I’ll start by outlining some normative claims that touch on the philosophical underpinnings of both movements, what they share, and where they differ from each other. Then I’ll try to figure out whether harm reduction’s moral claims could or should appeal to people interested in EA’s approach to evidence-based ways of doing good at scale, and vice versa. This exercise provides a chance to look at what each school of thought has to offer the other.

Introduction

Effective altruism and harm reduction both start with the observation that the world contains vast, preventable suffering, much of which persists because dominant moral frames and policy defaults are poorly aimed. Each movement proposes a shift in perspective that makes previously invisible or neglected interventions suddenly obvious.

The pivot EA suggests is that people (especially in rich countries) with disposable resources can move from not donating, or donating based on sentiment and proximity, to deliberately maximizing impact, which most of them currently don’t do. A modest redirection of money, time, and talent guided by evidence and expected value can save or radically improve far more lives than intuition suggests. The reframe proposed by harm reduction is that policymakers, clinicians, and advocates can move from trying to coerce or shame people who take unpopular risks (psychoactive substance use, smoking, sex work) to empowering them by providing safer options, more accurate information, and non-judgmental services. Instead of trying to force abstinence from activities the majority rejects, harm can be reduced in the world as it is actually lived.

Both movements’ adherents claim that their signature interventions look radical only because our default moral lens is skewed. Shifting from charity-as-virtue to charity-as-optimization or from prohibition-as-protection to autonomy-plus-safety allows new possibilities to open. Beyond these similarities, however, there are also deep differences in philosophical foundations and political instincts.

Philosophical foundations

EA: from Mill and Singer to malaria and shrimp

While EA as a movement began in the late 2000’s, its intellectual genealogy goes back to philosopher Peter Singer, in particular his 1972 essay, “Famine, Affluence, and Morality,” and even farther back to a longer tradition of consequentialist and utilitarian thinkers like Jeremy Bentham and John Stuart Mill. Singer’s essay argues that if you can prevent something bad “without sacrificing anything of comparable moral importance,” you are morally obliged to do so. From this act-utilitarian perspective, outcomes are what matter, and the location of the people affected (whether they are in your hometown or on another continent), whether they are alive now or will be in the future, or whether they are even people or other sentient beings with moral worth, shouldn’t change the calculus.

EA then attempts to put these utilitarian ideas into practice in a pragmatic way. The Center for Effective Altruism defines four core principles of its ethos. Prioritization refers to the process of using evidence to rigorously weigh the relative impact of different actions we can take to help instead of relying on our intuitions. Impartiality echoes Singer’s imperative to weigh all those affected equally regardless of their distance from us in space and time. Open truthseeking refers to the habit of reflecting on our views regularly with an openness to change them as we discover new evidence. Collaborative spirit emphasizes collaborating with others on altruistic goals with “high standards of honesty, integrity, and compassion.”

The institutional face of EA, consisting of organizations like GiveWell (charity evaluation), Open Philanthropy (grantmaking), and 80,000 Hours (career advice), builds this into practice. To learn about what cause areas should be prioritized, they do things like estimate disability-adjusted life years (DALYs) saved by various interventions, support and learn from randomized controlled trials, weigh the moral significance of various species, and assign probabilities to various forms of AI risk. Even when EAs acknowledge “moral uncertainty” or allow pluralism, for example by allowing for virtue ethics or deontology as side-constraints in considering possible actions, the default goal is still maximizing expected value.

Harm reduction: rights-based consequentialist pragmatism

The harm reduction movement’s members come to it bringing with them a variety of ethical intuitions. Its roots are found not in abstract moral reasoning or an explicitly defined, shared philosophy and are instead practice-driven. It began as an umbrella term for a set of pragmatic responses to concrete problems encountered by practitioners working in a number of fields dealing with various forms of socially stigmatized risk-taking like sex work and intravenous opiate use. Nonetheless, it’s possible to identify a couple of conceptual strands that recur regularly in harm reduction discourse and drive its practice.

Harm reduction frequently centers a rights-based approach to morality. The National Harm Reduction Coalition in the US calls for respecting “the rights of people who use drugs” in its presentation of the principles of harm reduction and Harm Reduction International describes it as “grounded in social justice and human rights.” Philosophical pragmatism in the tradition Dewey, James, and Peirce has also been described as “one of the underlying theories of harm reduction” and lying “at the heart of harm reduction” as its practices grew out of on-the-ground experience rather than academic theorizing or top-down bureaucratic initiatives. Moral philosophers advocating for freedom as a foundational concept, like Mill’s articulation of the harm principle in On Liberty, were the first to make explicit the ideas that underpin the resistance to prohibitions on sex work and psychoactive substances. To thinkers like Mill, these prohibitions are harmful in principle, not because of their consequences, but simply because they restrict the individual’s liberty. Most closely connected to EA’s approach, utilitarianism plays a prominent role in harm reduction as it’s practiced, as the arguments for its superiority to criminal or medical framings of the problems it’s applied to tend to be justified on cost-benefit grounds.

How different are these approaches?

The approaches to ethics behind both EA and harm reduction contain a strong dose of consequentialism. For the former, this is an integral part of what distinguishes the framework from more conventional approaches to philanthropy. For the latter, consequentialism supplies just one of the multiple moral arguments for why it’s a better approach to addressing its areas of concern than competing models. Adherents of both regularly invoke straightforward cost-benefit analyses to convince stakeholders to adopt their approach. They differ in at least two important ways, though, with regard to additional moral commitments that affect what counts as a legitimate input into those analyses.

Harm reduction proponents center their ideas as a response to coercive and paternalistic measures. They may dismiss efforts that an EA might consider to net out positive if they involve what they see as unacceptable infringements on individual liberty to choose behaviors the majority regards as too risky or even irrational. In the stark words of psychiatrist Thomas Szasz, “freedom is more important than health.” For example, they may oppose, as a matter of principle, policies like tobacco taxation or framings of addiction as a disease to be cured that EAs would advocate for because a DALY-based cost-benefit analysis shows the possibility of a big win on purely utilitarian terms.

In turn, the principle of impartiality stressed by EAs is responsible for an important and distinctive aspect of their worldview. In an effort to take the welfare of moral persons from the far future into the same consideration as those currently living, they will seek out and incorporate information on the possible effects of interventions on future generations as much as possible. This is taken furthest through the idea, contested even within EA, of longtermism, the view that positively influencing the far future is the key moral priority of our time. This isn’t generally an instinct shared by harm reduction proponents, who tend primarily to be concerned with reducing the immediate suffering of those taking unpopular risks. Because some of the most frequent criticisms of harm reduction approaches to psychoactive use, for example — like the justification of prohibition of some substances alleged to be “gateways” to more dangerous ones, or the idea that the prevention of youth uptake needs to be a strong consideration when promoting less risky forms of use — appeal to long-run considerations, they are likely to view such arguments with a more skeptical eye than most.

In practice, both traditions are more pluralistic than a strict reading of their slogans might suggest. Many EAs appeal to moral uncertainty and accept side‑constraints like autonomy and consent as genuine moral reasons that can limit policies with otherwise high expected value. Some also draw on virtue‑ethical considerations about integrity, trust, and movement‑building effects. Conversely, harm reduction advocates routinely engage on consequentialist terms: they run cohort studies and natural‑experiment analyses, contest “gateway” claims with longitudinal evidence, and argue that syringe access, naloxone, safe consumption sites, or low‑risk nicotine products outperform punitive or abstinence‑only approaches on DALY-convertible measures like infections, overdoses, and mortality. There is internal diversity of thought on hard cases like differential tobacco taxation or youth‑access restrictions where some harm reduction proponents accept least‑restrictive nudges to shift behavior, while others view these as unacceptable paternalism. EAs aren’t averse to weighting autonomy costs and legitimacy effects in their analyses, and harm reduction organizations regularly quantify outcomes to prioritize campaigns and secure scale. So the disagreement in specific cases is usually less about whether consequences matter and more about which constraints are to be included and how heavily they should be weighted in the moral calculus.

What can EA learn from harm reduction?

EA and harm reduction share a taste for pragmatism, but the latter’s history inside adversarial, morally charged policy domains surfaces blind spots that EAs are prone to miss. None of these are totally unfamiliar or undiscovered, as they’ve been raised as critiques of EA in the past, but harm reduction provides both a vivid set of examples and a number of tested practices to help counter them.

One of EA’s strengths is the relentless focus on quantification above anecdote and emotional salience. But many of the most consequential harms in harm reduction domains are relational and institutional, and therefore rarely map cleanly to DALYs. Loss of trust in authorities, fear of police contact that keeps people away from services, and criminal records that foreclose jobs and housing are all factors that undeniably affect the total cost of an intervention, but analysts may be tempted to treat them as second‑order. Harm reduction’s rights language functions as a guardrail in encouraging a perspective that sees coercion and degradation themselves as public health risks. Policies that look efficient on paper can unravel when people avoid them or when the legitimacy costs poison future cooperation. A harm reduction-informed perspective can encourage EA evaluations to consider when and how impacts of an intervention on autonomy, dignity, and institutional trust can be made first-class considerations in modeling them, rather than more implicit caveats.

