Palau Wants the United Nations to Review Nicotine. But Who Will Review the Evidence?

A recent article published by the European Network for Smoking and Tobacco Prevention (ENSP) celebrated a call from the Pacific nation of Palau for the United Nations to review nicotine and strengthen global action against emerging nicotine products. At first glance, this may sound like a reasonable public health initiative. After all, who could object to reviewing evidence?

The problem is that when international tobacco control organisations talk about “reviewing nicotine,” they rarely mean conducting a balanced assessment of all the evidence. More often, they appear to be building a stronger case for restrictions, bans, and prohibition while ignoring evidence that challenges their preferred narrative. The article is therefore less notable for what it says than for what it omits.

The most striking feature of modern tobacco control discussions is that nicotine itself has increasingly become the villain. Not smoking, not combustion, and not the inhalation of tar and thousands of toxic by-products produced by burning tobacco, but nicotine. This shift is remarkable because for decades, the scientific and public health consensus was clear: people smoke for nicotine, but they die from smoke.

That distinction formed the foundation of nicotine replacement therapies such as gums, patches, lozenges, inhalers, and sprays. Yet when nicotine is delivered through consumer products that compete with traditional tobacco control approaches, many organisations suddenly speak as though nicotine itself is the primary public health threat. The ENSP article follows this familiar pattern. There is extensive discussion of nicotine products, youth concerns, environmental impacts, and industry influence, yet there is little meaningful discussion of the central question: what happens to smokers when safer nicotine alternatives are restricted or eliminated?

That omission matters because public health policy should not be judged by intentions but by outcomes.

The call from Palau aligns closely with a position that has become increasingly common within parts of the international tobacco control movement, where novel nicotine products are discussed primarily as threats requiring stronger controls rather than as potential harm reduction tools. This approach assumes that reducing access to nicotine products will improve public health, but that assumption is far from settled.

Countries that have embraced vaping and other lower-risk nicotine products have often experienced substantial declines in smoking prevalence. Meanwhile, countries pursuing increasingly restrictive approaches continue to struggle with illicit markets, enforcement challenges, and persistent smoking rates. Yet these outcomes rarely receive the same attention as youth experimentation statistics. As a result, the debate has become increasingly focused on preventing nicotine use rather than reducing smoking-related disease, even though those goals are not necessarily the same thing.

One of the themes frequently promoted by Palau and allied organisations is the environmental impact of tobacco and nicotine products. Environmental impacts should absolutely be considered, but they should be considered consistently. A disposable vape creates waste, but so does a cigarette pack, every pharmaceutical nicotine product, and countless other consumer goods used every day.

The relevant question is not whether a product creates waste but whether its environmental costs outweigh its public health benefits. Removing lower-risk nicotine alternatives because they generate waste would be a strange form of public health policy if the result is more smoking, greater cigarette consumption, and ultimately more tobacco-related disease. A balanced assessment would examine both sides of that equation, yet balance is often missing.

Virtually every modern anti-vaping campaign eventually arrives at the same destination: protecting youth. Protecting young people is an entirely legitimate public health goal, but problems arise when youth concerns become the sole lens through which policy is evaluated.

Public health policy affects entire populations. Millions of adults smoke, millions struggle to quit, and millions are trying to avoid smoking-related disease. When discussions focus almost exclusively on youth risks while largely ignoring adult benefits, the analysis becomes distorted. A policy can reduce youth vaping while increasing smoking, reduce legal access while expanding illicit markets, and produce unintended consequences that undermine its stated objectives. These possibilities deserve examination rather than dismissal.

Palau itself has implemented one of the world’s strictest approaches to vaping, including prohibitions on e-cigarettes. This raises an obvious question: what evidence demonstrates that prohibition works better than regulation?

Around the world, the history of prohibition is mixed at best. Where demand exists, supply often follows. Restrictions can create black markets, bans can generate enforcement challenges, and consumers frequently seek alternative sources when legal options are removed.

Australia’s experience should serve as a warning. Policymakers promised that tighter controls would reduce vaping and protect public health. Instead, Australia has witnessed the rapid expansion of illicit tobacco and illicit vape markets, growing involvement from organised crime groups, and increasing violence linked to the illegal trade. Yet these lessons are rarely incorporated into international discussions. The assumption often remains that stronger restrictions automatically produce better outcomes when reality is usually far more complicated.

Perhaps the most concerning aspect of these international discussions is the narrowing range of acceptable viewpoints. Increasingly, anyone who supports tobacco harm reduction is portrayed as advancing industry interests. Scientists who highlight relative risk differences are accused of helping tobacco companies, researchers who support regulated vaping are treated with suspicion, and consumers who successfully quit smoking through vaping are often dismissed as anecdotes.

This creates an environment where only one side of the debate is considered legitimate. That is not science. Science advances through disagreement, scrutiny, and competing interpretations of evidence. A genuine United Nations review of nicotine would welcome those perspectives rather than exclude them.

It would examine evidence from countries with different regulatory models, compare outcomes rather than intentions, and analyse smoking rates, cessation rates, illicit market growth, youth use, adult use, and overall public health impacts. Most importantly, it would ask a simple question: compared to what?

Compared to smoking, what are the risks? Compared to smoking, what are the benefits? Compared to smoking, what outcomes are actually being achieved?

Without those comparisons, discussions about nicotine become detached from the very public health goals they claim to pursue.

The review should not begin with the assumption that nicotine itself is the problem. It should begin with the question that matters most: how do we reduce disease, death, and suffering caused by smoking?

Any product, policy, or intervention should be evaluated against that benchmark, not against an idealised vision of a nicotine-free world, political preferences, or ideological commitments. It should be judged against real-world outcomes.

Because if the objective is truly to save lives, then the evidence should lead the policy, not the other way around.

And perhaps before the United Nations reviews nicotine, it should review the consequences of the policies already being promoted in nicotine’s name. Across much of the world, smoking remains responsible for millions of deaths every year. The question is not whether nicotine use can be reduced. The question is whether the pursuit of nicotine-free ideals is preventing policymakers from embracing strategies that could reduce smoking-related harm today.

That is the debate many public health organisations seem increasingly reluctant to have, which is precisely why it needs to be had.