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KUCHING: Ask the average Malaysian what causes smoking-related diseases and the answer will almost certainly be nicotine.
This is a belief that has been repeated so frequently through decades of anti-smoking campaigns, public health messaging and everyday conversations that many people have come to accept it as an unquestionable fact, even though a growing body of scientific evidence suggests that the reality is considerably more complex than that.
While there is little disagreement that smoking remains one of the leading preventable causes of disease and premature death worldwide, researchers increasingly distinguish between nicotine itself and the harmful substances produced when tobacco is burned, arguing that a clearer understanding of this distinction is necessary if adult smokers are to make informed decisions about their health.
This concept, often referred to as risk literacy, has become increasingly relevant as traditional cigarettes now exist alongside a growing range of alternatives, including heated tobacco products, e-cigarettes and vaping devices, all of which deliver nicotine in different ways and carry different risk profiles.
The issue is not whether smoking is harmful but whether all nicotine-containing products carry the same level of risk and whether consumers are receiving sufficient information to understand the differences between them.
As Malaysia continues to regulate tobacco and nicotine products under an evolving public health framework, understanding these distinctions may become increasingly important not only for smokers considering their options but also for policymakers, healthcare professionals and the broader public.
Understanding the role of combustion
To understand why scientists increasingly differentiate between cigarettes and smoke-free alternatives, it is first necessary to understand what happens when a cigarette is lit.
According to PMI Science, when a smoker ignites a conventional cigarette, the burning tip can reach temperatures exceeding 800 degrees Celsius, triggering a process known as combustion in which tobacco is broken down through intense heat, producing smoke that contains thousands of chemicals generated by complex chemical reactions occurring during the burning process.
Many of these chemicals have been identified by health authorities around the world as toxic or potentially toxic, while dozens have been directly linked to cancers, cardiovascular disease, respiratory illnesses and a wide range of other smoking-related conditions that continue to place a significant burden on healthcare systems globally.
For decades, scientific research has consistently shown that the overwhelming majority of smoking-related diseases are associated with repeated exposure to these toxic substances found in cigarette smoke, rather than the nicotine that smokers seek when they light a cigarette.
This distinction is central to the growing scientific focus on combustion, with researchers increasingly examining whether eliminating or reducing the burning process can significantly reduce exposure to the harmful chemicals that have long been associated with smoking-related disease.
According to Philip Morris International (PMI), which has invested heavily in the development and research of smoke-free alternatives over the past decade, the primary cause of smoking-related diseases is the inhalation of harmful chemicals produced during tobacco combustion, rather than nicotine itself.
PMI Science, the company’s scientific research platform, states that its smoke-free products are designed to either eliminate combustion entirely or substantially reduce the formation of harmful chemicals by avoiding the burning process that occurs in conventional cigarettes.
While such findings originate from industry-funded research and should therefore be considered alongside independent scientific evidence, they nevertheless reflect an increasingly accepted understanding within the broader scientific community that combustion is the principal source of many smoking-related toxicants.
The nicotine misconception
Few substances have become as misunderstood in public discourse as nicotine, largely because it has been inseparable from cigarettes for more than a century and is therefore often blamed for virtually every disease associated with smoking.
The reality, however, is that nicotine and smoking-related disease are not the same thing.
Nicotine is the naturally occurring compound in tobacco that creates dependence, which explains why many smokers find it difficult to quit despite being fully aware of the health risks associated with smoking, but addiction and disease causation are separate scientific questions that are frequently conflated in public discussions.
Health experts acknowledge that nicotine is not harmless.
It is addictive, can increase heart rate and blood pressure, and may negatively affect brain development among adolescents and young people, which is why health authorities consistently stress that nicotine products should not be used by minors, pregnant women or individuals who do not already use nicotine.
However, researchers have long distinguished between the addictive properties of nicotine and the disease-causing effects of the toxic chemicals generated through combustion.
This distinction has become increasingly important because many smokers mistakenly believe that nicotine itself is responsible for cancers and respiratory diseases, when in reality those illnesses are primarily associated with long-term exposure to cigarette smoke and the numerous toxic compounds it contains.
A commonly cited phrase among tobacco harm reduction researchers is that people smoke for nicotine but die from the smoke, a statement that, while simplified, reflects the scientific distinction between addiction and the toxic effects of combustion.
A changing nicotine landscape
The nicotine marketplace of today looks vastly different from the one that existed even 15 years ago, with adult consumers now having access to a wide range of products that deliver nicotine without relying on the same combustion process used by conventional cigarettes.
Among the most widely discussed alternatives are heated tobacco products and electronic cigarettes, both of which operate differently from conventional cigarettes despite often being grouped together in public conversations.
