There is much to welcome in Lung Foundation Australia’s agenda for reform, including earlier diagnosis, equitable access to screening, better treatment, specialist lung-cancer nurses, genomic testing, less stigma, and comparable care for people living in rural, remote, and disadvantaged communities. These are important objectives directed at a serious injustice.
Lung cancer remains Australia’s leading cause of cancer death, and its burden is not distributed evenly. Cancer Council Australia reports an incidence of 31 cases per 100,000 people in the least disadvantaged areas, compared with 52 per 100,000 in the most disadvantaged. Incidence is higher in remote areas than in major cities, while mortality rises from 27 deaths per 100,000 in major cities to 41 per 100,000 in very remote Australia. Aboriginal and Torres Strait Islander people are also more than twice as likely to be diagnosed with lung cancer as non-Indigenous Australians.
This is what inequity looks like when it reaches the oncology clinic, and Lung Foundation Australia is right to insist that where someone lives, what they earn or which community they belong to should not determine whether their cancer is found early or whether they receive high-quality care.
But genuine equity must begin before somebody develops lung cancer. It must include a more difficult question: are Australians who smoke, particularly those who have been unable to quit through conventional methods, being given accurate information and practical access to every reasonable way of leaving combustible cigarettes behind?
That is where the current approach becomes harder to defend.
Lung Foundation Australia’s recent corporate plan places welcome emphasis on prevention, equity, and reducing tobacco and vaping harm, while its lung-cancer blueprint similarly identifies prevention and risk reduction as a central priority. Yet the organisation’s broader advocacy record reveals a tension that deserves scrutiny.
In its 2023 Impact Report, Lung Foundation Australia celebrated its contribution to tobacco-law reform, including what it called a “crackdown on vaping.” The same report discussed equitable access to care, reducing stigma, and advocacy for the National Lung Cancer Screening Program.
A crackdown may be an understandable response to youth vaping, illicit supply, predatory marketing, and the deliberate recruitment of people who have never smoked. Nobody arguing seriously for tobacco harm reduction should dismiss those concerns. Children should not vape, people who do not smoke should not start, products should meet enforceable safety standards, marketing to young people should be prohibited, and the tobacco industry should be treated with the distrust its history has earned.
Those propositions, however, do not settle the separate question of what should be available to an adult who already smokes.
Protecting young people from nicotine uptake and helping established smokers escape combustible tobacco are both legitimate public-health goals, but they are not the same policy problem. Treating them as though they are can produce avoidable harm because a policy designed entirely around preventing initiation may make switching more difficult, expensive, or unattractive for the people facing the greatest immediate risk.
That is the uncomfortable contradiction: Australia increasingly speaks the language of equity downstream while remaining reluctant to apply it upstream.
Australia’s National Lung Cancer Screening Program is a major achievement. The Commonwealth committed $263.8 million to establish the program, which commenced on 1 July 2025 and allows eligible Australians aged 50 to 70 with a substantial smoking history to receive low-dose CT screening through Medicare. Cancer Australia estimated that a targeted, risk-based program could prevent more than 12,000 lung-cancer deaths over its first decade.
That deserves unqualified support because earlier detection can mean earlier treatment, more therapeutic options, and a substantially better chance of survival. Ensuring the program reaches First Nations communities, people on low incomes, and those outside major cities is essential.
Screening, however, detects disease; it does not remove the exposure responsible for much of that disease.
It is possible to celebrate screening while still asking whether Australia is using every credible means of reducing smoking. Indeed, the people invited into the screening program are precisely those for whom that question is most urgent. A coherent strategy would use every screening encounter as an opportunity to offer compassionate, individualised help to stop smoking, including established cessation treatments, behavioural support and, after an informed discussion of risks and uncertainties, regulated non-combustible alternatives for adults who have not succeeded with other approaches.
Finding cancer earlier is not a substitute for preventing it.
The inequality in lung-cancer outcomes is preceded by a profound inequality in smoking. The Australian Institute of Health and Welfare found that in 2022–23, 13.4 per cent of people in the most disadvantaged areas smoked daily, compared with 4.1 per cent in the most advantaged areas. People in disadvantaged areas were therefore about 3.3 times as likely to smoke daily. The geographical divide was even greater, with daily smoking prevalence reaching 20 per cent in remote and very remote areas, compared with 7 per cent in major cities.
