Nicotine Dependency Harm Reduction

What if we do relapse? What then? Hopefully, relapse will instill a deep and profound respect for the power of one hit of nicotine to again take the mind's priorities teacher hostage.

Hopefully, belief in the Law of Addiction will thereafter forever remain beyond question. Hopefully, we'll immediately work toward reviving and strengthening our dreams and start home again soon. But if not, what then?

And what if relapse was to the dirtiest, most destructive, and deadliest form of nicotine delivery ever devised, the cigarette?

We're told it accounts for 20% of all deaths in developed nations.[1] According to the World Health Organization, smoking is expected to claim more than a billion nicotine addicts by century's end.

My late friend and nicotine toxicologist Heinz Ginzel, MD wrote, "burning tobacco ... generates more than 150 billion tar particles per cubic inch, constituting the visible portion of cigarette smoke. But this visible portion amounts to little more than 5 to 8 percent of what a lit cigarette discharges and what you inhale during puffing. The remaining 90% of the total output from a burning cigarette is in gaseous form and cannot be seen."[2]

Those unseen gases include carbon monoxide, hydrogen cyanide, hydrogen sulfide, ammonia, and methane.

Many health advocates wish they could immediately transfer all smokers to less destructive forms of nicotine delivery. And many are now strongly advocating it.

But what would be the consequences?

How many fewer deaths would occur if smokers switched to alternative nicotine delivery? We really don't know. While most harm reduction advocates are extremely optimistic and expect massive reductions, their suppositions ignore the fact that most smokers have already logged years of tobacco toxin and carcinogen exposure.

And how does continuing use of the super-toxin nicotine factor into the damage being done?

What are the long-term risks associated with electronic cigarettes, heat not burn tobacco products, and replacement nicotine in long-term ex-smokers? It may take decades before science can untangle relative risks and draw reasonably reliable conclusions.

Since this page was first written, the nicotine marketplace has expanded fast — including tobacco-free nicotine pouches promoted as “clean,” “discreet,” and “no smoke.” Youth surveillance has already had to track pouch use alongside vaping, and co-use is a growing concern.[18] One national adolescent study found nicotine pouch use and pouch-plus-e-cigarette co-use significantly increased from 2023 to 2024.[19] And social media has become a powerful channel for normalizing and marketing pouches, often portraying them as trendy and relatively harmless.[20]

As for any traditional combustion-type cigarette claiming to be "natural" or less harmful than other brands, don't buy it. Inhaling gases and particles from a burning toxic waste dump isn't just inherently dangerous and extremely destructive, it's deadly.

A 2008 study examined the effects of smoke upon normal embryonic stem cell development from three cigarette brands suggesting harm reduction benefits. It found that smoke from these so-called harm-reduction cigarettes inhibited normal cell development as much "or more" than traditional brands.[3]

Some public health advocates are alarmed that harm reduction campaigns may actually be backfiring, keeping millions who would have successfully arrested their chemical dependency hooked and cycling back and forth between cigarettes and other forms of nicotine delivery.

They're seeing a significant percentage of smokers coaxed into trying e-cigs end-up hooked on both cigs and e-cigs. They're called "dual-users."

A 2020 study focused on use-status changes among surveyed dual users between 2013 and 2016. It found that while two years later 7% of dual users had become e-cig only users, and 12% were able to stop using all tobacco products, that 26% were still dual users, and 55% had returned to smoking.[4]

That’s right. Based on that 2013–2016 data, more than 80% were still smoking.

Research hints that, in order to reach familiar blood nicotine levels, smokers attempting to transition to vaping may need to learn to compensate for slower e-cig nicotine delivery by inhaling a second longer.[17]

Modernizing and weaponizing a century of cigarette marketing targeting youth, today e-cig manufacturers are pushing hard to hook and keep teens hooked on nicotine. With an ever-increasing array of tempting flavors, with thousands of social media posts throwing around terms like "safe" and "safer," how could kids resist?

Although sickening, my concern isn't only about a new generation of youth becoming nicotine addicts.

Is there any question but that the neo-nicotine industry will do its damnedest to keep them enslaved and buying until death, its damnedest to suppress efforts to free them, and its damnedest to entice complacent ex-users to relapse and join them?

I hold in my hand sample packets containing two 2mg pieces of "Fresh Fruit" and "Ice Mint" Nicorette gum with tooth whiteners. I was told that these sample packs were being distributed free to individuals passing through New York's Grand Central Station.[15]

As reported in 2008, after meeting with FDA staff, Pfizer voluntarily stopped distributing free samples of "Fresh Fruit" flavor gum and lozenges.[5]

But it's as though nicotine peddlers learned little from the millions of kids that camel once attracted to smoking.

While I applaud efforts to minimize harm, the harsh reality is that, from a quality of life perspective, nicotine dependency is a life-threatening chemical dependency whether delivered via cigarettes, pouches, oral tobacco, e-cigs, or NRT.

As an educator, my main concern isn't about relative risk (lesser of evils). It's in helping nicotine addicts become free.

It's in helping them put their chemical dependency permanently behind them.

It's why it pains me to include this harm reduction section here at the tail end of this book.

I worry that some struggling ex-user reading this section, who would have succeeded if it hadn't been here, will instead seize upon the words that follow as license to relapse.

But the alternative, relapse to cigarettes without understanding relative risk, is also unacceptable.

Still, as Dr. Ginzel noted, it would be nice if we knew the actual relative risks in contrasting smokeless tobacco to NRT. But we don't.[6]

What is the relative risk when comparing cigarettes to oral tobacco, e-cigs and NRT? Frankly, science doesn't know.

What we do know is that 48.8 million smokers in the United States have now successfully quit.[7]

Clearly, smokers face super-serious risks of many different types of cancers, breathing disorders including emphysema, and circulatory disease.

Most smoking's risks, with its 50% adult kill rate, are well known. What is less often discussed is nicotine's long-term effects.

Although we still don't know whether long-term NRT user health concerns are directly caused by nicotine, complaints from long-term users range from rapid heartbeat, headaches and heartburn, to mouth sores, jaw pain, sore tongue, sore throat, and "nicotine gum butt."[8]

As you can see, while the list of unproven possibilities is many, few concerns come anywhere near smoking's known risks. Clearly, smoking's harms are vastly greater and far more life-threatening than nicotine's.[9]

In 2001, at the first United Nations treaty negotiation session for the Framework Convention on Tobacco Control, the tobacco industry asked that smokeless tobacco products, including Swedish snus, be protected from comprehensive bans.[10]

Snus is an oral moist tobacco product consumed without spitting. Snus use has been associated with a reduced risk of lung cancer as compared to cigarette smokers.[11]

Still, snus use is associated with pancreatic cancer and other health risks.[12]

While relative risk remains uncertain, one study found that cigarette smokers switching to smokeless tobacco products could potentially reduce health risks.[13]

But again, as a nicotine cessation educator, my dream isn't about seeing you develop the patience needed to allow you to adapt to and remain slave to a cleaner and less destructive forms of delivery.[14]

It's in seeing you develop the "one day at a time" patience needed to go the distance and allow yourself to sample the amazing sense of quiet and calm that arrives once your addiction's chatter goes silent.