A clear and worsening division within public health has turned the debate over nicotine into a moral panic, with potentially dire consequences. Shot on location at GFN 2026 in Warsaw, Poland, longtime nicotine researcher and former University of Geneva professor of public health Jean-François Etter examines the irrational push to prohibit safer nicotine products. He explores public health groupthink, how arbitrary nicotine limits leave people underdosed, and why innovation may ultimately render opponents of tobacco harm reduction obsolete.
Featuring:
JEAN-FRANÇOIS ETTER
Nicotine & Tobacco Harm Reduction Researcher
Former Prof. of Public Health, University of Geneva
@etterjfZ profetter.substack.com
Transcription:
GFN interview — Jean-François Etter on 30 years of nicotine research
Global Forum on Nicotine 2026
Brent Stafford 0:00:05
You've been at this a long time. Fill our audience in a bit about what your experience is around researching nicotine.
Jean-François Etter 0:00:13
Yes. Well, I started about 30 years ago. And yes, things change a lot in the past 30 years. We know a lot more about the risks. We know also a lot more about what works as prevention measures. We know more about the industry misconduct because of documents released in the meantime. But I think the most important change, of course, is the arrival of the new products.
the debate about harm reduction and the division in the field. We didn't have such a division in the field 30 years ago at all. It appeared with the arrival of e-cigarettes and now the field is so polarized, but this did not exist when I started in this field here.
Brent Stafford 0:00:58
Describe the division. What is that?
Jean-François Etter 0:01:01
Yeah, in the field of tobacco harm reduction there's a clear division and a worsening division I would say between people who are in favour of tobacco harm reduction and new products and non-combustible products and people who are against this approach and who think that we should change our objective from tackling tobacco and combustible products to tackling nicotine itself.
So even, for instance, the leadership of the FCTC, the Framework Convention for Tobacco Control, during the last conference of the parties last year said that they want to have a new interpretation of the Convention in order to target nicotine itself. So it's not in the text, but it's their interpretation, which I think is abusive.
Brent Stafford 0:02:01
Is it a moving of the goalpost? Is it as simple as that, or is there something more?
Jean-François Etter 0:02:06
Yes, it's a moving of the goalposts from tobacco and mortality and morbidity caused by combustion to nicotine. It's been going on for a long time. It's not recent actually.
Brent Stafford 0:02:20
So this is tobacco control where the division is in and public health in general?
Jean-François Etter 0:02:26
Yes, exactly. The objectives are not the same anymore. I think one of the groups wants to decrease mortality and morbidity, and the other groups just wants to decrease nicotine use. Nicotine use is a new target, so this is debatable because the harm comes from combustion, not from nicotine itself. and nicotine can help smokers quit smoking.
So the change of the goalpost is really something that's debatable.
Brent Stafford 0:03:01
Yeah, it's frustrating, is it not?
Jean-François Etter 0:03:04
Yes it is, yes it is because there's an opportunity now to have smokers switch from combustible products to new products. The field is very innovative and there's a feeling that this change is being blocked by mostly public health people for reasons that are not really defensible I think.
Brent Stafford 0:03:31
We're talking about nicotine here, so let me ask you, is nicotine dangerous?
Jean-François Etter 0:03:38
In the sense that it is addictive when smoked. Yes, but it's indirect. What's dangerous is the smoke, the toxic component in the smoke, not the nicotine itself. But pure nicotine, like for instance in a nicotine patch, it's not addictive because the patch delivers the nicotine too slowly for it to be addictive. and it's not toxic.
The nicotine patch was invented in the 1980s, the nicotine gum in the 1970s, and during decades nobody said that these products were dangerous. But suddenly because you have those new vapes and nicotine pouches, et cetera, nicotine becomes the enemy instead of tobacco. It doesn't make sense.
Brent Stafford 0:04:32
A lot of people when pressed on that issue would say that, well, maybe it's because nicotine vapes and nicotine pouches are very successful at getting smokers to quit and that might threaten tobacco control's kind of livelihood.
Jean-François Etter 0:04:51
Yes, this would be the conflict of interest argument, certainly. They feel threatened. But I think also that a lot of people sincerely believe that they are doing the right thing. There's a phenomenon of groupthink.
If you attend only those conferences that are against tobacco harm reduction and read only the output of the WHO and the FCTC, And if you don't take time and it's, It takes hard work and time to read the literature and understand the nuances in this field, so it's easier. I think it's an easier narrative. Nicotine is the enemy.
