Public health has learned over the past few decades to embrace harm reduction when abstinence-only approaches miss their mark. From distributing condoms to prevent transmission during the HIV crisis, to needle exchange programs and supervised injection sites, evidence showed again and again that when removing all risk is not possible, less risk saves lives. Today, tobacco harm reduction finds itself at a crossroads worldwide, including in Canada.
Few voices make that tension clearer than Canadian physician Dr Mark Tyndall. With a career spanning the HIV epidemic, addiction medicine and infectious disease research, Tyndall has seen firsthand what happens when practical solutions to human health stall out because of politics or moral discomfort.
With the spread of HIV worldwide in the 1980s and ’90s came intense opposition to preventive tools like condoms and needle exchange programs, despite strong evidence that they work. In Vancouver, harm reduction measures such as supervised injection facilities lowered rates of HIV transmission and overdose deaths. These measures were initially contentious but eventually became public health orthodoxy.
Smoking kills more people than HIV ever did
While running a cohort study in 2011, Tyndall noticed a striking trend: Participants weren’t dying mainly of causes related to HIV anymore. Instead, it was illnesses related to smoking, such as lung cancer and heart disease, that made up an increasing proportion of deaths. Subsequently, he started promoting vapes as less risky alternatives to combustible cigarettes. The response was encouraging. But public support for vaping faced backlash that has resonated with previous oppositional forces to harm reduction in HIV prevention.
Naturally, the primary problem is the fact that nicotine is often confused with combustion, despite the science showing that harms result from inhaling smoke produced by burning tobacco, not nicotine consumption.
This distinction is not just an abstraction. Public Health England (now UK Health Security Agency) has consistently found that vaping exposes users to far fewer toxicants than smoking does. While Sweden’s decades-long experience with snus — an oral, non-combustible tobacco product — is leading to the nation achieving unprecedentedly low smoking rates, not because more smokers are quitting but because they are switching. These findings confirm that supporting the use of safer nicotine alternatives can lower disease at the population level.
Canada’s contested path
Unregulated nicotine pouches are now readily available for purchase online without age verification. In fact, real-world data have consistently shown that youth access may actually rise when legal products become harder for adults to acquire.
In comparison to other nations, Canada has moved more conservatively towards embracing and regulating nicotine products. Federal regulations enacted in 2024 restricted the sale of nicotine pouches to pharmacies, where they were kept behind the counter. So far, only one brand has been approved by Health Canada.
The goal of the course was to reduce youth uptake. But Alberta Premier Danielle Smith has publicly taken issue with this strategy, highlighting that making safer nicotine options less accessible than cigarettes sends the wrong message. She rightly questions why safer nicotine products are subject to harsher retail restrictions than cigarettes.
Smith and officials in Alberta have also cited unintended consequences. Unregulated nicotine pouches are now readily available for purchase online without age verification. In fact, real-world data have consistently shown that youth access may actually rise when legal products become harder for adults to acquire. This is a pattern witnessed worldwide: When a product/substance is less legally available without eliminating demand, informal markets fill the gap.
Why restricting a highly demanded product is counterproductive
Economic research reinforces that concern. One recent study of Canadian provincial bans on flavours found that retail sales of nicotine vapes fell by about 30 per cent following the bans’ implementation. Cigarette sales, meanwhile, increased by nearly 10 per cent.
That change exemplifies the substitution effect: When safer alternatives are less appealing or available, some consumers switch back to smoking. Instead of reducing nicotine use, restrictive policies may shift it to more dangerous products.
Canada has also adopted a regime of progressively higher excise taxes on nicotine products. But while taxes can discourage consumption, they can also reduce the price gap between cigarettes and safer alternatives, decreasing smokers’ motivation to switch or encouraging them to obtain their preferred products illegally.
In several provinces, reports indicate that black-market vape products are becoming more openly available, occasionally accompanied by violence against retailers — a worrying echo of organised-crime patterns familiar from tobacco smuggling.
Youth Protection and Adult Harm Reduction Are Not at Odds
Federal regulators have made youth protection the central rationale for tougher rules. Impact assessments cite concerns that the alternatives, including nicotine pouches, as well as other options, could draw in new young users — especially with promotion on social media and endorsements by influencers.
Striking the right balance
Protecting minors is unquestionably important. But evidence from other harm reduction fields indicates that limiting adult access is not the best approach to protecting youth. Such licensed retail systems, robust age verification, advertising restrictions and focused enforcement can curb youth access while allowing adults to make their own choice. The balance is delicate. But policies that place safer products out of reach compared to cigarettes are likely to deter smokers currently trying to quit.
Opposition to nicotine alternatives frequently moves beyond questions of smoke to concerns about nicotine per se, even though decades of medical research show that nicotine, while addictive, is not toxic per se. For doctors like Tyndall, the ethical question is simple: When there’s a less dangerous alternative available, does it even make sense to try to talk smokers into not using nicotine?
Tobacco harm reduction is achieved without massive new public spending programs. It demands proportionate regulation, accurate risk communication and access to less harmful products.
Canada is now at a crucial crossroads. It can double down on restrictive policies that threaten to strengthen illicit markets and force substitution back to cigarettes. Or it can reset in favour of evidence-based regulation that draws a clear line between combustion and non-combustion products.
The focus should still be on reducing smoking-related disease. If history is any guide, progress will not flow from moral discomfort or regulatory inconsistency, but from aligning policy with scientific evidence and real-world results.