These disparities do not exist because disadvantaged Australians have failed to absorb a public-health slogan. Smoking is shaped by dependence, stress, mental illness, trauma, social environment, housing insecurity, the availability of support, and the concentration of tobacco retailing in particular communities. It is also sustained by a product engineered to deliver nicotine rapidly and repeatedly.
Price increases and public education have contributed to Australia’s substantial decline in smoking, but the people who continue to smoke are increasingly concentrated in populations facing the greatest barriers to quitting. That changes the equity calculation because a policy that merely inconveniences a professional living near several participating pharmacies may create an insurmountable barrier for someone in a remote community, someone without reliable transport, or someone deciding whether they can afford both a consultation and a smoking alternative.
Equal rules do not necessarily produce equitable outcomes.
Public discussion of vaping frequently collapses several distinct propositions into one. Vaping is not harmless: nicotine can produce and sustain dependence, aerosol may contain substances capable of causing harm, product quality varies, and the full effects of long-term use cannot yet be known with the confidence possible for cigarettes, which have been studied for generations. Australia’s National Health and Medical Research Council has appropriately warned that the relative harm of vaping and smoking is difficult to quantify and depends on the device, liquid, and pattern of use.
Uncertainty about the precise size of the risk difference, however, does not mean the risks are identical.
Cigarettes burn tobacco, producing smoke that contains the toxicants responsible for much of the cancer, cardiovascular disease, and chronic lung disease caused by smoking. Non-combustible nicotine products avoid that particular process. The relevant comparison for an adult who smokes is therefore not between vaping and breathing clean air; it is between continuing to smoke and switching completely to a regulated non-combustible product.
That distinction is fundamental.
The Royal College of Physicians’ 2024 evidence review concluded that e-cigarettes remain an important tool for reducing the deaths, disease, and inequality caused by tobacco. Crucially, it did not propose an unregulated commercial free-for-all. It recommended maintaining access and affordability for adults using vaping to quit while reducing the products’ appeal and availability to children and people who do not smoke.
The evidence on cessation has also strengthened. The 2025 Cochrane review found high-certainty evidence that nicotine e-cigarettes increase smoking-cessation rates compared with nicotine-replacement therapy. The review did not declare the products harmless or eliminate uncertainty about long-term effects; it answered the narrower but important question of whether they can help more people stop smoking, and the evidence indicates that they can.
This does not mean every smoker should vape. It means the option should be discussed honestly rather than obscured by messages that leave people believing vaping and smoking are equally dangerous.
Australia’s policy is not an absolute prohibition. Since October 2024, adults have been able to obtain certain therapeutic vaping products containing no more than 20 mg/mL of nicotine from participating pharmacies without a prescription, subject to clinical assessment and state or territory law. Higher-strength products require a prescription, and all legal vaping products are restricted to therapeutic supply through pharmacies.
In other words, the Australian system already concedes the central harm-reduction principle that vaping may have a role in smoking cessation and the management of nicotine dependence. The dispute is about whether the resulting system works well enough in practice.
Are suitable products reliably stocked, and can people in regional and remote areas obtain them? Are prices competitive with cigarettes and the illicit market, and do health professionals understand the current evidence? Are smokers being told that complete switching is likely to reduce risk, while dual use may preserve much of the danger? Do restrictions make legal products so difficult or unattractive to obtain that consumers return to cigarettes or buy unregulated products instead?
These are empirical questions that should be measured rather than answered through institutional instinct. A policy cannot be called equitable merely because a legal pathway exists on paper.
The most common objection to tobacco harm reduction is that it compromises the ideal of ending nicotine dependence, but it does not have to. If someone can stop smoking and cease all nicotine use, that is the best outcome. If someone can quit using behavioural support, nicotine-replacement therapy, varenicline, or another established treatment, they should be supported to do so. If someone has repeatedly tried those approaches without success but can switch completely to a regulated non-combustible product, that is still a meaningful public-health gain.
