1. Introduction: A revealing forum
From June 19 to 21, the Global Forum on Nicotine (GFN) was held in Warsaw. At a workshop titled “Who's missing from the tobacco harm reduction conversation?”, speakers highlighted a striking absence: despite the rise oflower-risk nicotine alternation (Tobacco Harm Reduction, THR), several essential categories remain excluded from the debate.
These missing voices include current and former tobacco users, incarcerated people, individuals in extreme poverty, drug users, indigenous populations, ethnic minorities, and people with mental health disorders. Their common thread: high rates of smoking and limited access to cessation solutions.
Frontline healthcare professionals—nurses, pharmacists, and social workers—are also underrepresented, even though they are often the first point of contact for affected populations. Community organizations, despite their in-depth knowledge of the field, are rarely involved in policy design.
Finally, young adults, often targeted by regulatory restrictions, remain largely absent from consultations, even though they are among the main users of nicotine alternatives. This lack of inclusion raises serious doubts about the fairness, effectiveness, and legitimacy of current public health measures.
2. The weight of scientific data that is too little heard
Non-combustible products such as e-cigarettes — in other words, fried — have demonstrated their effectiveness in reducing the risks associated with smoking. They allow many smokers to quit cigarettes while maintaining a nicotine intake, without combustion, the main vector of toxicity.
Yet, a deep divide persists between scientific results and public perception. The general public, and even some healthcare professionals, remain disoriented in the face of an avalanche of conflicting messages. Sensationalist media reports, misinterpreted studies, alarmist statements from medical figures... all contribute to fueling the confusion.
This lack of clarity, compounded by the absence of coherent educational campaigns, deprives millions of smokers of an opportunity to effectively quit. In the age of misinformation, scientific expertise is not always sufficient to guide political or individual choices.
3. Marginalized populations: invisible beneficiaries
Those excluded from the debate are often the most vulnerable. The homeless, incarcerated, drug addicts, and the mentally ill all have smoking rates well above average, yet remain outside of harm reduction programs.
These groups rarely have stable access to prevention, care, or nicotine replacement therapy. Their smoking is sometimes criminalized or stigmatized, exacerbating their isolation. In prisons and shelters, vaping is still poorly accessible, or even prohibited, despite evidence of its effectiveness.
Ignoring these populations reinforces a two-tiered healthcare model. Community initiatives have proven that it is possible to adapt policies to the specific needs of these groups. All that's missing is the political will.
4. Clinical case: a fatal prohibition
In Dublin, Dr. Garret McGovern recounted the dramatic journey of a patient with chronic obstructive pulmonary disease (COPD), addicted to tobacco despite already having lost one lung.
Refusing traditional substitutes, she considered vaping as a last resort. Her pulmonologist forbade it, arguing that it would be "as harmful as cigarettes." This recommendation blatantly contradicts the available data.
McGovern denounces an ideological stance that could prove lethal. "A doctor should do everything to save a patient's life, not close the only door that's still open," he concludes. This anecdote embodies the ravages of a medical discourse disconnected from scientific realities.
5. Give users back their place
Dr. Sharifa Ezat Wan Puteh of the University of Malaya called for a refocusing on the needs of smokers. She emphasized the fundamental right to information and free choice among all available methods—pharmaceutical or alternative.
Smokers are experimenting with their own solutions. This empirical knowledge deserves to be heard. Including users in policy development also strengthens their effectiveness and acceptability.
Effective public health can only be inclusive, participatory, and rooted in the experience of those most affected.
6. The essential role of testimonies
For McGovern, the testimonies of former smokers who have converted to vaping are powerful levers for change. More telling than numbers, they humanize the debate and illustrate the concrete benefits of harm reduction.
These stories, often ignored by legislators, nevertheless show what policies could accomplish if they aligned with lived realities. Creating platforms for consumers to listen and express themselves has become a democratic necessity.
7. Tobacco: the great forgotten of harm reduction
While opioids and HIV benefit from harm reduction approaches, tobacco remains marginalized. This inconsistency is all the more problematic given that tobacco kills more people than all other substances combined.
The GFN calls for this anomaly to be corrected by fully integrating tobacco into global strategies. All risky products should be treated equally, based on their actual danger, not their symbolic or political weight.
8. Barlinnie: Scottish model of rupture
In 2018, Barlinnie Prison replaced cigarettes with vaping. The result: improved air quality, reduced respiratory problems, and a calmer prison climate.
This success demonstrates that risk reduction works even in extreme contexts. All it takes is willpower, education, and a minimum of logistical resources. The Scottish experience is now being emulated in several countries.
9. Political resistance: between fear and inertia
Why so much hesitation, despite the evidence? Policymakers fear being accused of being complacent toward the tobacco industry. Some prefer inaction to poorly understood reform.
Added to this is strong ideological pressure, fueled by dogmatic rhetoric and a glaring lack of professional training. As long as policies are not based on rigorous scientific analysis and genuine listening to users, progress will remain timid.
Conclusion: for a truly inclusive health policy
The Warsaw GFN concludes bluntly: any effective public health strategy against tobacco use must include users, field practitioners, and marginalized groups. Excluding them is tantamount to sabotaging collective efforts.
Highlighting lived experiences, diversifying approaches, and deconstructing prejudices about nicotine are all levers for fairer health. Harm reduction is not a concession: it is an ethical requirement in the face of the failure of coercive approaches.
In 2025, faced with a persistent tobacco epidemic, the urgent need is to rethink the fight against tobacco as an approach based on science, inclusion and respect for rights.