Unintended consequences are at the core of why harm reduction exists as a concept. Drug and alcohol control offer a running lesson in perverse effects, as when supply‑side crackdowns lead to more potent and adulterated products or bans on sterile equipment drive blood‑borne infections. Tobacco regulation has its own versions in the form of flavor bans nudging adults back to cigarettes or into illicit markets and advertising prohibitions that incidentally suppress truthful risk communication. Because of this history, harm reduction’s habit is to ask, before acting, how might this backfire, and on whom? For EAs, this highlights the importance of considering backfire scenarios in cause area evaluations. If an intervention expands a black market, erodes service uptake, or generates political backlash that crowds out better policies, our models are improved when those pathways receive explicitly quantified weight.

For EAs, especially those that are strongly convinced by longtermist reasoning, future people matter just as much as those alive today. But harm reduction experience shows how less determinate future worries, like “gateway” hypotheses or speculative effects on normalization of substance use can be used to block concrete, tractable benefits for living people. The corrective is not necessarily to ignore the future, but to discipline it by requiring explicit estimates before letting a conjectured risk outweigh immediate, well‑evidenced gains. In practice, this pushes toward reversible policies such as piloting and monitoring safe‑consumption sites, permitting low‑risk nicotine products while tracking youth uptake, and sunsetting coercive elements unless supported by data. This can ensure that present benefits are realized while still bounding future risks.

One of the most well-known slogans of harm reduction advocates, adopted from the disability rights movement, “nothing about us without us,” can also serve as a useful reminder for EAs. People who use illegal substances, smoke, or sell sex possess local knowledge about incentives, enforcement patterns, and behavioral substitution that formal models can easily miss. Their participation improves domain knowledge, helping to reveal bottlenecks and surface overlooked harms and opportunities early. Prioritizing affected‑community co‑design could improve EA projects across cause areas. This includes things like budgeting for peer researchers, sharing intermediate findings for critique, and planning for legitimacy effects (compliance, uptake, political durability) as part of the expected value calculation.

Taken together, these lessons point to a more rights‑sensitive EA practice: quantify relentlessly, but price autonomy and trust; model backfires, not just benefits; resist letting hazy long‑run fears veto solid near‑term gains; and upgrade participation from courtesy to core methodology.

What can harm reduction learn from EA?

EA’s distinctive contribution is methodological: make trade‑offs explicit, quantify expected value, publish assumptions, and update in public. Harm reduction campaigns often have compelling narratives and strong prima facie evidence, but budgets are finite and opportunity costs are real. Systematically comparing options with transparent cost‑effectiveness models rather than relying on intuition or political tractability alone would help harm reduction allocate marginal dollars between, say, naloxone distribution, syringe services, contingency management for stimulants, smoking‑cessation through low‑risk nicotine, or housing‑linked supports. EA orgs like GiveWell make their spreadsheets, moral weights, and sensitivity analyses public. They routinely find that some programs are an order of magnitude more cost‑effective than others, and they communicate that clearly (e.g., saving a life for on the order of $3,500–$5,500 via top global‑health programs). Adopting that level of quantitative transparency, and inviting critique, could improve harm reduction credibility with funders while disciplining internal priorities.

Relatedly, EA’s willingness to privilege measured impact over empathetic pull offers a useful corrective. It is often more emotionally satisfying to fund broad “wrap‑around” services than narrowly targeted, high‑leverage interventions. Yet the evidence that certain harm reduction staples avert deaths and infections at very low cost is strong: community naloxone distribution prevents overdoses and is cost‑effective with modeled estimates of one death averted per roughly 89 kits distributed; syringe services halve HIV/HCV incidence and, combined with medication, cut transmission by more than two‑thirds. Building comparable cost-effectiveness analyses around such effect sizes, and letting the numbers guide marginal spending, can mean backing programs that feel less comprehensive but save more lives.

EA also stresses prospective risk analysis: model backfires, specify priors, and test sensitivity to pessimistic assumptions. Harm reduction’s history teaches that blunt controls can backfire, but the mirror image is also true: some structured constraints appear to reduce harm at population scale. Scotland’s minimum unit pricing for alcohol, a paternalistic nudge many harm reduction advocates distrust, was associated with a 13.4% reduction in alcohol‑attributable deaths and significant hospitalization declines, especially in deprived groups. Tobacco taxation shows similarly robust links to lower prevalence and even downstream outcomes like reduced infant mortality. Harm reduction can incorporate these findings without abandoning its focus on rights by demanding high‑quality evidence of benefit, preferring least‑restrictive designs, and quantifying regressivity, illicit‑market displacement, and enforcement harms.

Finally, EA’s norm of “open truth‑seeking” is operationalized through preregistration, randomized controlled trials and natural‑experiment designs, and adversarial collaboration. Harm reduction practice already uses many of these tools, but making them movement norms by publishing forecasting intervals for expected deaths averted and preregistering before‑after evaluations of policy changes would strengthen advocacy and guard against motivated reasoning. Where constraints clearly fail, harm reduction should emphasize it, such as COVID‑era evidence that relaxing methadone take‑home rules improved retention and client experience. Where there’s robust evidence of constraints having a strong net benefit, harm reduction can consider endorsing them as provisional, monitored, least‑restrictive instruments in a broader rights‑respecting framework.

Harm reduction can borrow some of EA’s best habits of publishing models, comparing marginal cost‑effectiveness, and explicitly pricing in dignity, regressivity, and enforcement harms. That combination keeps harm reduction anchored to its rights‑based ethos while maximizing the lives and suffering averted per dollar.

Summary: A wide range of evidence from a years of surveys across the world shows that basic facts about nicotine, tobacco, and smoking, known to subject matter experts for years and sometimes decades, are unknown to a majority of those that make life and death decisions about them. Of particular importance are people who use nicotine or tobacco regularly and the medical professionals that advise them. Efforts to disseminate accurate information could be highly cost-effective interventions to reduce smoking-related disease, but need to be evaluated more rigorously.

Introduction

This post continues the exploration of some of the core claims of tobacco harm reduction (THR) advocates through an effective altruist (EA) lens, with the aim of understanding whether interventions in this area could represent a cost-effective way of improving human well-being. Earlier in this series, I looked at claims about the safety of nicotine and the usefulness of reduced risk products in helping people transition away from smoking. The next important claim is about the lack of awareness of the relative risk of various ways of using nicotine and tobacco.

Almost everyone in the field, whether they lean more towards skepticism or enthusiasm for harm reduction, agrees that using different nicotine and tobacco products poses different levels of risk to the user’s health. This fact is often referred to as the “continuum of risk,” with cigarettes generally placed at the most harmful end of the spectrum. And while disagreements abound about the quantification of relative risks for particular methods of ingestion, there is also widespread agreement about the rough order of harmfulness among the most commonly used products.

The distressing claim observed and stressed by THR advocates is that the majority of the general public, as well as that of the most relevant populations — people who use tobacco and nicotine, the doctors that they turn to for advice, and policymakers crafting laws and regulations around their use — are either unable to place the products in even roughly the correct order on the continuum, or are unaware that it even exists and think harms are about the same no matter what they’re consuming. Some of the more strident opponents of promoting THR, on the other hand, have referred to the idea of the continuum as a “hypothesis lacking sufficient empirical evidence” due to its not taking into account second-order population-level effects on smoking initiation.

From the perspective of someone looking for cost-effective interventions to reduce tobacco-related disease, this claim is quite important: even if some products make a significant dent in health risk and are compelling substitutes for the more dangerous ones, if the people using them and the experts those people look to for advice don’t know this, it’s a lot less likely they will try them. If there are large numbers of people unaware of these facts, we have a potentially quite effective way of helping just by informing them, analogously to approaches to sexually transmitted infections and illnesses spread by sharing needles. This post digs into the evidence behind the advocates’ claims, some possible reasons for what they’ve observed, and implications for cost-effective interventions.

Who doesn’t know?

Data around awareness of the science around the harms of nicotine and tobacco use consists mostly of surveys conducted in a number of different populations. This knowledge is obviously critical for people who use nicotine or tobacco since not knowing the effects of switching from one product to another prevents them from being able to make considered decisions. The beliefs of medical professionals are also critical, as these are the people trusted to provide expert advice on health; if they don’t have it, they obviously can’t provide it. The views of the non-smoking public also matter greatly: if people are overall misinformed, even if they never use nicotine, they may support ineffective policies that harm those that do.

A brief sample of the most relevant research can be found below. For even more detail, the Safer Nicotine Wiki assembles an exhaustive range of evidence from surveys of each of these populations across the world.

General public

The average person in most countries is quite confused about a number of different aspects of this topic.

• In a 2018 sample taken in the US, only about a quarter of respondents thought vaping was less harmful than smoking

• In another US survey from 2020, the number was even lower, with just over a tenth answering “less harmful” when asked to compare vaping and smoking risks

• More than a third of people asked in an Australian pharmacy chain thought vaping is as harmful as smoking

• A 2016 survey in the UK indicated only about 12% of respondents perceived vaping as “a lot less harmful” than smoking

• In 2021, less than a quarter of those polled in Poland believed smokeless tobacco, heated tobacco, or e-cigarettes were less harmful than smoking

• 80% of respondents to a recent survey in France believed electronic cigarettes cause cancer

The trend in these data also shows that awareness is generally going in the direction of beliefs becoming less accurate over time. For example, in the UK, the percentage of adults who thought vaping was less harmful than smoking dropped from 44% in 2013 to 27% in 2024; in the US, the same numbers went from 41% to 25% between 2013 and 2016.

