By Mirza M. Abeer, CEO, Association for Smoking Alternatives in Pakistan (ASAP)
When it comes to tobacco, the absolute gold standard for public health is clear: never starting, or quitting cold turkey, is the best possible option for your body. However, we must face a difficult reality. Millions of people struggle with severe nicotine dependence and find themselves unable to quit through sheer willpower alone. Far too often, these individuals are left without viable help, stigmatized, and treated as lesser beings unworthy of medical support. This “quit or die” approach is fundamentally flawed. If a patient cannot quit cold turkey, we have a moral and medical obligation to offer scientifically researched, less harmful alternatives to help them transition away from combustible tobacco, gradually lower their nicotine intake, and ultimately quit altogether.
At the Association for Smoking Alternatives Pakistan(ASAP), our mission is to cut through the noise, remove the stigma surrounding nicotine, and ground the conversation in objective, peer-reviewed science.
Here is what internationally renowned public health institutions and clinical studies have concluded regarding alternative nicotine delivery systems.
1. The Real Enemy is Combustion, Not Nicotine
A pervasive myth in both the public and medical communities is that nicotine is the primary cause of smoking-related cancers. The science says otherwise. Nicotine is highly addictive, but the immense cancer burden associated with smoking is driven by the combustion of organic plant material, not the nicotine itself.
Long-term clinical data evaluating Nicotine Replacement Therapy (NRT) has consistently demonstrated no correlation between continuous unburned nicotine consumption and lung cancer. In the landmark Lung Health Study, which followed participants for 7.5 years, researchers found that smoking was a significant predictor of lung cancer, whereas the use of NRT alone was entirely statistically insignificant.[3]
2. A Substantially Reduced Toxicological Profile
While alternative nicotine products like e-cigarettes are not completely risk-free, they present a drastically reduced toxicological profile compared to smoking combustible tobacco. According to comprehensive evidence reviews, regulated nicotine vaping exposes users to a significantly lower amount of harmful substances—including biomarkers linked to cancer, respiratory, and cardiovascular conditions—when compared with active smoking. Because vapes do not burn tobacco, they bypass the primary mechanism that creates deadly toxins in the short and medium term.[1]
3. Clearing the Air on EVALI
The 2019 outbreak of EVALI (E-cigarette or Vaping Use-Associated Lung Injury) is frequently cited as proof that vaping is acutely dangerous. However, rigorous forensic and epidemiological investigations confirmed that this outbreak was not caused by standard, regulated nicotine e-liquids.
The U.S. Centers for Disease Control and Prevention (CDC) conducted forensic analyses of bronchoalveolar-lavage (BAL) fluid from EVALI patients across 16 states. They found that Vitamin E acetate—a cutting agent used in illicit, black-market THC (cannabis) cartridges—was present in 94% of the case patients tested, definitively linking the lung injuries to unregulated adulterants rather than commercial nicotine vaping.[2]
4. A Proven Catalyst for Smoking Cessation
Alternative nicotine delivery systems are powerful harm-reduction tools intended for adult smokers trying to quit. High-certainty clinical evidence from the Cochrane Database of Systematic Reviews indicates that nicotine e-cigarettes are highly effective at helping individuals stop smoking for at least six months. The review found that vaping is even more effective at achieving long-term smoking abstinence than traditional Nicotine Replacement Therapies (NRTs) like patches or gums, and is more effective than behavioral support alone.[4]
A Compassionate Path Forward
To medical professionals, policymakers, and the public: it is time to embrace a more compassionate, evidence-based approach to smoking cessation.
We must protect youth by keeping adult products out of their hands through strict regulation, but we cannot simultaneously rip the life rafts away from adult smokers trying to save their own lives. By integrating scientifically validated alternatives into clinical guidance, doctors can help patients systematically break their addiction to deadly combustible smoke, wean down their nicotine concentrations over time, and eventually achieve a completely nicotine-free life.
References
- [1] Association of Directors of Public Health (ADPH). (2023). Nicotine Vaping Position Statement. Contains main findings from the Office for Health Improvement and Disparities (OHID) 2022 evidence update. https://www.adph.org.uk/networks/eastofengland/wp-content/uploads/sites/4/2023/12/EoE-ADPH-Vaping-position-statement.pdf
- [2] Blount, B. C., et al. (2019). Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. Centers for Disease Control and Prevention (CDC). https://www.researchgate.net/publication/338088684_Vitamin_E_Acetate_in_Bronchoalveolar-Lavage_Fluid_Associated_with_EVALI
- [3] Murray, R. P., Connett, J. E., & Zapawa, L. M. (2009). Does nicotine replacement therapy cause cancer? Evidence from the Lung Health Study. Nicotine & Tobacco Research, 11(9), 1076–1082. https://pubmed.ncbi.nlm.nih.gov/19571249/
- [4] Lindson, N., et al. (2025). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010216.pub10/full