Heated tobacco products contain processed tobacco that is heated to lower temperatures than those required for combustion, producing an aerosol containing nicotine without generating smoke in the traditional sense, while electronic cigarettes and vaping devices heat specially formulated liquids to create an inhalable aerosol commonly referred to as vapour.
Although these products differ significantly in their design and operation, they share one important characteristic: neither relies on the same high-temperature combustion process that occurs when a cigarette burns.
According to PMI Science, the absence of combustion results in substantially lower levels of many harmful chemicals compared to cigarette smoke, although the company emphasises that smoke-free products are not risk-free and contain nicotine, which remains addictive.
This distinction is important because discussions about tobacco harm reduction are not centred on whether smoke-free products are completely safe, but rather on whether eliminating combustion changes the overall level of risk compared to continued cigarette smoking.
What independent science says
The distinction between smoking and smoke-free alternatives is not confined to tobacco industry research, with numerous independent public health organisations also acknowledging that different nicotine products carry different levels of risk.
The United Kingdom’s National Health Service (NHS), for example, states that while vaping is not risk-free and is not recommended for non-smokers, current evidence indicates that it exposes users to significantly fewer harmful chemicals than conventional cigarette smoking.
Similarly, an extensive evidence review conducted by researchers from King’s College London for England’s Office for Health Improvement and Disparities found that biomarkers associated with exposure to harmful substances were substantially lower among individuals who exclusively used vaping products compared to those who continued smoking cigarettes.
Researchers involved in the review emphasised that long-term studies remain ongoing and that smoke-free products should not be viewed as harmless, but they nevertheless concluded that the available evidence consistently demonstrates significantly lower exposure to many toxic substances compared with smoking.
The same principle has emerged in studies examining heated tobacco products, where researchers have observed reductions in exposure to a range of harmful chemicals among smokers who completely switch away from combustible cigarettes.
However, public health experts are careful to stress that reduced exposure does not mean zero exposure, and that smoke-free alternatives continue to contain substances that may pose health risks, particularly with prolonged use.
The conversation, therefore, is not about safety versus danger but rather about understanding relative risk.
Why risk literacy matters
One of the greatest challenges in public health communication is helping people understand that risk rarely exists in absolute terms.
Most individuals naturally prefer simple categories, viewing products and behaviours as either safe or unsafe, good or bad, harmful or harmless, even though the reality is often far more nuanced.
The concept of risk literacy seeks to bridge this gap by helping individuals understand how different activities, products or behaviours compare in terms of risk, thereby enabling more informed decision-making.
For adult smokers, this distinction may be particularly important because inaccurate perceptions can influence behaviour in unintended ways.
A smoker who believes that cigarettes, heated tobacco products and vaping products all carry identical risks may see little reason to explore alternatives or seek additional information, whereas someone who understands the role of combustion may be better equipped to evaluate available options alongside healthcare advice and smoking cessation support.
Importantly, improving risk literacy does not mean encouraging nicotine use, nor does it mean undermining efforts to reduce smoking prevalence.
Rather, it means ensuring that adults have access to accurate, evidence-based information that enables them to understand the relative differences between products while continuing to recognise that complete cessation remains the most desirable outcome.
The Malaysian context
Malaysia’s tobacco control landscape continues to evolve through regulations aimed at balancing public health priorities, consumer awareness and youth protection, particularly following the implementation of the Control of Smoking Products for Public Health Act 2024.
At the same time, smoking remains a significant challenge.
According to the Global Adult Tobacco Survey (GATS) Malaysia 2023, approximately 4.8 million adults in the country currently smoke tobacco products, while nearly six in ten smokers report that they are considering quitting or planning to quit in the future.
The survey also found that around 1.4 million adults use electronic cigarettes, highlighting the growing presence of alternative nicotine products within the Malaysian market.
These figures suggest that millions of adults are making decisions related to smoking, quitting or alternative nicotine products, underscoring the importance of ensuring that those decisions are informed by accurate information rather than misconceptions.
Beyond black-and-white conversations
As the science surrounding nicotine products continues to evolve, many experts argue that public discussions must move beyond simplistic narratives that treat all products as identical, recognising instead that different products operate in different ways and expose users to different levels of risk.
None of this changes the fundamental public health message that quitting tobacco and nicotine use altogether remains the best option for health.
However, for adults who would otherwise continue smoking, understanding the distinction between nicotine, smoke and combustion may represent an important step towards making more informed choices.
Rick literacy is not about promoting any particular product.
It is about ensuring that adults have access to clear, accurate and science-based information so that decisions about smoking, nicotine use and cessation are guided by evidence rather than assumption.
In an increasingly complex nicotine landscape, that understanding may prove essential not only for individual decision-making but also for broader conversations about public health, regulation and the future of tobacco harm reduction in Malaysia.
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