By: Dr. Aftab Ahmed Khan, Family Physician and Public Health Expert
For decades, public debate has focused on nicotine. As physicians, we know the greatest danger begins when tobacco burns. That distinction is more than a matter of scientific precision. It lies at the heart of why smoking remains one of Pakistan’s leading preventable causes of disease and premature death. Every day, physicians treat patients living with chronic obstructive pulmonary disease, cardiovascular disease, stroke and multiple forms of cancer linked to years of smoking. While nicotine is the substance that sustains addiction, it is the smoke produced through the combustion of tobacco that exposes smokers to the overwhelming majority of the toxic chemicals responsible for smoking-related disease.
When a cigarette burns, it creates a complex mixture of more than 7,000 chemicals, including dozens known to cause cancer and many others identified as harmful or potentially harmful to human health. Every inhalation carries tar, carbon monoxide and numerous toxic compounds deep into the lungs, where they damage tissue, impair blood vessels and increase the risk of disease throughout the body. This understanding has shaped decades of medical research and tobacco control efforts worldwide. It is also why physicians have consistently urged smokers to quit. Medical science commonly emphasizes the principle that “prevention is better than cure,” and the most effective way to prevent the health risks associated with smoking is to stop smoking altogether.
Yet medical science also recognises the reality that quitting is not easy. Nicotine dependence is a chronic condition, and many smokers make repeated attempts to quit before they succeed. Some never do. As clinicians, we meet patients who understand the risks, genuinely want to stop and have tried multiple times, yet continue smoking because addiction is rarely overcome through willpower alone.
It is in these circumstances that tobacco harm reduction enters the conversation. Harm reduction is neither a new nor a controversial principle in public health. We encourage seatbelts even though the safest journey is one without a road accident. We provide clean needles to reduce the spread of blood-born diseases. We prescribe methadone to reduce the harms associated with opioid dependence. In each case, the objective is not to endorse a harmful behaviour but to reduce the harm when eliminating that behaviour immediately is not possible.
The same principle applies to smoking. Tobacco harm reduction begins with a simple clinical question. If an adult smoker cannot or will not quit despite repeated efforts, can reducing exposure to the toxic products created by combustion reduce the health risks associated with continued smoking? An increasing body of scientific evidence suggests the answer deserves careful consideration. While no nicotine product should be considered risk free, scientific assessments increasingly distinguish between the risks associated with combustible cigarettes and those associated with smoke-free alternatives because the absence of combustion significantly reduces exposure to many of the toxic substances found in cigarette smoke.
This distinction should not be misunderstood. Tobacco harm reduction is not intended for young people, non-smokers or former smokers. Nor should it replace smoking cessation, which remains the best possible outcome for every smoker. Rather, it offers another evidence-based approach for adults who would otherwise continue smoking combustible cigarettes. Recognising relative risk does not weaken tobacco control. It strengthens by aligning public health advice with scientific evidence.
Several countries, including Sweden, the United Kingdom and Japan, have incorporated harm reduction into broader tobacco control strategies while maintaining strong youth protections and encouraging smoking cessation. Their approaches differ, but they share a willingness to evaluate emerging evidence and adapt policy accordingly. Pakistan need not replicate another country’s model, but it should be willing to engage with the same scientific questions rather than dismiss them outright.
As physicians, our responsibility extends beyond treating disease. It includes helping patients understand risk accurately. Oversimplifying complex issues may make public messaging easier, but it can also leave adult smokers believing there are no important differences in risk between products that involve combustion and those that do not. Patients deserve information that reflects the best available evidence, enabling them to make informed decisions in consultation with healthcare professionals.
Protecting young people should remain a priority, with stronger measures to ensure that underage individuals do not have access to tobacco and nicotine products. Efforts should focus on preventing underage use and ensuring these products remain out of reach of young people. There is also a need to strengthen the training of general physicians in smoking risk assessment and establish smoking cessation clinics at the town level, ensuring that professional quitting support is accessible to smokers across the country.
Smoking has never been a simple public health challenge and there are no simple solutions. Prevention, cessation support, regulation and public education will always remain the foundation of tobacco control. But science has also taught us that understanding risk requires nuance. As physicians, our duty is not to simplify evidence until it fits familiar narratives. It is to communicate that evidence honestly, help patients make informed decisions and remain open to approaches that have the potential to reduce disease and save lives. That is how medicine has always progressed and it is how it should continue to do so.
Source: ProPakistani