Nicotine and tobacco users

Similarly to the overall population, surveys show a lack of knowledge among users about relative risk.

• A survey of a large (50,000+ person) group of people that smoke across seven different countries found 40-80% of respondents in every country thought nicotine was the primary cause of tobacco-related cancer

• Fewer than 20% of adults who smoke in a 2021 US sample believed vaping to be less harmful than smoking

• Fewer than a quarter of people who smoke polled in Sweden had accurate risk perceptions about snus

• More than two thirds of a sample of people who smoke in France and Germany thought nicotine causes cancer and more than a third believed vaping to be as harmful or more harmful than smoking

• Fewer than half of Kuwaitis polled online thought vaping was less harmful than smoking

These numbers have alarmed even advocates and promulgators of strict regulations. The director of the US FDA’s Center for Tobacco Products published a commentary in Nature Medicine in 2023 warning about the health impacts of the lack of awareness of the continuum of risk among people who use tobacco products.

Health care professionals

Given the ample research from the past fifteen years, the extensive training they receive, and the prevalence of tobacco use, one might expect health care professionals to have a solid understanding of the continuum of risk. The largest effort to understand perceptions among this population was conducted in 2022 and consisted of interviews with more than 15,000 physicians in 11 countries on four different continents. Large majorities in each country said that helping their patients to quit smoking was a priority for them, but they displayed many of the same misperceptions as the public and consumers:

• More than half of the doctors in each country (including 97% in India) believed nicotine causes cancer

• More than two thirds in each country thought nicotine is responsible for COPD

• Fewer than a third recommended trying any reduced risk product to their patients for the purpose of reducing or stopping smoking

Smaller studies show results in line with these data. A survey of health care professionals in India indicated more than two thirds believed nicotine to be the main cancer-causing component of tobacco smoke; a survey of US doctors conducted by researchers at Rutgers indicated more than 80% thought nicotine contributes directly to cancer, COPD, and cardiovascular disease; more than a third of UK clinicians surveyed in 2020 either didn’t know whether vaping was less harmful than smoking, or thought it was equally or more harmful.

Why has this happened?

The data are pretty clear that the harm reduction enthusiasts are correct when they claim that massive numbers of people have beliefs widely contradicting the body of scientific evidence. Both common sense and academic research suggest that the lack of awareness of relative risk worsens health outcomes for consumers. Determining the underlying reasons for the confusion is important for figuring out whether it can be cost-effectively rectified. There are a couple of plausible contributing factors.

Rapidly changing evidence base

Some of the most popular noncombustible products are pretty new, and the research on them is recent enough that it hasn’t been disseminated widely enough for awareness to spread. This is most true of heated tobacco, which was launched in 2014 with the introduction of IQOS but only in a few select markets, and to a lesser extent of nicotine pouches and vaping, which began to appear in the mid-2000’s.

This factor is less relevant for snus, which was invented centuries before the modern cigarette and has been studied since the 1970’s, and chewing tobacco, which is even older. While these products have generally become safer over the last few decades, it has been known to experts for much longer that their health risks pale in comparison to those of cigarettes.

Misinformation and fake science from industry

Even when research is disseminated, results indicating a lower risk for anything tobacco-related can be met with strong skepticism due to the long history of reduced risk claims from the industry that turned out to be false. These include the initial long period of the denial of smoking causing cancer, the claims of light cigarettes being a safer alternative, and the idea that filters protect the user’s health by reducing the amount of tar or nicotine ingested when smoking.

It wouldn’t be too surprising for people unfamiliar with and uninterested in the details of research to instinctively dismiss reduced risk claims by pattern-matching to the statements above, which are fairly well-known to be false, especially if they don’t come from sources in which they have strong trust.

Misleading reporting on lung injury outbreak

In 2019, the supply chain of black market THC cartridges in the USA was contaminated with vitamin E acetate, an additive intended to fool buyers into thinking they were buying a purer product. As a result, thousands of people were hospitalized and several dozen died, as inhaling VEA can result in severe, acute damage to the lungs. When the manufacturers realized what happened, they stopped using the additive, and the outbreak ended in early 2020.

Both the extensive media coverage and the poor communication from federal agencies contributed to significant public confusion about the outbreak, primarily by conflating the risks of using illegal THC devices with legal nicotine vapes. This resulted in an abrupt and lasting worsening of risk perceptions both in the US and in other countries.

Misinformation from NGOs

A number of organizations generally trusted by the public on important health-related issues like infectious diseases and air pollution spread false claims related to the continuum of risk in their public communications.

The most prominent of these is the World Health Organization. Its fact sheet on vaping contains a number of false statements and its informational material on smokeless tobacco and nicotine pouches simply lists a number of purported health risks without any mention of their role in harm reduction or their relative risk compared to smoking. A group of UK public health experts called these and other publications out as “blatant misinformation” and a prominent US academic awarded the organization the “Most Egregious Statement About Electronic Cigarettes” for 2024.

Many other NGOs have and continue to spread similar misleading claims, particularly about vaping, including the American Cancer Society, American Heart Association. and the American Lung Association. By lending their brand to these statements, they likely contribute to misperceptions both among the general public and among health care practitioners who are unfamiliar with the evidence.

What has been done?

A number of governments, health departments, and research organizations have recognized the problems detailed above, and have launched initiatives to try to ameliorate them. The main approach has been straightforward: try to disseminate more accurate information to people who smoke and the people they turn to for help if they’re trying to quit.

The UK National Health Service provides what is probably the clearest, most succinct guide on using vaping to cut down on or quit smoking. It provides straightforward answers to the most common questions raised by those interested in using them. The New Zealand Ministry of Health maintains a similar site, Vaping Facts, informing people about product choices, challenges in transitioning from smoking, and supporting friends in the process of switching.

Academic researchers working in tobacco-related fields have also worked on several fronts to correct misperceptions. For example, some university departments have published videos aimed at the public to communicate what they know in an easily digestible way. Others publish podcasts, blogs, and Substack newsletters bringing the latest research to a broader audience. They also push back on incorrect or exaggerated claims in the academic literature through publications in high profile journals like Nature and the British Medical Journal. Medical practitioners with larger public platforms knowledgeable and concerned about the information gap have also contributed to this work, in the form of videos, podcasts, print books, online publications, and articles in popular media.

What could be done?

The numbers show pretty clearly that efforts so far to counter the false beliefs that end up resulting in more disease and early deaths haven’t been adequate. This is where it gets interesting from the perspective of an effective altruist, or anyone interested in impactful interventions for global health. If there are cost-effective ways to bring more accurate information to the relevant groups, these would represent strong candidates for a cause area in global health due to the massive impact of smoking across the world. A couple of unexplored areas stand out.

Gauge effectiveness of awareness campaigns

While some of the efforts to correct misperceptions, like the government websites in the UK and New Zealand, have been quite extensive, there haven’t been any significant efforts to evaluate how many people they reached and how their risk perceptions were affected by them. This would be critical information to inform support of similar initiatives, and EA-aligned orgs like GiveWell have a strong track record in this area.

There has been some research trying to quantify how much people adjust their behavior when learning more about the continuum of risk. These and similar results can serve as a helpful data point when assessing impact this work could have.

Fund organizations disseminating the science

There are a number of existing organizations working on bringing more accurate information to consumers. One might think tobacco companies would have strong incentives to do so and be at the forefront of these efforts, but while this happens to some extent, the inherent conflict of interest resulting from the fact that most of them still rely primarily on selling cigarettes for their revenue, theie continued unethical practices in sponsoring research, and their support of bans on safer products whenever they compete with their own offerings prevent them from being a credible source of advice for the public.

Consumer advocates and informed health care practitioners are likely to be a better fit for providing unbiased explanations of the state of the science. Many of them are highly funding-constrained. For example, CASAA, the largest US-based association representing vapers, will suspend operations in August 2025 because they ran out of funds. The largest international umbrella orgs (INNCO and WVA globally, ETHRA in Europe, and CAPHRA in Asia) all run on small budgets hamstringing their effectiveness, and sometimes faced with the dilemma of either not being able to do much or accepting industry money thereby drawing skepticism from the public and potential donors. The majority of advocacy organizations across the world receive no funding at all and are run on a purely volunteer basis. This represents a big opportunity for impact-focused funders.

Develop more rigorous cost benefit analyses

It’s pretty clear from back of the envelope calculations presented by effective altruist organizations like Open Philanthropy and earlier in this series that increased use of reduced risk products is a net health benefit to the population. A number of open questions remain about whether and how better information could lead to less smoking-related disease:

• People don’t switch only for health reasons; factors like product appeal, social environment, and cost are also important influences on decisions

• Availability is an issue that won’t be solved through better information alone; for people who smoke in countries where some or all alternatives are banned, knowing what’s safer doesn’t help if you can only get it on the black market (which in turn also makes it less safe)

• While the problem is global, the cost-effectiveness of better risk communication may vary among different populations - for example, doctors may find it easier to understand the risk continuum concept and have more opportunity to disseminate it

More in-depth analyses of these and other questions would be critical in helping funders interested in global health determine how it stacks up against other efforts when considering it as an impactful cause area.

