Chasing Ghosts

I’ve been exchanging emails with Riccardo Polosa, and in one of his recent notes, he distilled the entire nicotine debate into a single, unsettling idea: we are chasing ghosts. Not casually, not rhetorically, but systematically. Entire policy frameworks, public health campaigns, and regulatory instincts are still oriented toward a threat that no longer exists in the form we remember it. The architecture is still there, the language is still there, the urgency is still there, but the object of fear has changed, and no one seems willing to admit it.

For most of the twentieth century, nicotine and death were fused in a way that felt inseparable. If you wanted nicotine, you had to light a cigarette. There was no alternative pathway. That meant inhaling smoke filled with tar, carbon monoxide, and thousands of toxic byproducts created by combustion. The devastation this caused was real, visible, and undeniable. Entire generations were shaped by it, hospital wards filled with patients suffering from emphysema, lung cancer, and cardiovascular disease. It wasn’t abstract. It was immediate, personal, and relentless.

But something subtle and consequential happened during that era. We didn’t just learn to fear the delivery system, the burning cigarette, we learned to fear the molecule that came with it. Nicotine itself became the symbol of the damage, the stand-in for the harm, the thing we blamed when we couldn’t easily separate cause from context. It was labelled “addictive,” and that label didn’t remain a neutral scientific descriptor. Over time, it hardened into a moral category. Addiction became shorthand for danger, weakness, and inevitability. It carried emotional weight far beyond its pharmacological meaning.

That is the ghost we are now dealing with.

Because over the past decade, the landscape has changed in a way that would have been almost unimaginable fifty years ago. We have, in practical terms, separated nicotine from combustion. The fire, the actual engine of disease, can now be removed from the equation. Nicotine can be delivered without smoke, without tar, without the cascade of toxic chemicals that made smoking so deadly. This is not a theoretical shift; it is a technological and behavioural reality already playing out across populations. And yet, the institutional response remains anchored in a world where that separation did not exist.

When policymakers and public health authorities react to nicotine today, they are not responding to the current evidence base. They are responding to memory. They are responding to decades of accumulated harm that were never actually caused by nicotine in isolation, but by the way it was historically delivered. The emotional imprint of that history is so strong that it overrides the distinction that now matters most: the difference between smoke and no smoke.

So the ghost persists.

The word “addiction” is the mechanism that keeps it alive. Detached from its original context, it continues to carry an implicit conclusion: if something is addictive, it must be harmful. But that conclusion only holds if the addiction leads to damage. If the primary source of harm has been removed, then the word begins to lose its explanatory power and take on something else entirely. It becomes a moral signal rather than a medical one. It tells us how to feel about a behaviour, not what that behaviour actually does.

This is where Riccardo Polosa’s question becomes so disruptive. If a form of nicotine use leads to little or no harm, why should it concern public health at all? It’s a simple question, but it cuts through layers of inherited thinking. Because if the answer cannot be grounded in measurable health outcomes, disease, disability, or premature death, then what remains is not science, but discomfort.

We see the inconsistency when we look at other substances. Caffeine produces dependence. It alters mood, affects withdrawal, and is used habitually by millions of people every day. Yet it is not framed as a public health crisis. There is no sustained effort to eliminate its use, no sweeping moral language attached to its consumption. The reason is not that caffeine is fundamentally different in how it interacts with the brain, but that it was never historically tied to mass mortality. It never became a ghost.
Nicotine did, and we are still reacting to it as if nothing has changed.

In Australia, this ghost-chasing manifests in a regulatory framework that collapses all nicotine products into a single category of concern. Combustible cigarettes, which are responsible for the overwhelming majority of tobacco-related deaths, are treated in policy discussions alongside non-combustible alternatives as though the differences between them are marginal or uncertain. The signal this sends to the public is clear, even if unintentionally so: there is no meaningful distinction to be made. Risk is flattened. Context disappears.

But this is where the consequences of chasing ghosts become tangible. When people are told implicitly or explicitly that all nicotine products are equally dangerous, the incentive to move away from the most harmful form is weakened. If every option is framed as a cliff, there is no visible path to safer ground. What should function as harm reduction becomes obscured by a blanket of caution that refuses to differentiate.
A coherent public health strategy should act like a map, guiding individuals away from the highest risks and toward lower ones. It should reflect gradients, not absolutes. Instead, what we have is a map drawn from memory, not from present reality, a map where every road is marked with the same warning, regardless of where it leads.

And beneath this, there is a deeper layer that rarely gets acknowledged openly. If nicotine can exist in forms that do not produce significant harm, then the basis for opposing it shifts. It is no longer about preventing disease; it becomes about the discomfort with dependence itself. The focus moves from outcomes to behaviour, from health to perceived virtue.

At that point, the argument is no longer scientific. It becomes philosophical, even ideological. It rests on the belief that reliance on any substance is inherently undesirable, regardless of its effects. It frames chemical assistance as a kind of impurity, something that should be eliminated not because it causes harm, but because it violates an ideal of how people ought to live.

This is the final stage of ghost-chasing. When the original threat has been neutralised, but the emotional and moral framework built around it remains intact, it begins to operate independently of evidence. It no longer needs the fire to justify its existence. The ghost is enough.

And while we are preoccupied with that ghost, the source of harm continues to operate in the background. Combustible cigarettes have not disappeared. They remain the primary driver of tobacco-related disease and death. The tragedy is that we now have the tools to significantly reduce that burden, tools that align with how people actually behave, tools that offer an off-ramp from the most dangerous form of nicotine use.

But those tools are being constrained, diluted, or dismissed, not because they fail to reduce harm, but because they resemble something we have already decided to fear.
We are not lacking solutions. We are lacking the willingness to update our understanding.

And so the ghost remains at the centre of the conversation, absorbing attention, shaping policy, and distorting priorities. It feels real because it is rooted in real history. But it is no longer an accurate reflection of present risk.
Until that distinction is acknowledged, until we stop reacting to nicotine as if it still arrives wrapped in smoke, we will continue to misdirect our efforts. We will continue to treat vastly different behaviours as if they are the same. And in doing so, we will allow the real, ongoing harm to persist, not because it cannot be prevented, but because we are too busy chasing what no longer exists.