Then, well, going into the details of the mechanisms of nicotine addiction, the relative risks of each product, it takes time and energy and competence also. to read and understand this literature. So I think it's hard work. And perhaps a lot of people perhaps do not have the training, the necessary training, or for some reason sincerely believe.
So it's not just conflict of interest, although they exist. I think a lot of people are honest and sincerely believe that nicotine should be the enemy.
Brent Stafford 0:06:21
So partly it's a go with the crowd issue.
Jean-François Etter 0:06:25
Yes, it's reinforced, I think, also by social media, tribalization and misguided leadership by the FCTC leadership, the WHO leadership, even the European Union, the EU commissioner. for Health, Varely, said that he's 100% sure that nicotine pouches and heated tobacco and e-cigarettes are just as dangerous as cigarettes. Of course, if the leaders say this, people will follow.
They don't necessarily have the means to understand all the nuances in the field.
Brent Stafford 0:07:11
So when somebody at that level, the level of the EU commissioner, makes statements like that, I mean, is it incompetence? Is it dangerous?
Jean-François Etter 0:07:25
Well, I would say it is incompetence because it's not too difficult to read the literature and understand what's at stake, especially if you are the EU commissioner. And is it dangerous? Yes, it is, because then the regulation will be influenced by these sort of statements, and fewer smokers will switch to non-combustible products.
Perhaps some young people will start using nicotine, but they'll start smoking instead of starting with nicotine pouches, for instance. So yes, this has consequences, of course.
Brent Stafford 0:08:05
Now, we've heard in interviews this week already that the illicit evapour market globally is $47 billion a year.
Jean-François Etter 0:08:20
Impressive, I didn't know that.
Brent Stafford 0:08:21
76% of the entire global evapour market is illicit. It's impressive.
Jean-François Etter 0:08:28
It's incredible. Yeah, it's an illustration of something that we have been knowing for decades, for more than a century at least, since the prohibition in the United States a century ago and even before that. So, yeah, prohibitions and bans do not make the demand disappear. Nicotine, when tobacco was introduced in Europe in the 16th century, it was immediately successful.
At the time when people traveled on horseback or buy foods, tobacco spread across Europe in only a few years or a few decades. So we're not going to get rid of nicotine or tobacco. And the view, the end game view, the view that prevalence should be decreased to zero is a view which has a necessary corollary, prohibition, because you're not going to get rid of the demand.
Then the issue becomes how do we help smokers quit smoking and how do we provide people with products that are as little toxic as possible.
Brent Stafford 0:09:45
Now, all the time, obviously, for good reason, we all talk about the smoker, the current smoker that still needs to switch. But that $47 billion a year in illicit market, so it's about $62 billion total annual. Those are people that are already using these products. Exactly. So what do we do? We try to take those products away from the people who are already using them?
Is that the goal?
Jean-François Etter 0:10:13
Yes, I think it's ideological. It's not rational. We should not look at a rational strategy here. It's more like a moral aversion against nicotine or a moral panic about nicotine use by young people. And it's not pragmatic. It's really ideologic. So it's not rational. It makes it more difficult to oppose because people will stick to their ideology.
If someone is very pragmatic, then he can change his mind. I mean, he can read the new evidence or Understand that, for instance, in Brazil, in Mexico, in Australia, criminality has developed and the market has been given to criminal gangs and cartels, and then switch and modify the regulations. But they don't. It's ideological, and it's very hard to change this.
Brent Stafford 0:11:23
You mentioned the FCTC. The last one was COP 11. But before that, in COP 10, the president, I believe, of the FCTC made a speech at the start of the conference and called for a whole-of-society approach to handling the scourge of nicotine.
Jean-François Etter 0:11:45
Yes, I also hear whole of governments. And since their approach is prohibition, they say very clearly, they want very clearly that the first option is to ban these products and prohibit them. Then the necessary of that is enforcement.
Enforcement and whole of government or whole of society means police, the justice, and of course we know that this falls more heavily on most vulnerable people, the poor, people with mental health issues who have difficulty quitting smoking, illicit drug users, most of whom smoke and they also have difficulty stopping smoking.
So these people then are exposed to over-policing, repression. They're also exposed to the criminality and contact with the criminal groups who sell the illicit vapes. And sometimes it's the same people who also sell illicit drugs. So yeah, there's a lack of compassion, I think, behind this approach.
Brent Stafford 0:12:56
In a way, they put the control in tobacco control.
Jean-François Etter 0:13:00
Exactly. Exactly. It's really the old approach of repression government-based interventions rather than talking to people, working with them and understanding how and why they use these products and developing with them acceptable and more effective regulations actually.