Introduction

This post continues the examination of tobacco harm reduction (THR) advocates’ core claims from an effective altruist (EA) perspective. The last post looked at the safety of nicotine and what it implies for the tractability of THR. This one will investigate the assertion that for smokers trying to quit, using a noncombustible product like a vape or a nicotine pouch is the method likeliest to lead to success.

Like the level of health risk from smokeless products, understanding how effective they are in reducing smoking is critical in determining whether THR is a tractable method. If they don’t work well enough, then money spent promoting them to smokers isn’t well used, no matter how safe they are. If they work better than other existing approaches, that implies a pretty urgent need to let smokers, and the health care professionals advising them, know, so that they can switch and reap the health benefits as soon as possible.

Support for this claim comes from many corners, including consumers, governments, and academia. Advocates have called Juul, one of the best-known noncombustible products, the “most successful anti-smoking device ever made.” The UK National Health Service calls vaping “one of the most effective ways to quit smoking.” A study in Discover Social Science and Health claims snus is “most effective and efficacious method for quitting smoking in Norway.”

On the other hand, skeptics claim that while the evidence around the effectiveness of reduced risk products for cessation is still evolving, there are other “proven” and “approved” methods that do work. The American Lung Association urges smokers “Quit, Don’t Switch” to vaping because the “Food and Drug Administration has not found any e-cigarette to be safe and effective in helping people quit.” Many university health centers discourage nicotine pouch use for cessation as there is “no data to show nicotine pouches as a safe or effective way to quit.”

What methods exist?

To gauge how credible the claim about the effectiveness of reduced harm products is, it helps to understand the baseline of how well other methods work. Because of the variety of ways and contexts in which people smoke across the world, it’s hard to put a single number on any method. That said, we can infer some rough figures from the available data.

The success rates of unassisted quit attempts for daily smokers tend to fall into the 3-5% range, so an average smoker could expect one in every 20-30 attempts to succeed. In most parts of the world, while the least effective, this is still the most common method of successfully stopping, because it’s used by a large majority of people attempting to quit. For smokers in less affluent countries, few additional tools are available or affordable. But even in a recent analysis in the US, more than two thirds of former smokers reported having quit this way.

Counseling, nicotine replacement therapy, and pharmaceuticals (primarily bupropion and varenicline) are the three mainstays of the WHO’s current clinical treatment guidelines. By and large, none of them work very well - any given quit attempt is a lot more likely to fail than succeed, no matter what combination of tools is used.

Counseling and NRT

Providing behavioral support on how to navigate the challenges of stopping smoking appears to improve the success rate slightly. “Support” is a pretty broad term for different types of interventions including individual sessions with an expert, text messages, and financial incentives, but two recent meta-analyses estimated these can, on average, bring the quit rate up by about half, to around 10%.

Nicotine replacement therapy lies on the boundary between pharmaceutical and non-pharma tools as there are both prescription and over the counter products available. A Cochrane meta-analysis indicated they can raise the odds of a successful attempt to 6% from an 4% average in the control groups. However, observational data indicate that effectiveness in a non-clinical setting may not be as high: a survey study in England showed no benefit of over the counter products compared to unassisted quitting, and in the US, the introduction of over the counter NRT in 1996 didn’t result in a measurable increase in quit attempts nor in successful cessation in the population.

Pharmaceuticals

The two most commonly used and studied pharmaceutical products recommended to assist cessation are bupropion and varenicline. Data on the effectiveness of both is somewhat sparse as they are neither as well known nor as accessible as other methods, requiring a doctor visit and prescription in most countries.

The idea behind the use of bupropion is that it blocks nicotinic acetylcholine receptors, thereby reducing the pleasure experienced when smoking. Randomized, controlled trials show a roughly 20% 12-month abstinence rate for people using it, although most of these are of fairly small groups of a few hundred people, and some observational data even suggest no long-term benefit outside of the study setting.

Varenicline has a similar mechanism of action, binding to nicotinic receptors to reduce nicotine cravings. It appears to result in a similar increase in quit rate in RCT’s, with 12-month abstinence in most studies around 15-20%. In head to head comparisons with bupropion, it tends to do a bit better.

Alternatives

There are a number of tools beyond the WHO’s recommendations, both behavioral and chemical, that seem to have potential to help, but lack robust or large scale evidence. Hypnotherapy has been tried and studied a bit, but doesn’t seem to show a measurable effect. Cytisine is a plant-derived nicotine receptor agonist that’s been used in Eastern Europe for decades and from which varenicline was derived, shows roughly similar effectiveness to other pharmaceuticals although with more limited and low quality data. Finally, psychedelics show significant promise in sustained cessation, but with very limited data. In a small pilot study, more than half of smokers who went through three psilocybin experiences with subsequent counseling were still abstinent a year and a half later.

Effectiveness of reduced risk products

So how do reduced risk products compare? There have been both RCT’s of trials in clinical settings - giving people various products along with some instructions on how to use them - and analyses of observational data attempting to determine trends when either a product appeared on or disappeared from the market in a specific area, or regulations were tightened or loosened.

Clinical data

The most up to date and comprehensive review of RCT’s comes from the Cochrane Library, which looked specifically at e-cigarettes, comparing them to NRT and behavioral support. Their headline conclusion was that there is, as of 2025, high certainty evidence that vapes with nicotine are a bit over 50% more effective than NRT, raising the odds of cessation at twelve months to 10% compared to 6%. Another systematic review showed a similar improvement of vaping over both and NRT and placebo. The only head to head comparison between varenicline and vaping showed about the same level of effectiveness. Heated tobacco appears to perform similarly or slightly better in the limited RCT’s available. Snus hasn’t been studied much in a clinical setting, although one small study in the US showed similar effectiveness to an NRT product while another in Sweden didn’t produce a significant difference between real and placebo snus.

Observational analyses

Almost nobody in the real world encounters noncombustible products in a clinical setting. Observational data provide a window into real-world effectiveness, with the obvious caveat that they can only demonstrate correlation. Across a number of countries, a number of signs point towards the conclusion that broader use of e-cigarettes, snus, and heated tobacco products results in significant reductions in smoking at the population level. These reductions are greater than any observed after the introduction of the tools detailed above.

For snus, this is most obvious from data in Scandinavia, where it is most commonly used, and has been for decades. As early as 2003, Sweden had the lowest smoking rate in Europe at 18%. While its tobacco control measures didn’t and still don’t differ significantly from its neighbors, it has, as of 2024, become the only country in the world to have started with a significant share of smokers (about half of all Swedish men smoked in 1960) and driven it down to below 5%. Similarly, in Norway, a big drop in smoking has coincided with strongly increased use of snus in the past twenty years. While these are, again, only correlations, they are quite large, and confirmed by retrospective analyses of specific populations in both countries. I couldn’t find an alternative candidate for a plausible explanation of the large difference other than the widespread use of snus and the fact that it has remained legal in these two countries while the EU banned it everywhere else.

In the case of e-cigarettes, population data show a similar correlation, with an increase in cessation under liberalized policies and decreases in places where regulations become stricter. In England, the government announced in 2017 that the smoking quit success rate jumped as e-cigarettes became popular to the point of becoming the most-used quitting aid, a finding confirmed by time series analyses. Similar correlations were observed by researchers in the USA. Notably, states that implemented partial or full bans appeared to see corresponding increases in cigarette sales. A similar study on the relationship between vape flavor bans and young adult smoking showed the same pattern. Researchers in New Zealand identified a similar pattern when comparing the drop in the smoking rate to that of Australia, with the populations vaping the most (young adults) also showing the biggest drops in smoking.

For heated tobacco products, the data is more limited, but trends in at least one country, Japan, point to a potentially large effect in a similar direction. Cigarette sales began dropping more steeply after the introduction of IQOS in the country, a trend that has continued until this day. HTP’s account for more than a third of tobacco sales overall and have overtaken cigarettes for the first time in Tokyo.

Conclusions

So are the advocates correct in claiming that noncombustibles represent the most promising tool for the average person looking to quit smoking? While the data from RCT’s seems to indicate a rough tie at the top, the population level data is a pretty strong sign that they’re right. The reason is highlighted in another study surveying quit attempts in the UK: vapes are an order of magnitude more popular than any other cessation method, so the sheer number of people using them can’t help but result in many more people giving up smoking than through other means.

One can speculate about why people prefer vaping, snus, and their ilk to pharmaceutical approaches or counseling. I’ll try to explore this further when looking at the normative claims made by advocates, but one theme often stands out when I talk to users of these products: they are commercial products marketed to help them meet their goals in a non-coercive way. It’s a lot more comfortable to be treated like a person trying to find a less risky alternative to something they enjoy doing than a patient with a disorder to be fixed through medical intervention. They fit the spirit of harm reduction in the sense that Shaun Shelly defines it: “helping them achieve their drug use aims (including abstinence) in the way that causes the least harm to them.”

