Dr. Charles A. Gardner earned his PhD in developmental neurobiology from the University of Michigan and has held senior positions at the US Department of Health and Human Services, the World Health Organization, and several global health foundations. With over 30 years of experience in public health, Gardner has recently become a strong voice in rethinking how we approach nicotine; and he advocates for “de-demonizing” the substance.
Tobacco Asia (TA): Charles, let’s start with the big picture. Why has nicotine been so thoroughly demonized in the United States and many other countries?
Dr. Charles A. Gardner (CG): The short answer to your question is that cigarettes deliver nicotine; and cigarettes are responsible for probably 99% or 98% of all tobacco related deaths. And so, for decades now, the fields of tobacco control and public health have been using the words “nicotine” and “tobacco” and “smoking” as if they are synonyms -- which they are not. They’re three different words. In fact, if you go back to old tobacco control scientific studies, it’s often difficult to tell what they’re talking about, because they use those words interchangeably. So nicotine gets demonized because cigarettes kill people; and killing people is bad.
TA: There are sources claiming that 80% of US physicians still believe that nicotine actually causes cancer…
CG: That misunderstanding continues to shape policy and practice. And this is true in other countries as well, for example India. So, 4 out of 5 doctors are profoundly misinformed if they believe that nicotine itself -- the molecule -- causes cancer or heart disease or lung disease. It just doesn’t. And that’s where equating nicotine and tobacco as if they were the same has really caused a lot of confusion. And that has led to the demonization; and that leads then to prohibitions.
TA: How did this narrative that nicotine is bad, bad, bad take hold?
CG: It’s because nicotine is associated with cigarettes or tobacco. We need to distinguish nicotine from the product that’s delivering the nicotine. One of the products that delivers nicotine is a nicotine vape, sometimes also called an “e-cigarette.” A survey just came out showing that in the United States the percentage of the adult population who thinks that nicotine vaping is more harmful than cigarettes has been increasing steadily over the past 10 years. The same is true, by the way, but not quite as bad, in the UK. And that’s an interesting observation. People are getting more and more misinformed, I would say.
The real question is who’s misinforming them, because that does not happen by accident. And I hate to say it, but it’s certainly not the [tobacco] industry that’s doing the misinformation there. It’s public health itself that’s doing that. And I guess there are also many anti-nicotine lobbies around -- or prohibitionists if you like -- that are exaggerating harms, invoking the “think of the children” rhetoric.
At the start, several decades ago, the people in the field of tobacco control were fighting the good fight against smoking-related cancer and heart and lung disease. But that then slowly shifted toward demonizing the industry that produces those products. And then there was a point where they started saying to themselves – almost like a religious mantra – that there is no safe tobacco product. In their minds, a tobacco product is nicotine. But it seems they gave up on [their] efforts to prohibit cigarettes long ago for some reason.
Now they prohibit nicotine vapes and nicotine pouches in different countries, having moved to that “nicotine is the culprit” mantra. They say that it doesn’t matter if you are switching from a deadly tobacco product to a safer nicotine alternative because you are still “addicted” -- even though the word “addiction” is not even technically correct. The proper word would be “dependent.” There’s a saying often used among ex-smokers who quit with safer nicotine alternatives: “Why is your concern about my nicotine dependence more important than my concern over not dying from smoking cigarettes?” I think that carries a lot of truth in it.
TA: So would you say that reduced risk products such as gums, lozenges, inhalers, and of course nicotine pouches and vapes are a smoker’s best chance for quitting cigarettes or cigars, or any combustibles?
CG: Yes. All of these are in the toolkit for smoking cessation. That’s the number one health benefit we’re going to see from all of them. I think of these safer nicotine alternatives -- which is everything from nicotine patches and gums to nicotine vapes and nicotine pouches and snus and even heated tobacco products -- as health interventions because they clearly help some people quit smoking. But we also know that every person who smokes is different. So, one thing will work for one person, but not for another. So, the more variety of safer nicotine alternatives, the better it is because we have somewhere between 1.1 billion people and 1.3 billion people on Earth smoking deadly cigarettes.
TA: Millions of ex-smokers worldwide have successfully quit by switching to these alternatives, yet there are governments and regulators who have banned vapes and even heated tobacco products. Does that make sense?
CG: Well, first of all, they’re doing that at the behest of and on the recommendation of the World Health Organization [WHO]. So that becomes a whole different conversation. Mexico, for example, even has written its prohibition of nicotine vapes into its constitution. So [those governments] are really serious about wanting to get rid of these safer alternatives. But all of these countries are leaving deadly cigarettes legal and available on every street corner. It still baffles me.
TA: Is prohibition a folly?
CG: Prohibition almost never works. It does not make things magically go away. It drives them underground where they are under the control of criminals who don’t care how old the person they’re selling to is. They don’t have any age checks in illicit markets. So, you achieve the exact opposite of what you claimed you were trying to achieve when you prohibited things.
But another bad side effect of prohibitions and demonization is that we also end up prohibiting research. If you are deliberately focused on finding harms, that is all you are going to find. To a hammer, everything looks like a nail. It’s because of that that we did not learn for many, many decades that there are some health benefits from cannabinoids. That only slowly began to change when older people in their 50s and 60s recovering from chemotherapy began to go on record, saying that cannabinoids helped them alleviate pain and nausea. That started a shift. It tilted the needle of public opinion, at least in the United States.