These outcomes are not identical, but neither are their risks.
Harm reduction begins with the recognition that people do not always move directly from the most dangerous behaviour to the ideal outcome and that sometimes they move first to something less dangerous. We accept this principle throughout healthcare: we use opioid-substitution treatment rather than demanding immediate abstinence as a condition of care, encourage condoms even though eliminating exposure would prevent more infections, and prescribe medications that manage risk when lifestyle change alone has not succeeded.
None of this means abandoning the best outcome. It means refusing to make perfection the enemy of substantial improvement.
A credible Australian harm-reduction strategy would not choose between protecting children and helping adults who smoke. It would do both by communicating clearly that cigarettes are the most dangerous nicotine product while acknowledging that non-combustible products are not risk-free. It would prevent sales to minors, restrict youth-oriented promotion, and enforce manufacturing, ingredient, and device-safety standards, while preserving practical and affordable access for adults seeking to stop smoking.
It would integrate cessation and harm-reduction support into lung-cancer screening, mental-health services, alcohol and other drug services, correctional health, and Aboriginal community-controlled healthcare. It would train clinicians and pharmacists to discuss relative risk without exaggeration or evasion and emphasise complete switching because prolonged dual use may provide far less benefit than replacing cigarettes entirely.
Most importantly, it would monitor what happens in the real world, including smoking, vaping, switching, relapse, youth uptake, and illicit-market participation across different socioeconomic and geographic groups. Regulation should be judged by outcomes, not intentions.
This is not pro-vaping policy; it is pro-quitting policy informed by differences in risk.
Lung Foundation Australia deserves credit for helping make lung cancer a national priority. Its advocacy for screening, specialist nurses, genomic profiling, survivorship services, and better care has helped move a neglected cancer closer to the attention it warrants, while its insistence that people with lung cancer deserve compassion rather than blame is especially important.
That same compassion should extend to people before diagnosis, including the person who has tried to quit six times, the person using cigarettes to cope with severe psychological distress, the person living hundreds of kilometres from a participating pharmacy, the First Nations smoker who has good reason to distrust systems that prescribe solutions without listening, and the low-income smoker for whom price, convenience and immediate relief matter more than an abstract promise about future health.
These people do not need another lecture about smoking. They need credible options, truthful information, and a health system prepared to meet them where they are.
Australia should continue discouraging nicotine use among young people and people who have never smoked, and it should continue pursuing a smoke-free future. But it should also recognise that refusing to distinguish between products can protect the ideal of abstinence at the expense of people who remain exposed to combustion.
A genuinely equitable lung-cancer strategy cannot begin with the scan. It must begin with the person who still smokes, the reasons they continue, and the alternatives they can realistically access.
Earlier detection, better treatment, and equitable access to specialist care are all essential, but the fairest lung cancer is the one that never develops. If Australia is serious about making lung cancer a fairer fight, people who smoke deserve every reasonable opportunity to leave combustion behind.
Like other budgetary areas, the Health Budget is finite. Governments and policymakers are obliged to try to maximise outcomes within a finite funding quantum. That must mean giving preference to the most cost-effective ways of improving health. If the Lung Cancer Screening Program is estimated to save 12,000 lives over a decade, the next question we need answered is ‘what is the total cost of this program over that decade compared to the cost of other programs which might also help to reduce death and disease?’ Health programs are often criticised because preference is given to costly and relatively ineffective interventions at the bottom of a cliff rather than to cheaper and more effective prevention at the top of the cliff. The cost of safer, smoke-free nicotine products is borne by smokers rather than taxpayers. Therefore their cost-effectiveness for taxpayers is extraordinarily high even if their effectiveness is very low, which we know is not the case. I have never heard of a reputable individual or organisational advocate for tobacco harm reduction arguing that conventional tobacco harm reduction should be scrapped and be replaced by smoke-free nicotine products. It is ludicrous in the extreme to implement an expensive screening program when, vaping, an extremely cost-effective preventive intervention is so severely restricted that it is tantamount to having been banned.
I couldnt agree more, This is a brilliantly written article, presenting clearly the case for providing smokers with adequate and correct information and viable alternatives to smoking.