Where does this leave EA’s wondering about tobacco harm reduction as a cause area? Some of the questions in the last post about cost-effectiveness and the degree to which it’s worthwhile to actively promote it remain open. That said, if there are reasons to oppose the prioritization of THR as a cause area, I think the case is strong that concerns about whether it actually lowers smoking better than other methods shouldn’t be one of them.

Summary: This is the first in a series of posts examining a few of the core claims of tobacco harm reduction advocates from an effective altruist perspective. While experts across a range of views on tobacco harm reduction agree that noncombustible products are at least an order of magnitude less harmful than cigarette smoking, we don’t currently have any rigorous quantification of the risks and benefits of nicotine taken in various noncombustible forms. Supporting the development of better models could be highly impactful. Rough modeling across a wide range of plausible risk levels still supports the tractability of noncombustibles in helping to address the health risks from smoking despite the current lack of clarity.

Introduction

Tobacco harm reduction (THR) advocates argue that reduced risk products such as nicotine pouches, snus, and vapes should be viewed as an integral part of our approach to reducing death and disease from smoking. Having laid out some of their core claims in my previous post, I want to follow up by examining each of them through an effective altruist (EA) lens. The purpose is twofold: to get a better understanding of how well THR-related interventions fit as a cause area given the longstanding interest from EAs in smoking in the developing world, and to gain insight into the community more broadly as an example of “non-EAs who seek to do good.”

The first claim: nicotine isn’t particularly dangerous and its risks are generally overstated due to its historical association with smoking. Perhaps the most-cited THR quote of all time is Michael Russell’s assertion that “people smoke for nicotine but they die from the tar.” The science has advanced considerably since he made that claim in 1976. Advocates continue to argue that “nicotine itself is relatively safe” and that it is “no more harmful to health than caffeine.”

Why does this matter? Even the stauncher skeptics of THR as a policy agree that heated tobacco products (HTPs), vaping, snus, and nicotine pouches are significantly less harmful overall than cigarette smoking. Majorities of not just the general public but of the medical practitioners to whom they look for advice aren’t just unaware of this, but believe the exact opposite. For an EA, doesn’t that in itself strongly suggest importance and neglectedness of THR given the number of smokers in the world is more than a billion and growing, and several million of them die an average of a decade earlier each year?

Maybe so, a skeptic might say, but there’s a big question of tractability: promoting any kind of nicotine or tobacco product as safer runs the risk of more people who wouldn’t have been smokers using it and being harmed by it, potentially wiping out the gains from the current and future smokers who switch. Communicating about their relative safety compared to smoking may also cause people to overestimate their substantial absolute risk to health. It’s all well and good for governments and industry to insist that these are tools meant exclusively for smokers to reduce harm, but it’s reasonable to think nontrivial numbers of non-smokers would start using them if they were more widely viewed as mostly harmless and more extensively promoted. (To say nothing of the “gateway hypothesis” that use of noncombustibles might even cause subsequent smoking - but that’s a story for another post.)

The goal of this post, then, is to examine two questions relevant to EA’s about the claim that nicotine is relatively harmless. Is it true? And to the extent it is, how should that impact our judgment of the tractability of THR interventions?

Translating the claim into DALYs

“Nicotine isn’t particularly dangerous” isn’t specific enough of a claim to say much of any use about, so I’ll tweak it a bit to something that gets to the core of what the advocates say, but allows us a better look from an EA perspective. EAs commonly try to quantify the impacts of problems and proposed solutions to them in terms of disability-adjusted life years (DALYs) gained or lost. The effect of the use of nicotine on a population depends on dosage and method of ingestion. So a reasonable question to ask is “to what extent would the DALYs gained or lost as a result of broader daily use of the most popular noncombustibles affect our estimate of the net effects of promoting them?”

Unfortunately, it’s quite challenging to assign a specific number or even a range of DALYs either for a specific product category or for noncombustibles overall. There are a couple of issues that plague research across product types that are unique to this field:

1. Lack of randomized, controlled trials: for obvious ethical reasons, there haven’t been any experiments giving nicotine and tobacco products to nonsmokers for extended amounts of time and seeing what happens to them.

2. Lack of long term information: most of the products are so new that we have at best a decade or two of data on nonsmokers that have used them. Snus is a notable exception here, as it’s been used for hundreds of years in Sweden.

3. Product heterogeneity: HTPs and e-cigarettes were commercialized very recently, and product development has been rapid, so even someone that has been vaping for 10-15 years has likely used a number of different technologies with potentially different risk profiles. This is even true for snus, as the Gothiatek standard that significantly reduced the concentration of tobacco-specific nitrosamines (TSNAs) and other potentially risky components was implemented gradually across the last few decades.

These problems come in addition to those inherent to evaluating the level of risk of any ingested substance: research on in vitro and animal models is plentiful but the potential risks and benefits they demonstrate often don’t pan out in the real world, and population-level epidemiological work is littered with confounds — maybe even increasingly so, as tobacco use becomes more correlated to demographic attributes with causal impacts on health.

We don’t have rigorous estimates

Most attempts to survey the overall risks of noncombustibles try to answer a slightly different question, and usually focus on one specific product category: does it represent a significantly lower health risk than cigarettes, and are smokers are likely to switch to it?

The Norwegian Institute of Public Health published a thorough report on snus in 2014 and updated it five years later with a couple more studies. The National Academies of Science in the US worked on something similar for vaping. A Cochrane review examined heated tobacco products in 2022. These reviews all provide substantial evidence that each of them are significantly safer than and help people quit smoking, but none of them attempt even an approximate quantification of their overall absolute risk.

A paper on snus from 2004 reports the first attempt I’m aware of to quantify the risk of a noncombustible category. A panel of nine experts was asked by email to answer the question: “Relative to the risk to a lifelong smoker of conventional cigarettes (e.g., Marlboro Red and Newport), what is the relative risk of premature total mortality to a lifelong user of LN-SLT products (e.g., Ariva and Swedish snus)?” The median answer was 9% for ages 35-49 and 5% for ages 50+. Interestingly, the estimates ranged from 0% at the low end to 75% at the upper end, with only two of the panelists rating themselves as “very confident” in their estimates even after three rounds of estimation. One of them also “began with and continued to submit estimates higher than all others” and “provided no comments to justify his/her response, even after panel co-members had criticized the estimates” and was therefore dropped from the final calculation. The paper provides little detail on how each expert arrived at their number.

A more recent and broadly disseminated estimate is the report from the Royal College of Physicians (RCP) in the UK on vaping, cited numerous times by THR advocates and reaffirmed in subsequent evidence reviews: “Although it is not possible to quantify the long-term health risks associated with e-cigarettes precisely, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure.”

While admirably cautious in its phrasing, the report also never elaborates on any details of the modeling that led to the 5% number. Its preceding paragraph cites a publication that “quantified the likely harm to health and society of e-cigarettes at about 5% of the burden caused by tobacco smoking.” This is an article discussing a two-day workshop during which invited experts estimated the harms of various nicotine-containing products by scoring them on a set of criteria proposed by the UK Advisory Council on the Misuse of Drugs — many of which, like how much their use “contributes to damage at an international level” and “decline in the reputation of the community,” are unrelated to health risks that would directly impact DALYs lost from their use. The report also doesn’t explicitly state whether there’s a connection between RCP’s quantification and the exercise the article describes.

It’s tempting to translate the RCP report’s carefully worded claim into the assertion that we can take the DALY loss from smoking, divide it by twenty, and have a reasonable ballpark estimate of the harm from vaping. In fact, the Open Philanthropy shallow investigation on tobacco control did so, probably because there were no other concrete numbers from credible sources. As the THR skeptics at The Lancet point out, though, we should be clear about the flimsiness of the foundation on which this number rests, and understand that the authors of the report themselves give little indication that it was intended to be used in this way.

Critics who refer to the 5% figure from the RCP report as a “myth” often imply our estimate of risk should be higher. I don’t see a compelling reason for that. I’m not aware of any significant evidence that its authors missed or that has come to light since its publication that would give us reason to do so. It continues to be the case that, as one expert put it in 2024, vaping has “not been linked conclusively with any chronic disease.” The authors of the report itself suspect the number is “unlikely” to be larger than 5% and “may well be substantially lower.”

We could use better models

Realizing how sparse the existing work was and not wanting to let the perfect become the enemy of the good-enough, I initially attempted to try to come up with my own bottom-up quantification based on an exhaustive review of specific conditions plausibly caused or worsened by noncombustibles. This turned out to be wildly ambitious, so although I think the work represents a decent start on an overview of the majority of plausible substantial risks and benefits, I’ve moved these to an appendix below.

So is saying “we don’t really know, probably less than 5%” pretty much all a curious non-expert can do until better research comes along? No - I think there at least two important and actionable conclusions given the current state of affairs.

First, the fact that there’s no explicit modeling of risks for a potentially key set of tools for reducing one of the largest causes of human disease and suffering appears to be a great opening for funding from EAs to help make that research happen. Tobacco companies more or less wrote the book on promoting fake science to undermine the work that demonstrated the harms of cigarette smoking. Some of them continue attempted manipulation of the regulatory process for noncombustibles to protect their own market share. At the same time, majorities of both consumers and medical practitioners continue to be mistaken about basic facts in part thanks to deceptive communication about risks from non-governmental organizations. Given the dearth of funders seen by both advocates for and skeptics of THR as fair arbiters in this space, this looks like a unique opportunity.

