacco-free generation” means. Other definitions of a tobacco-free generation mean prohibiting the sale of tobacco products to adults born after a certain date (for example, people born after 1 January 2009 in the UK). That would be a completely useless measure against cancer - young people are already migrating away from smoking, and very few will continue to smoke for the multiple decades that lead to serious illness.
Complementing the above-mentioned policy measures, implement regular public health campaigns to raise awareness of the damaging effects of tobacco and the benefits of smoking cessation.
CB: The Code even miscommunicates the communication goal. The damaging effects of tobacco and the benefits of smoking cessation? No. The damaging effects of smoking are the primary issue. Surely, it is possible to send an unambiguous signal to consumers, service providers, policymakers, and politicians about the critical health priority without getting into a complete mess over the important differences between smoking, tobacco use, vaping and nicotine use? It seems not.
Secondhand smoke
Some credit where credit is due. The section on second-hand smoke does remain focused on smoke - see policy brief. In doing so, it stays true to its mission and makes no recommendations about vapes or heated tobacco, which is a relief. This is non-trivial - according to the Global Burden of Disease data visualiser, there is one death from secondhand smoke for every five deaths from active smoking in the WHO European Region (202,143 vs 1,005, 859 death in 2023).
A final despairing word
They have spent four years drafting an updated Code Against Cancer. Yet on the most important issue, smoking, the WHO has created an incoherent mess that will likely do harm and possibly more harm than good.
The problem is the number of people and interests involved and a lack of real, determined commitment to reducing cancer. What might seem like idealistic aims, such as a tobacco-free or nicotine-free world, are just distractions and barriers to a pragmatic response to smoking-related cancer, which is the real problem.
So, there is only a qualified commitment to reduce cancer: it must be done in ways the authors find agreeable and around which they can form a consensus, even if a lazy and muddled consensus. As the number of authors increases, the required compromises and accommodations also increase. But these are not compromises with the people at risk. They are compromises at the expense of the people at risk.
In the 2001 animated film Shrek, the villainous Lord Farquaad declared to his knights:
“Some of you may die, but that is a sacrifice I am willing to make”
In this situation, the WHO, backed by the European Commission, has issued expert advice that would sacrifice people at risk of cancer by denying them options to avoid an agonising death. But in the name of a self-serving consensus, that is a sacrifice they are willing to make.
What makes this even more tragic and bizarre is the clear association with tobacco and health equity. At the very least we should be able to count on the WHO to speak up for populations who are disadvantaged. Throughout the world, communities and entire countries with lower socio-economic status have higher smoking rates. Preventing cancer and other diseases among these groups should be a WHO priority. When it comes to tobacco, this is clearly not the case.
They must also surely know that by engaging in credibility self-immolation on issues of nicotine they also directly impact the credibility of the WHO in general. So the damage is not just in perpetuating the leading cause of cancer but in undermining the efforts of WHO on the wide and important range of issues where effectiveness requires having maintained that public trust.