The belief that nicotine causes most smoking-related diseases is widespread—and wrong. Nicotine’s effects are what keeps people smoking, and its use may lead to dependency. But it is not the direct cause of smoking-related cancer, emphysema or cardiovascular disease. What kills people who smoke is the tar, carbon monoxide, fine particulates and thousands of toxic by-products created by burning tobacco. 

This distinction is well established in science, even if it is often obscured in public messaging. The US Food and Drug Administration has acknowledged that nicotine is not the main cause of smoking-related illness. The Centers for Disease Control and Prevention similarly notes that nicotine is not a carcinogen. The World Health Organization’s cancer research arm, the International Agency for Research on Cancer, does not classify nicotine as cancer-causing.

The clearest evidence that regulators do not believe nicotine is inherently unsafe is their attitude to nicotine replacement therapy. Patches, gums, lozenges, sprays and inhalers have been available and medically approved for decades around the world. 

If nicotine were dangerous at these levels, regulators would not allow over-the-counter NRT sales. But they’ve already made a judgment: Nicotine can be used safely long-term.

They are sold over the counter, recommended by doctors, and often used daily for months or years. Many people who smoke are advised to combine products, such as wearing a 21-milligram patch while also using multiple 4-milligram lozenges per day. Total daily nicotine exposure from approved products routinely reaches 20 to 40 milligrams.

If nicotine itself were dangerous at these levels, regulators would not allow NRT sales, certainly not over-the-counter. But regulators have already made a clear judgment: Nicotine can be used safely, long-term, when delivered without combustion. This is not a loophole. It is a regulatory admission.

Yet when nicotine is delivered through consumer products rather than medical ones, the tone changes dramatically. The molecule is identical. Doses are often comparable. Toxicant exposure is dramatically lower than smoking. Still, vaping and nicotine pouches are treated as suspect or dangerous, while cigarettes remain widely available.

This distinction cannot be explained by chemistry or toxicology. Sure, with vaping, trace amounts of other substances are also involved; the dose makes the poison—or in this case, doesn’t. But objections to consumer products widely focus on nicotine itself.

Witness the FDA’s bizarre warnings of the dangers of what it calls “nicotine addiction”—a term that according to modern definitions entails serious harms, not mere dependency. Or the WHO’s claim, among others, that exposure to nicotine harms the developing brain—a phenomenon not illustrated by generations who smoked from a young age.

In reality, it reflects regulators’ discomfort with consumer choice. Medical nicotine is controlled, clinical and gatekept.

Allied organizations and researchers pile on. The American Cancer Society, for instance, obfuscates on the question of whether nicotine is carcinogenic, amid a slew of other warnings about it. And a group of European cardiologists recently issued claims that nicotine is a “potent cardiovascular toxin” in calling for restrictions on consumer products.

NRT is rarely targeted by this outcry. And when regulators know that NRT is safe, their distinction between NRT and vapes or pouches reflects, in reality, their discomfort with consumer choice. 

Medical nicotine is controlled, clinical and gatekept. Consumer nicotine disrupts an abstinence-oriented framework that has dominated tobacco control for decades. It also challenges narratives that treat nicotine use as a moral failing rather than a choice on a spectrum of risk.

One common objection to vaping and other consumer nicotine products is that they deliver nicotine more rapidly than patches or gum, producing sharper “spikes” in blood nicotine levels. These spikes are often portrayed as dangerous. This misunderstands what matters for health.

Cigarettes are uniquely efficient nicotine delivery devices. Smoke inhalation sends nicotine to the brain within seconds, producing sharp arterial spikes repeated many times per day. These spikes matter for cigarette addiction, but they are not what causes disease.

Trying to hold both positions at once is not precaution. It is incoherence.

Nicotine replacement therapies were deliberately designed to avoid rapid spikes, making them less reinforcing—and less appealing to many people who want to quit smoking.

Vapes sit between these extremes. Modern devices deliver nicotine faster than patches or gum, but generally slower and at lower peaks than cigarettes. Nicotine pouches deliver nicotine even more gradually.

But any concern about spikes is really about dependency and subjective effect, not toxicity. That distinction matters. Cancer and mortality are public health threats. Dependency in the absence of serious harms is a mere regulatory issue. 

By refusing to distinguish between nicotine and smoking, regulators produce predictable harms. Cigarettes remain the most accessible nicotine product. Safer alternatives face bans, flavor restrictions and regulatory limbo. Illicit markets grow. People receive misleading health information. Public trust erodes.

Nicotine replacement therapy quietly acknowledges what public messaging denies: Nicotine can be used safely long-term. Science settled this years ago. Policy has not.