Second, the fact that we’re missing this piece of the puzzle doesn’t necessarily imply we should be frozen in inaction until it’s put into place. Skeptics often cite the precautionary principle in arguing that until clearer evidence of the extent of harm is established, access should be restricted as much as possible. But while we don’t and will never know everything, EAs can still model under uncertainty, and have done so in this field as well.

Noncombustibles are still a net positive in most plausible scenarios

To elaborate on that second point and come back to the initial motivation for this post: how much does the answer on noncombustible risk impact our assessment of tractability? Does the question of whether EAs should support THR in some form depend significantly on the difference between the plausible best and worst case scenarios?

Open Philanthropy (OP) modeling shows that across a broad range of estimates of noncombustible risk, there’s a good case to be made that the net expected effect of expanding THR is still positive.

As part of their shallow investigation of tobacco control I mentioned earlier, OP included a back of the envelope cost-benefit analysis of the net effect of e-cigarette use in the UK. For lack of better quantification, they used the Public Health England figure of 5% discussed above as the best-guess DALY reduction for vaping compared to smoking — in other words, if the average smoker loses ten years of life due to smoking, they assumed the average vaper would lose six months.

Holding all the other assumptions of the OP model constant and varying the number on vaping health risk lets us draw some basic conclusions. The break even point at which a world with vaping implies fewer DALYs than one without it is around a 25% harm reduction. In other words, any alternative product with at least the net effect on quitting smoking that they estimate vaping has had, and is at least 25% less DALY-reducing, results in a net positive effect. (Interested readers can check this by playing with cells C19 and C34 of the model.)

That’s all well and good, a skeptic might say, but doesn’t a model with increased risks become much more sensitive to the number of nonsmokers that start using nicotine or tobacco? This is also possible to check using OP’s calculation. Assuming an extreme “worst case” scenario of the entire population becoming daily users, the break even point is around 10% harm reduction. In other words, under the assumptions of the OP calculation, THR is a net positive for any product at least an order of magnitude less harmful than cigarettes — even if the entire nonsmoking population became users of that product and none of them would otherwise have become smokers. (You can see for yourself by increasing “total e-cigarette users” (C6) and decreasing “Percent e-cig users ex-smokers” (C12) and “Percent of ecig users who are dual users” (C24) correspondingly.)

There are a couple of issues I see with this interpretation of the modeling that I’ll try to explore in future posts:

1. The calculation only considers the current population and ignores anyone not born yet. A more thorough model would incorporate calculations about future generations, which would require assumptions not just about how common future use would be, but the degree to which vaping and other noncombustibles would continue to become safer or less safe.

2. The assumptions around the rate of existing smoking and its reduction are specific to the UK, and would come out differently in different countries - those with higher rates of smoking would see a greater overall benefit from THR, and vice versa for countries with less smoking.

3. Accepting the conclusions implies EAs shouldn’t oppose efforts to promote THR. It doesn’t necessarily mean that spending resources on promoting it is cost-effective, compared to OP’s 1,000x threshold, to other efforts to reduce smoking-related illness, or to the broader range of cause areas of interest to EAs.

Appendix 1: Risks

Since the most direct way nicotine affects the human body’s functioning is by binding to the nervous system’s nicotinic acetylcholine receptors, many of its purported risks start with its impact on the brain. These include widely circulated claims that the substance increases the risk of mood disorders, harms brain development, and adversely impacts judgments about risk.

There are a number of plausible risks of health problems unrelated to the brain as well. Most important among these are claims that nicotine use raises the risk of cardiovascular disease, of Type 2 diabetes, and increases the rate of tumor growth.

Mood disorders and cognition

There is plentiful evidence for a correlation between nicotine use and a number of mental health problems. The most well-documented of these associations are with schizophrenia, depression, and anxiety. The important question when assessing the risks is what this correlation implies about the direction of causality. Does a struggle with all or most of these issues result in more people using the substance to manage their symptoms (‘self-medication’) or is there a separate factor, genetic, or otherwise, that makes people more susceptible to certain mental health problems as well as to compulsive patterns of nicotine use? Or are there changes caused directly by the substance that exacerbate these issues?

The link (like most involving smoking) is tricky to study due to the lack of randomized controlled trials. A recent review attempted to address this gap by analyzing research using other methods including co-twin studies and Mendelian randomization. While it examined studies on cigarette smoking in particular rather than nicotine use in general, its results can still be informative — if there’s evidence that smoking doesn’t cause an increased risk of mental illness, that can serve as evidence that nicotine doesn’t, either, as long as there aren’t other factors in smoking causing a commensurate decrease in risk (probably a reasonable assumption).

The review supports the hypothesis that the correlation with depression is due to common liabilities rather than causation: “evidence from co-twin studies indicated that the association with depression was likely completely due to shared genetics. […] [T]here was either no evidence of an effect of smoking or there was evidence for an association in never smokers, suggesting that there is unlikely to be a causal effect of smoking.” Similarly, a longitudinal study of monozygotic twins in Finland showed no effect of smoking on depression.

The causal relationship between anxiety disorders and nicotine use seems a bit less clear. The most extensive review I could find concluded “empirical studies suggest that smoking, and nicotine specifically, can be anxiolytic” but “the parameters and mechanisms through which these effects occur are still poorly understood” and found some evidence from animal studies that “under certain conditions, nicotine can be anxiogenic.” A later but less extensive review similarly concluded that “nicotine may have both anxiolytic and anxiogenic effects at different doses based on the type of anxiety […] and potentially genetic background.”

In the case of schizophrenia, there is an extremely high and well-documented correlation between the two, but not much strong evidence for causality. A large majority (commonly estimated around 80%-90%) of people diagnosed with schizophrenia are daily smokers. There is fairly solid evidence of a variant of a specific gene (CHRNA5) playing a role in hypofrontality, believed to be the cause of many of the symptoms experienced by schizophrenics, and in animal models, nicotine appears to normalize function in the brains of animals with this variant. This provides some support for the self-medication hypothesis. On the other hand, one review examining associations between nicotine and psychosis overall concluded that “self-medication and reverse causation cannot fully explain the association” and that therefore the “jury is out on whether tobacco might be causally related to the risk for psychosis, or whether the association manifests through a shared genetic vulnerability, or is confounded by use of illicit substances or other social factors.” Another recent study, also using Mendelian randomization, concluded “the current evidence that smoking might be a risk factor for schizophrenia is not compelling.”

Development

Even if nicotine is safe for adults, it’s possible that its use affects younger people differently and adversely, both for unborn children whose mothers consume it, and for children and adolescents whose bodies are still developing.

The work I found on neonatal exposure consists mainly of results of animal models describing a number of plausible pathways through which maternal nicotine use could adversely impact prenatal development. A fairly recent review on nicotine replacement therapy (NRT) claims “the main evidence concerning NRT safety and impact on fetal/neonatal brain development is extrapolated from animal studies” and I also couldn’t find any human data on vaping. Two comparisons of mothers prescribed NRT with smokers and nonsmokers looking at risks of stillbirth and congenital anomalies showed no statistically significant risk increase, but since there’s some evidence that NRT in pregnant smokers works no better than placebo for quitting, it’s hard to say how much of it they were actually using.

There is a bit more work on snus. One study found a significant effect on birth weight and preterm delivery - but there was no data and therefore no adjustment possible for alcohol and other psychoactive substance use. Another showed no effect on birth weight for mothers using snus before and in the first eighteen weeks of pregnancy, but so many had quit by then that there wasn’t enough data for later periods. A sibling analysis comparing children born to the same mother during periods of both using and not using snus also found no significant effect on birth weight; the authors conclude “nicotine does not seem to be the main mechanism involved in the association between smoking during pregnancy and birthweight.”

A couple of large population studies on preterm births, stillbirths, oral cleft malformations, and Sudden Infant Death Syndrome found an increased risk for snus users compared to both non-users and those that used but stopped early in the pregnancy. Similarly to the birth weight study, there was no adjustment for alcohol or other psychoactive use in these, but they were able to adjust for a number of other factors including maternal age, BMI, years of education, hypertension, and diabetes.

Nicotine use is also correlated with various risk factors and illicit behaviors in children and teens. One UK study trying to tease out causality, specifically focusing on vaping, found the correlation between having ever vaped at 11 and an increase in various measures of maladjustment and delinquency at 14 was robust to a number of controls including baseline test scores, behavioral measures, and parental education and smoking. This supports the causal hypothesis, although the authors discuss a number of unaddressed potential confounds like the use of other psychoactive substances, as well as the fact that ‘ever use’ is a very rough measure that conflates everyone from one-time experimenters to daily users. Similarly, an analysis of the Population Assessment of Tobacco and Health (PATH) data found an association between ever having vaped and subsequent academic performance among 12 to 15 year olds. A recent scoping review including these and a couple of other studies concluded there is “some evidence that academic achievement may predict future e-cigarette use; less evidence supports the opposite direction.”

