When nicotine is blamed for lung cancer: what a clinician survey in Eastern Europe and Central Asia reveals about evidence translation
In a fast‑moving scientific debate, the weakest link is often not the evidence itself, but how that evidence reaches the point of care. A new baseline survey of clinicians and other health professionals in three Eastern Europe and Central Asia (EECA) countries suggests that, when it comes to nicotine and alternative nicotine products, risk understanding may be drifting from the distinctions that underpin modern tobacco control.
Between September 2025 and March 2026, we collected 433 completed questionnaires from health professionals residing in Georgia (n=71), Kazakhstan (n=203), and Ukraine (n=159). This was a convenience sample, using a mixed online/offline approach, conducted as a first‑round, pre‑training measurement of knowledge and practice related to smoking cessation support.
The purpose was not to “grade” clinicians. It was to identify what clinicians currently believe and do, because those beliefs and routines shape what smokers hear in consultations.
A striking signal: nicotine is treated as the direct cause of smoking’s biggest killers
Respondents were asked whether they agree that nicotine directly causes several smoking‑related diseases. The results were remarkably consistent: 90.5% answered “Yes” for lung cancer and 91.5% answered “Yes” for chronic obstructive pulmonary disease (COPD).
That does not fit comfortably with the wider evidence on what drives smoking-related harm. The core public health distinction is that nicotine is the primary driver of dependence, whereas the major burden of cancer, COPD, and cardiovascular disease arises from repeated exposure to toxicants generated by burning tobacco [1-3]. This does not make nicotine harmless, and it does not eliminate risks associated with nicotine-containing products. But it does mean that treating nicotine itself as the direct cause of the major diseases of smoking obscures the central role of combustion.
If nicotine is framed as the direct cause of lung cancer and COPD, then any nicotine-containing substitute can be intuitively perceived as essentially the same as smoking, even if it avoids combustion.
Alternative nicotine products are rarely seen as lower risk and are rarely recommended
We also asked respondents to compare the harmfulness of several products with combustible cigarettes. For e-cigarettes, only 11.3% said they are less harmful than cigarettes. Most respondents rated them as equally harmful (37.4%) or more harmful (46.7%). For heated tobacco products (HTP), only 8.1% rated them as less harmful than cigarettes; 34.9% rated them as equally harmful and 46.4% as more harmful. Perceptions of nicotine pouches were somewhat less negative but still marked by considerable uncertainty: 14.3% rated them as less harmful than cigarettes, 29.6% as equally harmful, and 33.9% as more harmful, while 15.2% said they did not know and 6.9% had never heard of them.
These perceptions do not align with how the evidence base treats these products. Regulators and expert reviews do not regard all nicotine products as equivalent to cigarettes. Public health authorities note that non-combustible products avoid the same level of exposure to combustion-related toxicants, although they are not risk-free [4-6]. The latest Cochrane review likewise finds that nicotine e-cigarettes can support smoking cessation, with higher quit rates than nicotine replacement therapy in pooled trial evidence [7].
This seems to carry over into clinical advice. Only 4.2% reported usually recommending oral nicotine pouches as a way to quit smoking, while 3.9% and 2.5% reported usually recommending switching to e-cigarettes and HTP, respectively. By contrast, 26.8% recommended over-the-counter NRT, and much larger shares recommended more familiar approaches such as social or family support (40.9%), self-cessation or willpower-based methods (37.6%), and counselling (31.2%).
Overall, THR options remain peripheral in self-reported routine recommendations in this sample.
Cessation practice is “front‑loaded” and training appears to be a lever
A second, highly actionable finding is how cessation support is delivered in routine care. Over the past month, many respondents reported that they often or always asked if the patient smokes (51.5%) and advised quitting (54.7%). But far fewer reported often or always helping patients to quit (24.9%) or organising follow‑up (24.9%).
The findings suggest that training may be part of the problem, but also part of the solution. Among respondents who reported any smoking cessation support training, 45.7% reported often/always organising follow‑up, compared with 20.9% among those reporting no training. This association does not prove causality in a convenience sample, but it is consistent with a simple hypothesis: training helps clinicians move from brief advice to structured support. Clinical guidelines have long emphasized that effective tobacco dependence treatment goes beyond identifying smokers and advising them to quit; it also requires assistance, pharmacologic support where indicated, and follow-up over time [8,9].
