Hierarchy of harm: nicotine alternatives in a post-tobacco era

At a recent Nursing in Practice conference, clinical fellow pharmacist Darush Attar-Zadeh guided nurses through smoking cessation, vaping, and nicotine replacement options. Here, we distil the key insights from his session and explore the hierarchy of harm he outlined for nicotine alternatives in a post-tobacco era.

Declines in smoking prevalence in the UK represent a major public health success. In England, adult smoking rates have fallen from nearly 20% in 2011 to around 10% in 2024. Even more significantly, prevalence among 16–24-year-olds has dropped from 44.3% in 1974 to just 8.2% today.

This progress has been reinforced by recent legislation, with the Tobacco and Vapes Bill ensuring that no one born after 2009 will ever legally be able to purchase cigarettes in the UK.

Moreover, this legislation will also give ministers the power to strengthen the existing ban on smoking in public places such as near children’s playgrounds and outside of schools and hospitals.

However, this shift away from traditional tobacco has been accompanied by a rapid rise in alternative nicotine products. Speaking at a Nursing in Practice 365 event in London on 30 April, clinical fellow pharmacist Darush Attar-Zadeh highlighted that vaping has now overtaken cigarettes in prevalence, particularly among younger populations.

Data from Action on Smoking and Health suggests that 20% of 11–17-year-olds in Great Britain have tried vaping – equating to around 1.1 million individuals – with 7% currently vaping and a significant proportion doing so daily.

Similarly, the Office of National Statistics reports that 5.4 million people aged 16 years and older vape in the UK, with vape use growing from 8.5% of women in 2023 to 10% in 2024.

While vaping is considered less harmful than smoking, it is not without risk. The long-term health effects remain uncertain, but emerging evidence points to respiratory harms and possible cancer risks, alongside concerns around nicotine addiction affecting brain development and concentration.

With an expanding range of products – including vapes, nicotine pouches and heated tobacco – many of which appeal to younger users, clinicians are increasingly faced with new challenges in addressing nicotine dependence in practice.

Hierarchy of harm

To help clinicians navigate these challenges, Mr Attar-Zadeh guided the nursing audience through a hierarchy of harm across nicotine delivery products, from most to least harmful.

Combustion was a key factor in shaping designation, with Mr Attar-Zadeh highlighting the importance of distinguishing between nicotine and tar. ‘Nicotine is addictive,’ he said, but it is the tar produced by combustion – with ‘69 cancer causing components’ – that kills.

‘Anything organic that you burn generates tar, generates carbon monoxide… even if you smoke cabbage, which no one does, that will still generate tar and carbon monoxide – so that’s what kills, not the nicotine,’ noted Mr Attar-Zadeh.

Combusted tobacco products

Cigarettes, shisha, cigars, and any other products that involve tobacco combustion – thereby, producing tar and carbon monoxide – sit at the top of Mr Attar-Zadeh’s hierarchy of harm.

Water pipes – otherwise known as shisha – also fit into this group, with many users mistakenly believing the water filters out the harmful compounds.

These products are carcinogenic and impact cardiovascular, respiratory and oral health. Additionally, they negatively affect fertility for men and women in multiple ways and can cause gastrointestinal issues, such as peptic ulcers, he highlighted.

Heated tobacco products

Heated tobacco products, such as those marketed as IQOS (‘I quit ordinary smoking’), heat tobacco to high temperatures without igniting it.

These products are growing in popularity in many countries – particularly in Japan, where nicotine vapes are banned.

While manufacturers claim this makes them significantly healthier, Mr Attar-Zadeh urged caution: ‘The scientists from the tobacco companies who make these are saying this is much healthier. Of course, they’re going to say that. But, independent research is needed on that.’

Existing research has found that these products are carcinogenic and usage acutely impacts the pulmonary system, including oxygen saturation levels and airway function.

In fact, recent research from a Japanese health ministry panel suggests that some heated tobacco products may be more harmful than regular cigarettes, producing greater amounts of cancer-causing substances.