There have been a couple of attempts to suss out whether there’s a connection between nicotine use and risk-taking behaviors. One small experimental study found no effect of nicotine on risk taking; two others found it decreased it. All three of these looked at acute effects of nicotine administration in a laboratory setting using the BART task, a well-validated but artificial measure of risk taking behavior. Beside lab-based experimental work, many studies document the correlation between use of nicotine and other behaviors considered risky. A couple of twin studies from Minnesota and Virginia found that genetic predispositions accounted for this correlation rather than nicotine use causing sustained changes in behavior.

Cardiovascular disease

Since smoking is a major risk factor for developing cardiovascular diseases, and nicotine has been shown to have a variety of acute effects on the circulatory system in both animal and human models, it’s natural to ask whether nicotine by itself raises the risk of heart disease, stroke, or other related problems. Most of the population-level research on this topic has been on NRT, snus, and vaping, since none of them are thought to include any other substances that could have an appreciable effect.

A 2024 study used multivariable Mendelian randomization to try to tease out the effects of nicotine from those of smoking on lung cancer, COPD, and heart disease. As some genetic variants are known to be associated with smoking heaviness and others are correlated with speed of nicotine metabolism, this method compares groups based on their genome to tease out the effects of nicotine on smokers separately from other constituents. The authors say the results suggest that “smoking-related outcomes are not due to nicotine exposure but are caused by the other components of tobacco smoke” for all three of the conditions they investigated.

The largest meta-analysis on NRT products I could find concluded that they “do not appear to raise the risk of serious cardiovascular disease events.” However, they did find an elevated occurrence of “less serious events,” mostly tachycardia. Most of the studies reviewed followed NRT users for only up to a year, and restricting the analysis to those of the longest duration made the association “more pronounced and statistically evident.” Since these studies followed only current or former smokers, there may be some risk factors unique to them that don’t apply to the non-smoking population.

Of the three different meta-analyses of the impact of snus I’m aware of, the most recent one found no significant effect on CVD risks. Of the two previous ones, one also found no effect while the second detected an effect on both fatal myocardial infarction and fatal stroke while finding no significant effect on non-fatal events. Some of these studies also include work on other forms of smokeless tobacco used in the US, which show a more consistent effect on CVD. The authors suspect this could be due to other constituents in these products such as tobacco-specific nitrosamines (TSNA’s) whose level is much more strictly regulated in the Swedish products.

In the case of vaping, a Health Canada-sponsored review published in 2025 found a “lack of evidence supporting any association of e-cigarette use with cardiovascular diseases and cardiac dysfunction or remodelling.” This review looked at exposures across a range of time scales (acute, short to medium, and long term).

Diabetes

Smoking has been known for some time to be robustly correlated with the development of Type 2 diabetes (T2D). There is an observable dose-response: more cigarettes smoked increases disease risk. There’s also a plausible biological mechanism: nicotine elevates blood glucose and induces insulin resistance by stimulating the release of catecholamines. Together, these observations lend support to the idea that the relationship is causal, and also applies to noncombustible products.

While I couldn’t find much data on T2D risk in NRT users or vapers, a fairly recent review of the findings on snus use including a number of large longitudinal studies mostly show no significant association between the two. A meta-analysis looking at the data from these and a few others also concluded there was no overall increased risk of T2D in snus users. Interestingly, however, there’s an indication of a dose-response relationship as the heaviest never-smoking consumers did show an elevated risk correlated with their level of use. The Norwegian public health group reached the conclusion that “high consumption,” which the study defined as more than four cans of snus per week, “of Swedish snus among men probably results in a large increase in the risk of type 2 diabetes and metabolic syndrome” while it is “uncertain” whether lower amounts do the same.

Cancer and tumor promotion

A number of health bodies including the International Agency for Research on Cancer, Cancer Research UK, and the American Cancer Society claim plainly that nicotine doesn’t cause cancer. However, there is some evidence suggesting the possibility that health outcomes for people who have cancer are worsened, in particular due to a biologically plausible role of nicotine in tumor growth.

For example, a study of prostate cancer patients in a cohort of Swedish construction workers found a higher risk of mortality (both from the cancer and overall) among those who were regular snus users before the diagnosis. A review of all cancer patients in the same group also found a higher risk of any-cause and cancer-specific death. The authors conclude nicotine is a “conceivable culprit” in the elevated risk while noting a number of limitations of the investigation - notably, risks were adjusted only for BMI, age, and age at diagnosis, and not for any other substance use or lifestyle factors.

The Norwegian public health body’s review on snus concludes that it “probably increases the risk of cancer of the oesophagus and pancreas, and possibly increases the risk of cancer of the stomach and rectum.” This seems to be based mostly on a 2023 review from some of the same authors as the two studies above.

Appendix 2: Benefits

Just as the effects of nicotine have generated numerous hypotheses about conditions it could worsen, a fair number of studies have looked at issues it might help alleviate. The brain and nervous system are again the obvious starting point, but downstream effects provide some plausible candidates for other areas.

Mood disorders and cognition

In the section on risks, I looked at but couldn’t find strong evidence for significant or reliable improvement by nicotine use in any group that’s been studied so far for anxiety, depression, or schizophrenia.

There’s some evidence that smoking is inversely correlated with age of onset of Alzheimer’s disease. As of 2010, a Cochrane review wasn’t able to find any studies on possible causation that met its quality threshold. A pilot study from a few years later showed improvements in several measures of mild cognitive impairment (MCI) after six months of transdermal nicotine treatment. The same group began conducting a larger, placebo-controlled study a few years ago, but haven’t published any results yet.

There’s also been a pretty robust observed negative correlation between smoking and Parkinson’s disease and even some evidence of a causal link. However, the largest placebo-controlled double blind trial conducted to investigate the role of nicotine specifically (using patches) showed no protective effect, at least for patients dosed for one year shortly after initial diagnosis. It’s possible some other component of tobacco smoke causes the effect, or that the timing of the intervention (after Parkinson’s has already been diagnosed) used in this study makes it ineffective, as former smokers also seem to develop the condition at a lower rate.

Body weight and obesity

Smokers tend to gain weight if they quit; they also weigh less on average. There’s a plausible biological mechanism for nicotine’s role involving its effects on energy homeostasis.

The effect of nicotine on body weight is measurable in at least one placebo-controlled trial of patches of former smokers and another of gum. Other studies seem to find no effect on weight gain, though. A recent master’s thesis tested vaping against a control and found an acute effect on subjective appetite but no change in reduced eating.

Gastrointestinal disease

Because smoking seems to be associated with better outcomes for ulcerative colitis, a few trials have looked at whether nicotine delivered via patch or enema could help these patients.

A Cochrane systematic review of a few small RCT’s showed evidence that nicotine administered in this form works better than placebo and about as well as standard medical therapy. There were more patients withdrawing due to adverse events, though, which is presumably why it isn’t actually used therapeutically. A small pilot study also showed an improvement in Crohn’s disease patients - an interesting finding since smoking is known to strongly worsen Crohn’s, which was hypothesized to be related to the effect of nicotine but may be due to other components of smoke.

In “Learning from non-EAs who seek to do good,” Siobhan argues that it’s healthy for lower-case effective altruism (“EA as a question”) to engage with other communities that share some of our goals but differ from us in significant ways — including empirical beliefs, explicit and implied ethical commitments, and epistemic standards — in order to learn from them. One of the main goals of this blog is to apply this proposal to the tobacco harm reduction community, a diverse group of advocates working to improve knowledge of and access to noncombustible tobacco products that are less risky than combustible ones. This post starts off that process by enumerating a few of the community’s core beliefs. The first three of these are primarily empirical, the next three normative.

While I believe all of these claims have at least a grain of truth to them, this post doesn’t endorse or attack any of them nor attempt to provide substantial evidence for or against them. The goal here is to show what, by and large, THR advocates agree on, and that the beliefs are distinctive in the sense that they often aren’t shared by the broader tobacco control world or the general public. In subsequent posts, I plan to critically examine each of them through an EA lens to help discover whether and how they could inform cause prioritization, generate new ideas for promising projects, or diversify our thinking in other areas.

Nicotine isn’t particularly dangerous

“People smoke for nicotine but they die from the tar.” - Michael Russell

Many discussions of the deadly effects of smoking begin with the role of nicotine, and THR advocates emphasize the substantial evidence that the substance, when consumed on its own, does not cause cancer, COPD, or heart disease, the main risk factors for smokers. One of the strongest points of evidence — emphasized because it’s generally uncontested even by opponents of THR — is that nicotine replacement therapy in the form of gums and lozenges has been used for decades by people attempting to quit smoking, to no detectable ill effect. One comparison often, and almost exclusively, made by THR advocates is to caffeine, arguing that the risk level of the two stimulants is similar.

This claim is core to the THR argument since the vast majority of products and approaches they recommend contain nicotine. That said, there is nuance regarding opinions on what specific groups may be exposed to additional risk, like people who have heart disease or are pregnant. There is also lively debate about whether the substance is not just low-risk but improves quality and length of life for some. Advocates present evidence of benefit from nicotine use for those suffering from a number of different conditions regardless of whether or not they are a current or past smoker, with investigation into its role in ameliorating the likes of schizophrenia, ADHD, and mild cognitive impairment.

