What the Evidence Says Amid Growing Global Consensus on Reduced-Risk Alternatives

A UK-based advocacy group, Action on Smoking and Health (ASH), in collaboration with several British universities, has conducted a review of the current evidence on the health effects of nicotine. Their overall conclusion is that nicotine is addictive but carries few direct health risks on its own. It's used in FDA regulated products that don’t contain tobacco, such as nicotine pouches and e-cigarettes, as well as nicotine replacement therapy (NRT) products. However, none of these products should be used by people who do not already consume tobacco or nicotine.

The review of current scientific evidence on nicotine's health effects confirms several well-established facts as well as some more recent findings, including:

• Nicotine triggers the release of dopamine, reinforcing repeated use.
• Cigarettes are deadly due to the carcinogenic substances released when a cigarette is burned and inhaled.
• Nicotine use, on its own, poses relatively little health risk compared to continued smoking.
• Nicotine e-cigarettes are recommended as a smoking cessation aid by two different UK government health authorities: the National Institute for Health and Care Excellence (NICE) and the National Health Service (NHS). In coming to this recommendation both agencies have relied on clinical trials and real-world evidence to demonstrate effectiveness.
• Cigarettes are the most researched consumer good in history; as a result, most of the scientific evidence on nicotine to date is linked to smoking itself. The evidence on the effects of nicotine in isolation from smoking to date indicate that its potential effects include:
  • Stress and difficulty concentrating due to nicotine dependence;
  • Temporary increases in heart rate and systolic blood pressure;
  • At very high doses, nicotine can be toxic and cause symptoms such as dizziness, nausea, and vomiting;
  • Perhaps the most notable conclusion in the ASH report is that nicotine does not cause cancer.

This thorough review reflects a growing global consensus on reduced-risk nicotine products: while nicotine is addictive, the science consistently shows that non-combustible alternatives are far less harmful than smoking and can play a critical role in helping smokers switch. It shows how nicotine alternatives like vapes and nicotine pouches can contribute to a better health for the population relative to continued smoking.

Laura Leigh Oyler

Vice President of Regulatory Affairs

The conclusions from UK public health bodies are highly relevant to American consumers, where millions of adults still smoke and could benefit from access to lower-risk alternatives. 

While the U.S. Food and Drug Administration (FDA) has acknowledged that certain non-combustible nicotine products can be “appropriate for the protection of public health” when authorized, the broader media discourse has often focused more heavily on youth use and potential risks than on relative risk for adult smokers. 

In contrast, the UK’s approach places greater emphasis on harm reduction—recognizing that switching from smoking to alternative nicotine products can substantially reduce health risks. This difference highlights a growing divide between regulatory communication and media narratives, and the clearer articulation of relative risk in the UK assessment may help inform a more balanced public understanding also in the U.S.

Nicotine is the primary addictive pharmacological component of tobacco smoke. It acts on nicotinic acetylcholine receptors in the brain (and elsewhere in the body), triggering the release of dopamine and other neurotransmitters, thereby reinforcing repeated use.

Most adults who use nicotine in the U.S. first became addicted through smoking cigarettes. The need to relieve nicotine withdrawal symptoms (cravings) is the main driver of continued smoking, and these symptoms are what make quitting difficult. However, nicotine is not what makes smoking so deadly—it is the thousands of carcinogenic and toxic chemicals released in the form of tobacco smoke when a cigarette is burned.

A recent review by the Royal College of Physicians (RCP) states that “nicotine itself poses little risk to health” compared to smoking, although “acute exposure can result in addiction as well as short-term increases in heart rate and systolic blood pressure.”

Nicotine-containing products can help people quit smoking and manage cravings without exposing them to most of the harm associated with tobacco. In the U.S., FDA-approved nicotine replacement therapy (NRT)—such as patches, gum, and inhalers—is a first-line treatment widely used to support smoking cessation. NRT is approved for use during pregnancy, for individuals with cardiovascular disease, and for children aged 12 and older. NRT is so safe and effective, it is often sold over the counter in pharmacies.

Though no manufacturer has sought approval for an e-cigarette as a NRT with the U.S. FDA, they  are recommended as a smoking cessation aid by the UK health authorities NICE and the NHS. Both clinical and real-world evidence support their effectiveness. A Cochrane systematic review found that people who use nicotine e-cigarettes are nearly twice as likely to successfully quit smoking compared to those using NRT. While vaping is not risk-free, it is significantly less harmful than smoking. 

This review summarizes the current evidence on the health effects of nicotine and outlines key implications for policymaking. It was produced by ASH, with contributions from professors at King’s College London, University College London, Imperial College London, the Royal College of Physicians Tobacco Advisory Group, and the University of Dundee, as well as researchers from the University of Bath and the National Centre for Smoking Cessation and Training.

Action on Smoking and Health (ASH) is an independent public health charity established by the Royal College of Physicians to end the harm caused by tobacco.