In today’s society, discussion continues around tobacco and nicotine products, their regulation, and their impact on public health. MUDr. Kamila Zvolská, Ph.D., physician at the Tobacco Addiction Center of the 3rd Department of Internal Medicine, Endocrinology and Metabolism, First Faculty of Medicine, Charles University, offers a comprehensive perspective on this issue, covering both health aspects and questions of regulation and potential approaches to resolution.
Specifics of Tobacco Use in the Context of Addictive Substances
“One of the most striking differences between tobacco and other addictive substances is that tobacco use does not—or only minimally—disrupt behavior,” explains Zvolská. “Smokers function normally during the day; their social conduct is not noticeably impaired.” This characteristic is a key factor in shaping public policy, because unlike other substances, tobacco does not cause acute behavioral changes with immediate negative societal effects. The most widespread form of tobacco use remains smoking combustible tobacco.
“Another specific aspect of smoking is that when we take patients’ histories, we classify as smokers not only those who smoke daily but also those who smoke occasionally,” Zvolská points out, underscoring the complexity of the issue
Secondhand Smoke and Its Health Implications
Zvolská also addresses the issue of secondhand smoke, which research shows poses health risks—particularly regarding cardiovascular disease. “This was the very reason smoking was banned in public spaces and restaurants. The immediate effect was a drop in hospitalizations for acute coronary syndromes,” she notes.
Links with Other Addictive Substances
An interesting aspect is the relationship between tobacco use and other drugs. “Among users of illicit drugs, smoking prevalence is more than double that of the general population,” says Zvolská. “And for those who have successfully withdrawn from alcohol or illicit drugs, smoking increases the risk of relapse.” This finding suggests that a comprehensive approach to addiction treatment should also address tobacco use.
Current Approach to Tobacco Regulation
Zvolská reviews the state’s current tobacco-control strategy under the 2023–2025 action plan, which includes four main initiatives:
- Support for brief interventions by healthcare professionals
- Support for tobacco-dependence treatment
- Tax differentiation among various tobacco and nicotine products
- Analysis of measures to reduce the availability and appeal of tobacco products
She regards the first two initiatives as important but emphasizes that they focus on treatment rather than prevention. “They treat people who already use tobacco—who already smoke. It is treatment, not prevention,” she explains. Regarding protection from secondhand smoke, Zvolská notes inconsistencies in current measures: “We can ask why exceptions exist—for instance, allowing hookah use in restaurants or permitting e-cigarettes.”
Harm reduction Approach
The harm-reduction approach is increasingly discussed in tobacco policy. As the literature states, “the harm-reduction approach in addiction emphasizes minimizing the adverse health, social, and economic consequences of substance use, rather than eliminating use per se.” In tobacco, this principle is often summarized as “people smoke for nicotine, but health risks are primarily due to the tar in cigarette smoke.” Thus, tobacco harm reduction can be defined as a less harmful method of nicotine consumption—namely, reducing smoking and its health burden.
“We can recommend only electronic cigarettes as a harm-reduction tool, because they are the only alternative that has data showing they help people quit smoking,” Zvolská says. “Other alternative nicotine or tobacco products lack those data—and snus isn’t legally available here.”
However, the literature suggests a broader spectrum of options. Systematic reviews and meta-analyses show that heated-tobacco products contain 40–90 % fewer harmful substances than cigarette smoke. In randomized clinical trials, smokers who switched to heated-tobacco products for six months showed statistically significant reductions in both exposure biomarkers and effect biomarkers compared to continuing smokers.
Oral alternatives are generally considered less risky than smoked tobacco. This includes low-nitrosamine oral tobacco (snus), which yields exposure and effect biomarkers comparable to non-smokers—and even more so for nicotine pouches.
The Need for a Comprehensive Approach
Zvolská calls for a more integrated strategy for tobacco control: “It would be helpful to have a single, comprehensive document on tobacco control. Instead, the issue is fragmented into sub-items.” As an ambitious goal, she proposes defining in the next national plan “a reduction in smoking prevalence to below five percent—that is the endgame.” Such a target, she argues, would signal readiness to implement truly effective measures.
The literature indicates that a balanced approach is needed: one that both supports smokers’ transition from conventional cigarettes to alternatives and minimizes uptake among non-smokers—especially adolescents. Evidence shows that with appropriate regulation, alternative products serve as substitutes for smoking and divert both smokers and non-smokers away from cigarettes, rather than the reverse.
It is clear that a comprehensive response to tobacco issues requires balanced measures that respect public-health objectives and adult consumers’ right to informed choice. Crucially, these measures must be grounded in scientific evidence and aimed at the long-term goal of improving public health.