Tobacco control organizations more skeptical of harm reduction maintain that nicotine bears unique risks. They claim that the framing of nicotine as similar to caffeine can “undermine public health” as, for example, the former is associated with mental health concerns among young people, and that studies with animals have shown nicotine to be more similar to opioids and cocaine than to caffeine in their propensity for self-administration.

Reduced-risk products provide the most effective known method to stop smoking

“FDA is forcing Juul to pull the most successful anti-smoking device ever made.” — Clive Bates

Citing both the studies on e-cigarette effectiveness in smoking cessation and testimonials from former smokers, government recommendations, as well as the population-level data from countries like Japan and Sweden, THR advocates argue that reduced-risk products not only work in helping smokers achieve better health outcomes, but that they are in fact the tool most likely to lead to success for the average smoker trying to quit. Therefore they are seen as the most promising path to achieving lower mortality at a population level.

In addition to highlighting the need to make products more accessible and smokers more informed about them, this belief implies that suggesting cold turkey or some combination of pharmaceutical nicotine replacement therapy and counseling to smokers before switching to a reduced risk product may be misguided. If use of less harmful products is more likely to help someone stop smoking sooner, then any potential harms from them need to be weighed against the additional risk from having smoked longer.

A number of tobacco control practitioners and medical professionals don’t accept this framing and argue that the research supporting cessation through noncombustible products is insufficient to serve as a reason to change recommendations to smokers. They suggest that the best message is “quit, don’t switch” because the studies indicating their effectiveness are flawed due to participation bias and other factors, and that other work has produced evidence of absence of a cessation benefit.

Experts and the general population are misinformed about basic facts regarding nicotine, tobacco, and smoking

“No education curriculum or public health campaign has bothered to de-construct the simplistic “smoking=tobacco=nicotine=harm” narrative.” — Sudhanshu Patwardhan

One of the few things both skeptics and enthusiasts about THR agree on is that some nicotine and tobacco products present a greater chance of health harm than others. This fact is often referred to as the “continuum of risk” by both groups, with cigarettes at the most harmful end of the spectrum.

The THR community observes a distressingly poor awareness of the specifics of this continuum among the general public, smokers, and even professional medical practitioners. Pointing to data like surveys showing basic misunderstandings about the health impacts of nicotine among doctors in related specializations, incorrect risk perceptions — in some countries, increasingly so — among smokers, and the “misinformation shock” caused by the “E-Cigarette and Vaping-Related Lung Illness” (EVALI) outbreak brought on by black market THC cartridges in 2019, they argue that providing each of these groups with more correct information is a missed opportunity for improving health outcomes, and that the numbers shows that efforts up until now have been not only inadequate but often counterproductive.

The broader tobacco control movement generally doesn’t overtly contest the idea of a continuum of risk; the term was coined in a mainstream journal article and the director of the US FDA’s tobacco division has referred to it explicitly. Nor does it deny the validity of the data indicating that majorities of important stakeholders hold false beliefs about it. However, some stauncher THR opponents have referred to the idea as a “hypothesis lacking sufficient empirical evidence” due to its not taking into account supposed population-level effects on smoking initiation, and most acknowledgments of the misinformation problem tend to be followed by heavy caveats around ensuring prevention of youth use.

Offering choice is morally preferable to coercive strategies

“The right to health underpins the right to tobacco harm reduction.” — Global State of Tobacco Harm Reduction

Effective altruists, while a diverse group in terms of specific moral philosophical commitments, tend to endorse some flavor of utilitarianism as most conducive to guiding correct action. The THR community comprises a range of groups with a more varied set of moral intuitions and commitments. One very commonly held idea is that of the moral importance of allowing people to choose the risks they take rather than attempting to limit their options through regulations.

The idea that choice is a moral end in and of itself, irrespective of how or whether it affects measured health outcomes, is shared by (or, one might say, inherited from) the broader harm reduction community, who have appealed to it in debates around the use of other psychoactive substances. One of the leaders of that movement defines harm reduction as helping people “achieve their drug use aims (including abstinence) in the way that causes the least harm to them” and argues this is “a basic human right that should be available to everyone.”

Notably, the argument does not rely on or cite any cost-benefit analysis of looser or tighter regulatory approaches, but is a rights-based moral claim that allowing choice is inherently better than attempting to restrict it. The practical implications of accepting some version of this argument can run the gamut from pushing for the legalization of all psychoactive substances to more incrementalist arguments that bans on less harmful products be replaced by taxes commensurate with the level of risk.

Skeptics of this line of thinking note that the use of psychoactive substances including nicotine and tobacco products can impose negative externalities both on a societal and personal level (citing second hand smoking as an obvious example).

Consumers should participate more in policy decisions and research

“[T]he legitimate concerns of public health advocates about the tobacco industry and its products had the unintended consequence of also marginalising and stigmatising smokers.” — Gerry Stimson

A normative belief related to but distinct from that of the importance of the right to choose one’s own risks is the view that nicotine and tobacco product consumers form one of the core stakeholder groups that should be consulted as part of policy debates (“nothing about us without us”) and as helpful partners in research. THR advocates argue that as a result of the hostility produced by the fake science peddled by the tobacco industry for decades in order to protect its profits, a broad range of groups, many of which attempt to give a voice to people who use nicotine, continues to be excluded from discussions that inform policy decisions and research priorities.

One oft-cited example is the closed nature of the Conference of the Parties (COP) on the WHO Framework Convention on Tobacco Control (FCTC), which has stringent requirements even on observer status ostensibly to prevent industry interference. These requirements result in a lack of representation from both organizations representing current smokers and those that have benefited from noncombustible alternatives as no grass roots organizations of any kind participate in the conference. This, advocates claim, means an essential perspective remains unheard, and the decisions made are more likely to be biased in a way that makes them less effective.

THR supporters also argue that greater consumer involvement in research on smoking cessation improves its quality. Switching to noncombustible products is quite different, they argue, from stopping smoking in other ways, in that a distinct culture and identity has developed around each of them. Therefore their users can provide knowledge of the practical realities of how that culture operates that would be difficult to obtain in any other way, and that is essential to designing research that meaningfully answers questions about whether and how they can benefit others.

THR skeptics argue that, given the history of the tobacco industry’s interference in policy and its attempts to deceive the public, extreme caution is warranted when dealing with anyone that could be suspected of deliberately or unwittingly advancing its interests. They point out that a number of consumer organizations have received industry funding or describe them as outright front groups.

Supporters of harm reduction in other contexts should apply the same logic to smoking

“The politicians who were my key allies, on […] on harm reduction more broadly […] [t]hose are often the same people who have been at the forefront in opposing tobacco harm reduction.” - Ethan Nadelmann

While philosophically aligned with the broader harm reduction world, THR is often felt by its advocates to be a neglected and underappreciated niche within it. They point out that both governmental and non-governmental organizations and individuals supportive of things like needle exchanges, safe injection sites, and birth control are sometimes simultaneously dismissive of, or outright hostile to, what THR supporters see as a substantially similar approach to tobacco use.

Explanations for this disconnect vary. Harm reductionists in other areas may not be familiar with the evidence regarding noncombustible options. The injustices motivating their engagement in issues around other substances or behaviors (e.g. racial justice, mass incarceration, or reproductive freedom) may not apply to smoking. They may simply not be aware of the scale of the problem because smoking has drastically reduced to the point of near-disappearance in their immediate social environment.

THR skeptics argue that the case of smoking is, in fact, materially different. They see the adoption of harm reduction language as an attempt by the industry to co-opt a sympathetic brand and hoodwink people into helping them maximize their sales by branching out into new product lines.

Yet it’s been years now that I’ve had the feeling that these communities need to talk to each other. Every year, smoking kills more people than HIV/AIDS, tuberculosis, and malaria combined. While smoking rates have plummeted in wealthy nations, nearly 80% of smokers now live in low- and middle-income countries, where access to cessation resources is limited and tobacco companies market aggressively.

The tobacco harm reduction movement offers a pragmatic response to this crisis. As researcher Michael Russell put it way back in 1976 (in the ancient times before crossovers became commonplace): “people smoke for nicotine but they die from the tar.” By helping smokers switch to dramatically safer forms of nicotine when they can't or won't quit entirely, we could help millions of people live longer and happier lives.

This approach aligns remarkably well with effective altruist principles. The scale is enormous, with over a billion smokers worldwide. It's notably neglected – despite the death toll, tobacco harm reduction receives little attention from funders and policymakers. Most importantly, it's tractable – we already have proven harm reduction tools.

I wrote about all this back in 2022 as part of Open Philanthropy’s cause exploration prizes, and my lazy side hoped that the attention we got would galvanize the EA community enough that I could go back to surfing and earning to give while EA and THR formed a lifelong bond and lived happily ever after. Sadly, the problems have continued piling up, with vape bans multiplying, misinformation rampant, and millions of smokers continuing to die early deaths while unaware of or unable to access better options.

The continuing crisis, however, also presents an opportunity for EA’s to step in and contribute. I’ll do my best here to present some evidence for why it’s worth it, and listen to your counterarguments. And if you are convinced, we’ll look at some ideas for how to do so.