Tobacco pouches

While the sale and marketing of tobacco-based snus pouches have been prohibited in the UK since 1992, these products – placed between the gum and cheek – are very common in Scandinavian countries.

Sweden has the lowest smoking prevalence in Europe at around 5%, partly due to widespread snus use, and is expected to become the first ‘smoke-free’ European country as a result.

However, it is important to note that tobacco-based snus pouches contain harmful heavy metals and are linked to cardiovascular disease; oesophageal, oral, and rectal cancers; and other harms.

Vapes (e-cigarettes)

Vapes are considered significantly less harmful than any combusted product because they do not produce tar or carbon monoxide.

In fact, England’s NHS actively uses them as a harm-reduction tool via the ‘Swap to Stop’ programme, offering free vapes to smokers to help them switch to a less harmful alternative. Moreover, vapes have been shown to triple an individual’s chance of quitting smoking.

Nevertheless, Mr Attar-Zadeh emphasised that ‘although vaping is less harmful than smoking cigarettes, it’s not without risk’.

Recent studies have linked regular vaping to higher risk of respiratory symptoms, asthma exacerbation, COPD, and lung inflammation – even in never-smokers.

Nicotine pouches (tobacco-free)

A growing concern, according to Mr Attar-Zadeh, is the rise of tobacco-free nicotine pouches, particularly among younger people. These contain nicotine and flavourings but no tobacco.

The absence of tobacco from these products meant that that up until very recently they fell outside usual regulations and could be purchased at any age.

After the Tobacco and Vapes bill received royal assent on 29 April 2026, however, it became illegal to sell nicotine pouches to anyone under the age of 18 in the UK.

The World Health Organization recently warned that tobacco companies are using marketing tactics associated with the historic promotion of cigarettes to fuel rapid global growth in nicotine pouch use.

Experts warn that the flavouring agents in these products are harmful, with cell studies indicating that usage may be linked to severe periodontal disease.

Nicotine replacement therapy (NRT)

Licensed NRT products – patches, mouth sprays, gums, inhalators – sit at the bottom of Mr Attar-Zadeh’s hierarchy of harm.

These products have passed clinical trials and are regulated as medicinal products, unlike vapes, which – despite the swap to stop programme – remain consumer products.

These medicines provide a low level of pharmaceutical grade nicotine without the tar, carbon monoxide, and other poisonous chemicals present in tobacco smoke.

Mr Attar-Zadeh noted: ‘NRTs give you far less nicotine than a cigarette. That’s why we always recommend the patch plus a spray together.

‘The patch is a bit like the sprinkler of nicotine. The mouth spray is like your fire extinguisher to put out the craving.’

Long-term NRT use is rare, Mr Attar-Zadeh said, but around 5% of users become addicted.

Like all medicines, NRT can cause side-effects, such as headache, nausea and dizziness, he noted.

Smoking cessation

Mr Attar-Zadeh highlighted that the ultimate goal is a ‘total quit’ of both smoking and nicotine.

‘I think we need to get that message across: stop smoking and also eventually stop the nicotine too, because we don’t want lifelong users of nicotine either.’

Nevertheless, it can be important to assess a person’s individual situation, he stressed.

For someone who is a chronic smoker, for example, any nicotine alternative is preferable to smoking combusted tobacco products, like cigarettes.

Mr Attar-Zadeh explained how one patient only managed to quit by using a raspberry flavoured vape, while another patient went from smoking 60 cigarettes a day to using NRT spray for three years.

The speaker described both of these stories as success stories, despite not fitting into the ideal narrative.

Take aways

Mr Attar-Zadeh emphasised that the key takeaways of his talk were:

• Smoking is the greatest harm
• Vaping does cause assault to your lungs
• Low risk does not mean no risk
• Be aware that nicotine pouches are growing in popularity among young people

Nursing in Practice offers a programme of exciting events throughout the year, delivering practical clinical updates and expert-led education. Whether you prefer face-to-face or virtual learning, register today to save your free spot at an upcoming event and connect with peers. Check out what’s on the calendar and join us at the next one!