A science-policy response: improve evidence translation, not blame
Across Europe, tobacco control increasingly sits at the intersection of medicine, regulation, and public communication. In that context, clinicians play a central role in how risk information reaches patients.
If clinicians (understandably, given limited time and competing priorities) carry an internal model in which “nicotine causes the major diseases of smoking,” then the conversation about THR is effectively closed before it begins. In such a framework, even clinically approved cessation pharmacotherapy and nicotine replacement therapy may be pushed off the table, not because they lack therapeutic value, but because they contain nicotine [4,8,10]. This risks two unintended consequences: first, smokers may receive less nuanced guidance about switching options when complete nicotine abstinence is not immediately achievable; second, clinicians may remain stuck in an ask-and-advise mode without the tools and confidence to support cessation over multiple visits.
The response should be practical rather than punitive: stronger pre-service and in-service training on smoking cessation, clearer communication on relative risk and uncertainty, and follow-up tools that make assist and arrange more feasible in routine care.
This survey is only a baseline snapshot, and it is not nationally representative. But it helps identify where training and communication can be improved. In smoking cessation, what clinicians understand and how they explain it to patients can shape which options patients see as realistic and achievable.
References
- National Cancer Institute. (2017, December 19). Harms of cigarette smoking and health benefits of quitting.
- Royal College of Physicians. (2019, October 28). Nicotine without Smoke: Tobacco Harm Reduction. London: RCP.
- National Academies of Sciences, Engineering, and Medicine. (2018). Public health consequences of e-cigarettes. Washington, DC: The National Academies Press. https://doi.org/10.17226/24952
- U.S. Food and Drug Administration. (2026, March 12). Nicotine is why tobacco products are addictive.
- NHS. (2025, October 10). Using e-cigarettes to stop smoking. NHS.
- Health New Zealand. (2026, January 22). Vaping. Health New Zealand.
- Lindson, N., Butler, A. R., McRobbie, H., Bullen, C., Hajek, P., Wu, A. D., Begh, R., Theodoulou, A., Notley, C., Rigotti, N. A., Turner, T., Livingstone-Banks, J., Morris, T., & Hartmann-Boyce, J. (2025). Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, 2025(1), CD010216. https://doi.org/10.1002/14651858.CD010216.pub9
- World Health Organization. (2024, July 2). WHO clinical treatment guideline for tobacco cessation in adults. Geneva: WHO.
- National Institute for Health and Care Excellence. (2025, February 4). Tobacco: Preventing uptake, promoting quitting and treating dependence (NICE Guideline NG209). London: NICE.
- Hartmann-Boyce, J., Chepkin, S. C., Ye, W., Bullen, C., & Lancaster, T. (2018). Nicotine replacement therapy versus control for smoking cessation. Cochrane Database of Systematic Reviews, 2018(5), CD000146. https://doi.org/10.1002/14651858.CD000146.pub5
Funding disclosure
This study was funded within a grant from Global Action to End Smoking (formerly known as the Foundation for a Smoke-Free World), an independent U.S. nonprofit 501(c)(3) grantmaking organization. The funder had no role in the conception, design, implementation, data analysis, interpretation of the study results, or preparation of this article.
Giorgi Mzhavanadze, MA in Economics
Affiliation 1: Healthy Initiatives (GO Zdorovi Iniciativi), 36 Rustaveli Street, Kyiv 01033, Ukraine
Affiliation 2: Knowledge-Action-Change, 8 Northumberland Avenue, London WC2N 5BY, United Kingdom
ORCID: 0000-0002-0336-311X
Email: g.mzhavanadze91@gmail.com
Giorgi Mzhavanadze works as an independent consultant on various research projects undertaken by multiple research institutions and NGOs. At the time this research was conducted, the author had a service agreement with the Ukraine-based NGO Healthy Initiatives. Healthy Initiatives is a non-profit organization aimed at promoting and strengthening public health and well-being, tackling the most urgent questions in need of an answer. The organization supports and implements projects in Eastern Europe and Central Asia to address the growing risks of non-communicable diseases.
In parallel, the author has service agreement with Knowledge-Action-Change (KAC), a UK-based private organization that focuses on harm reduction as a key public health strategy.
This study was conducted as part of the authors’ collaboration with Healthy Initiatives.