Brent Stafford 0:13:31
Jean-François, can you explain for us, that are in North America, what's happening in France when it comes to nicotine pouches? Are they actually illegal? Could you get thrown in jail for having a nicotine pouch?
Jean-François Etter 0:13:46
Yes, it's illegal. It's very recent. There was a panic around nicotine pouches and they prohibited them. It's been prohibited recently. So, yes, it's irrational. They were warned about the negative consequences, but they proceeded anyway. And I think this is not good policy. It's perhaps popular with a part of the electorate, but not with everybody.
The consequences of this prohibition are well known. Demand is not going to disappear. The black market is going to replace the official market, which means that there's no quality control anymore. Perhaps dangerous ingredients will be found in these illicit products. and this only gives the market to criminal groups, reinforces their influence.
I think there are other possibilities than banning products.
All the traditional measures all the traditional measures to control product from education to mass media campaigns to the control of the concentration of nicotine in the pouches, monitoring the markets to understand the behaviours, the products, the marketing strategies, and intervening at each step of the marketing and diffusion process.
Not using the nuclear option of prohibiting a product, it doesn't work, unfortunately. It may work, but it requires strong enforcement. And this also falls more heavily on the most vulnerable people.
Brent Stafford 0:15:53
Yeah, I mean, in my mind, it undermines the legitimacy of a government when they're making prohibitions like that.
Jean-François Etter 0:16:01
Exactly. And this is a serious issue because it extends beyond nicotine. I mean, there's an Ebola outbreak. We don't know whether it's going to come here or not with a 50% mortality rate. And WHO is discrediting itself in the field of nicotine with these extreme positions. And this has serious consequences.
If people don't trust WHO, then they may not trust it either in other fields of public health. So this is a serious issue, and it has consequences.
Brent Stafford 0:16:41
Tell me a bit about some of the more academic stuff around nicotine. You have a questionnaire that you put together, is that correct?
Jean-François Etter 0:16:51
Yes. The aim is to help vapers choose the right amount of nicotine for their e-liquid, the right concentration in milligrams per milliliter for their e-liquids, because in our surveys and I noticed that people underdose the liquids, so I wanted to help them choose the right amount in their liquids.
It's based on data and questionnaires that we collected in smokers, in vapers who are former smokers who successfully quit smoking with vaping. And we collected questionnaires in these people. We also collected saliva samples to measure cotinine. Cotinine is a metabolite of nicotine to measure their exposure to nicotine.
So combining these data, We also ask the vapers about what type of eliquids they use, what concentrations they use in their eliquids. So the questionnaire ends up in recommendations about the nicotine concentrations that people should use if they want to avoid withdrawal symptoms, relapsing to smoking and having a satisfactory experience with e-cigarettes.
Brent Stafford 0:18:12
Is there a number in terms of, you know, guess here what percentage of vapors are under dosing on their nicotine?
Jean-François Etter 0:18:23
It's difficult to actually define underdosing. The right dose is the dose that eliminates withdrawal symptoms. Craving, bad mood, depressed mood, irritability, anxiety, anger, difficulty concentrating, insomnia, weight gain. appetite, all these are withdrawal symptoms that should not exist if people dose the nicotine correctly.
What we've seen in our data, we've followed vapors during several months and we've seen that many of them want to gradually decrease the amount of nicotine, the concentration of nicotine in their e-liquids, thinking that perhaps they will decrease their addiction or little by little stop vaping. But this is ignoring a fact, the phenomenon of self-titration.
It's like, for instance, you're in this room, whether it's cold outside or warm outside, the room more or less remains at the same temperature. It's the same for a vaper or a smoker. He needs a certain level of nicotine in his blood and brain to feel comfortable to avoid withdrawal symptoms.
Then if, for instance, you vape at three milligrams per milliliter or six milligrams per milliliter and you're heavily dependent, it's not enough. So you need to consume more nicotine. liquid and expose yourself to more vapor unnecessarily because you need more. You just need more nicotine. You need perhaps 18 milligrams or 20 or even more.
So this was the aim to help people choose the right liquid for a satisfactory experience.
Brent Stafford 0:20:17
I can share some of that experience myself. In Canada, they knock down the nicotine concentration from 50 down to 20 milligrams per milliliter. And I was a two-pack-a-day smoker, so 50 is what I use. And being forced down to 20, I would consume much more vapor, and it would have a lot of problems with my vocal cords.