Either nicotine is too dangerous to allow patches and gum, or it is safe enough to allow adults to choose lower-risk consumer alternatives to smoking. Trying to hold both positions at once is not precaution. It is incoherence.

Photograph via Wikimedia Commons/Creative Commons 3.0

The post The Role of NRT Fatally Undermines the Anti-Vape Case appeared first on Filter.

The United Kingdom has, up to this point, regulated vaping products to ensure they are safe, taxing them at a fairly low rate to help nudge people from smoking to vaping. The United States, on the other hand, has failed to authorize most vaping products, which has led to illicit markets and confusion for retailers and consumers. 

My research looks at the consequences of both US and UK authorities making bad decisions, however. The US is increasing enforcement of its bad existing policy, whereas the UK is changing course by banning disposable vapes and other popular products.  

The US Food and Drug Administration (FDA) has authorized a small number of vaping products for sale, in only one flavor other than tobacco. It has also created a legal void by denying authorization to thousands of other products in a wide range of flavors—often far more popular than the authorized alternatives.  

Several convenience store owners I spoke with in the Philadelphia suburbs were pulling products from their shelves as a result of FDA actions.

The result is a massive illicit market in the US. In a recent analysis of discarded vaping packs, conducted across several states by the market research group WSPM, an astonishing 97 percent were not authorized to be sold. I also found most products sold were unauthorized in my own past research.

The FDA has started going after legal retailers of products of dubious legality, threatening them with fines and other legal actions. Several convenience store owners I spoke with in the Philadelphia suburbs were pulling products from their shelves as a result. These stores were all making over $2,000 per week in vape sales revenue in 2024, but were sent warning letters by the FDA towards the end of that year.

None of the store owners were sure how serious the FDA’s threats might be, but one of the owners had removed all unauthorized vaping products from his store and was left with just three brands on sale: all tobacco flavors made by a major tobacco company. 

Every owner I spoke with said they had taken “legal advice.” Yet they were not unduly worried, because all of them still earn far more from cigarette sales than they do from vapes.

One unregulated vendor I interviewed was making over $700 per week selling disposable vapes—up from almost nothing a year prior.

The unauthorized vaping products they were selling are now being sold instead on city streets, and at informal outlets like flea markets across suburbs, by vendors who often also sell illicit drugs.  

One vendor I interviewed was making over $700 per week selling disposable vapes. That isn’t much money compared with his business selling state-banned drugs, but it’s up from almost nothing a year prior. All traders watch for changes in demand, and if people cannot buy vapes legally, illicit sellers are happy to supply them. 

The problems with this are evident. Accountability for product quality and standards is lost, which could pose health risks for consumers. Unregulated traders have no incentive to adhere to age restrictions. And when informal markets are harder for many people to access, there’s a strong chance that vapers who used to smoke will revert to combustible tobacco—which is both deadly and readily available.

In the UK, meanwhile, the illicit vapes market has jumped from very low levels three years ago to 31 percent, according to my latest sampling in February. 

The UK’s ban on disposable vaping products is not due to take effect until June. But it appears that anticipation of it—with stores phasing out sales of disposables—may already be driving that part of the market underground. 

When it comes to refillable vapes, as regulatory expert Clive Bates told me, it is likely that Brits “prefer the products with larger tank sizes” that are illegal in the UK.

Smoking is the real threat—and when vapes are substitution products, banning or restricting them is liable to increase smoking. 

In the US, it is essential for the FDA to do a better job. One of the first tasks for Dr. Marty Makary, the incoming head of the agency, should be to speed up authorizations of good-quality vaping products that are currently in a legal limbo. A robust legal market of products consumers actually want must be the goal.

In the UK, the illicit market is still relatively small at present, with the majority of discarded packs reflecting legal sales. However, the recent surge in this market—with my latest numbers far higher than just a year earlier—should be cause for concern. Bans and restrictions will only fuel it further.  

The UK should revert to its former position of encouraging legal uptake of good-quality products and reverse its disposables ban. Recent evidence shows that smoking rates in parts of England are rising for the first time in 20 years, and this is likely linked to the clampdown on vaping. 

My sample sizes are small, and may not reflect the wider markets. But my research can be added to other evidence signaling terrible outcomes for public health. Smoking is the real threat—and when vapes are substitution products, banning or restricting them is liable to increase smoking. 

The vaping products consumers want must be legally available on both sides of the Atlantic. When that happens, tax policies that encourage switching from smoking to vaping will also be vital. 

Photograph by Engin Akyurt via Pexels 

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