TA: Nicotine apparently also does have health benefits. Can you explain some of those, please?
CG: Sure. The number one benefit of nicotine is that it can help people quit smoking, of course. We also know with relative certainty that daily nicotine use prevents Parkinson’s disease. We’ve known for decades that people who smoke cigarettes are 40% to 60% less likely to get Parkinson’s disease. Snus users also have a 60% lower risk. There [also] is pretty strong evidence that nicotine may either delay the onset of Alzheimer’s disease or prevent it to some extent completely.
Then, there are dozens and dozens of studies using nicotine patches that show that nicotine reduces symptoms in people who have attention deficit-hyperactivity disorder [ADHD], some forms of autism, bipolar disorder, schizophrenia, Tourette’s syndrome, and a number of other neurodiversity issues. My assumption is, what people are doing is self-medicating [with nicotine] because it helps them. There are many studies showing that people with ADHD or people with schizophrenia are far more likely to smoke cigarettes than neurotypical people, people without those mental health conditions. The problem is that smoking kills them. Authorities and the public just can’t take that mental leap to realize that nicotine might be benefiting people.
TA: Those studies you mentioned, they are not just fringe findings, but they are mainstream established findings, right?
CG: Yes, absolutely. They have nothing to do with tobacco control. It’s really just looking at the psychoactive effects of nicotine patches on people with some neurodiversity conditions. There are other potential positive benefits, including weight loss and ulcerative colitis, which is an extremely painful disease, where nicotine can help reduce symptoms. We’ve known that for decades. And the reason is that nicotine is -- among other things -- an immunomodulator. It reduces inflammation.
Nicotine is also helpful for some people with rheumatoid arthritis. The list goes on, but all of these things have been swept under the rug because we’ve decided to demonize nicotine.
TA: Nicotine also seems to help people to focus better and be more alert…
CG: This goes back to the foundational research on nicotine. There is no argument that nicotine, first of all, is psychoactive. It’s dependence-forming – for some people more than others – and it has psychoactive effects. Like caffeine, it increases focus, attention, and memory. But unlike caffeine, it also reduces stress and anxiety and possibly depression as well. And so, not surprisingly, some people find those effects pleasurable.
TA: And still, there are the critics who continue warning about nicotine. How do we achieve de-demonizing this substance?
CG: I think we maybe should take some hints from the field of cannabis activism, which helped tilt the needle of public opinion by getting testimonies from people recovering from chemotherapy, who said that cannabis helped them. Well, we have even more people – tens of millions – who have quit smoking with safer nicotine alternatives like vapes and nicotine pouches.
There is no shortage of older people in their 40s, 50s, and 60s who will be able to tell the public: “I tried everything to quit smoking. I tried patches. I tried gum. I tried counseling. I tried acupuncture. And nothing worked until I used a nicotine vape.” We need to get their voices and their faces in front of the public so they can see that it’s not just teens that are using these products. In the United States, there are 21 million adults vaping nicotine right now -- versus 1.4 million teens.
TA: But what about “protecting the children?”
CG: Well, anti-tobacco organizations like the Campaign for Tobacco Free Kids and Truth Initiative, they always hire teenagers to get their message to state legislators to beg for the prohibition of safer nicotine alternatives. But it must be getting harder and harder for them to find kids who can honestly say they’re addicted to nicotine because of vaping. The numbers don’t add up. Teen nicotine vaping in the United States has dropped 74% over the past 6 years, and it’s at a 12-year low now. And the use of any nicotine product in the United States is now at a 50-year low.
TA: Nicotine alternatives are valuable tools for harm reduction. We have established that. So why is harm reduction by using nicotine delivery alternatives such an important lens here?
CG: We deal with risks in life all the time. Driving a car can be dangerous, so we use harm reduction products called seat belts and airbags. These don’t prevent death, they don’t prevent all harm, but they reduce the risk of harm. If you ride a bicycle, it’s potentially risky, as you could be involved in a traffic accident or a fall. So we have a consumer harm reduction device called a bicycle helmet.
We don’t prohibit sex to prevent HIV and other STDs. We promote condoms to reduce the risk of transmission. This is harm reduction. It’s not meant to be 100% safe. But it is safer. Almost nothing in life is 100% percent safe. Keeping nicotine demonized undermines harm reduction and it keeps smokers trapped in the most dangerous form of nicotine delivery, combustible tobacco products. The demonization of nicotine sort of makes logic fly out the window.
TA: Tobacco control doesn’t seem to see it that way, given all those bans on reduced risk products around the world…
CG: If you are part of what I call “old school tobacco control,” you are “on the side of good and light,” and anything the tobacco industry does and says is “evil and a lie.” The world just doesn’t work that way. It’s not all black and white. There are nuances. The whole industry of nicotine and tobacco is changing dramatically, but “old school tobacco control” isn’t ready for the paradigm shift yet. It’s still stuck back in the 1990s or earlier. It’s almost a cult-like condition, where products that are not tobacco products are called tobacco products, where liquid aerosol is called smoke, and where preventing nicotine now has a higher priority than preventing death. Nicotine is not the enemy. Cigarettes are.