Jean-François Etter 0:20:42
Exactly, that's exactly what's happening.
You unnecessarily expose yourself to too much vapor and also it's a good thing for people to buy their liquids or when they first buy them in a vape shop because there they can try various flavours and various nicotine concentrations but they should also be aware that vendors there are interested in selling as much liquid as they can so they're not necessarily interested in advising people to use the highest concentrations because then they would sell fewer liquids, so people should be aware of that.
And also perhaps a thing that people can do is when you inhale, there's an apnea, a moment when you keep the vapor in your lungs and if you keep it a little bit longer, then nicotine absorbs more. So it's also a trick that you can use to inhale less vapor. It's not very comfortable to stop breathing for a few seconds, but it's a trick to go around.
Then we can ask why did the European Union and then Canada set this limit at 20 milligrams per milliliter? Where does it come from? Is there some scientific evidence behind that? I don't think so. It occurred during the writing of the Tobacco Products Directive in the years before 2014, so it's a long time ago.
There were not that many studies at the time that would help determine this level, so it was more like a political negotiation. Some people did not want too high concentrations because they feared that there would be nicotine poisoning. they more or less decided this because they estimated, they saw that it was about the same amount as people got from a cigarette.
It's not very rational because the exposure The dose that people inhale is determined not just by the nicotine concentration in the liquid, but also by the hardware, the coil and the wick and the power, and by the behaviour of the user, the number of puffs, the interval between puffs, the frequency of the puffing episodes, the depth of inhalation, etc.
Also, this was, of course, decided before nicotine salt arrived on the market, and it should be changed, I think. But there's rigidity in these things, and I have little hope that this limit will change.
Brent Stafford 0:23:58
Clearly, if you're a vapor and you've been around for a while, you know that there is a night and day difference between original OG 20 milligrams per milliliter, which is quite strong, you know, 2024. That was like, that does a high amount of nicotine and a 20 milligrams per milliliter in nicotine salt. The night and day difference. Yes.
And so one is pretty high if you're using the old school natural kind of thing, and it's not that high at 20. But you're right, there's no way that they're going to revisit that.
Jean-François Etter 0:24:39
I don't know. Maybe if the market changes, if there's pressure from the public, but it's not in this direction that the whole policy issue is going. It's in the other direction, I think. So, yeah, little hope, unfortunately.
Brent Stafford 0:24:59
So just think back five years ago, would you imagine that the stigmatization of nicotine use would be so much worse five years later?
Jean-François Etter 0:25:11
It's getting worse and worse, so I'm rather optimistic, but it's terrible and it's not getting better. But also there's hope in the sense that this field, the market and the manufacturers are so innovative. It's incredible how innovative they are.
A few years ago, I visited e-cigarette factories in Shenzhen, near Hong Kong, in the special economic zone, where everything that we use, our clothes, everything is made there. It's an incredibly large area, kilometers and kilometers of factories. It's absolutely amazing to see that, the power, the industrial power of China.
And after driving for more than two hours along factories and factories and factories, we arrived at the e-cigarette factories that we wanted to visit. And I was surprised by how young the managers, the CEOs were. There are people in their 30s, and we told them, well, in Europe, managers of Factwave would be at least in their 50s.
But they said, well, if we waited for people in their 50s to do something, then we would have done nothing. Innovators are young people. You have young people, very competitive. They compete with each other. And you have also capital riskers, people who are ready to risk capital. And the authorities behind that are also very reactive.
We were told that if they have a plan to build a factory, between the moment when they start and the moment when the factory is producing, that's one year. Imagine that in Europe, you would need many years. So it's a whole system and it's this strong competition between young people that explains why the field is so innovative.
So perhaps the change is going to come from the market itself, from the innovation, from the technology. So there's hope on this side, I think. We are going to see more innovations. Now it's the nicotine pouches, every few years you have new things that appear.
There is such a huge market for nicotine, such a strong demand and such competition between providers that more innovation will come and change will come from this side. And perhaps all these anti-tobacco harm reduction people will just be made obsolete by technological innovations. They're not going to change their mind, but maybe they will become obsolete themselves.
Brent Stafford 0:28:09
Well, the famous writer on science and innovation, Thomas Kuhn, made that point back in the 1950s, is that you might not be able to get the change, you just have to wait for the people to die off.
Jean-François Etter 0:28:23
Exactly, exactly. I don't know if it's going to be a scientific revolution in the Kuhnian sense, but it's an industrial revolution, I think, in this narrow field of nicotine and tobacco harm reduction.