Nature Health commentary urges harm-reduction shift on tobacco. Maldives policy points the other way.

A new commentary in Nature Health, published on 20 April 2026, argues that wider access to regulated smoke-free nicotine products, including vapes and heated tobacco, could accelerate the end of the global smoking epidemic. The proposal contrasts directly with the Maldives' current policy of full prohibition.

The piece, by Robert Beaglehole and Ruth Bonita of the University of Auckland and Tikki Pang of the Center for Healthcare Policy and Reform Studies in Jakarta, proposes a global "smoke-free 2040" goal of reducing adult daily smoking prevalence to below 5 percent by 2040. The authors argue that tobacco harm reduction should be formally integrated into the World Health Organization Framework Convention on Tobacco Control. The full article is available at the Nature Health website.

The commentary is a perspective piece by three named researchers, not WHO policy. The WHO continues to advise caution on e-cigarettes and has welcomed the Maldives' vape ban and generational tobacco prohibition.

Core argument

The authors state that combustion, not nicotine itself, is the primary driver of tobacco-related disease. They argue that smoke-free products such as e-cigarettes, heated tobacco products, nicotine pouches, and Swedish-style snus expose users to far lower levels of toxicants than cigarettes. They cite Sweden, where snus use is associated with lung cancer rates less than half the European Union average, Japan, where heated tobacco introduction in 2016 was followed by sharp declines in cigarette sales; and New Zealand, where smoking prevalence decline accelerated after 2018 alongside expanded access to regulated vaping.

The authors note that global smoking prevalence is around 16 percent of the population aged 15 and over and is projected to fall to about 10 percent by 2040 on current trajectories. A drop below 5 percent would require a sharper acceleration, similar to what New Zealand has recorded.

Youth and uncertainty

The commentary addresses three common objections. On the "gateway" concern that vaping leads young people to smoking, the authors say many studies are confounded by shared risk factors and that youth smoking has continued to fall in countries where vaping has become more common. They cite New Zealand youth smoking at around 1 percent. On long-term health uncertainty, they call for continued surveillance but argue the absence of combustion makes smoke-free products intrinsically less hazardous than cigarettes. On dual use, they cite biomarker studies showing lower toxicant exposure compared with exclusive smokers.

Regulation and tax

The authors call for risk-proportionate regulation. Combustible tobacco would face the strongest restrictions and highest excise taxes. Smoke-free alternatives would be regulated for safety, with youth marketing restrictions, but at lower fiscal burden to preserve their capacity to displace smoking. They specifically address low- and middle-income countries, arguing that risk-proportionate taxation can maintain government revenue while incentivising switching.

Maldives context

The Maldives has moved firmly in the opposite direction. President Mohamed Muizzu's government banned the import, sale, possession and use of e-cigarettes from 15 December 2024. The 19th Amendment to the Export-Import Act imposed a 200 percent import duty on tobacco, e-cigarettes, vaping devices and heated tobacco products. From 1 November 2025, tobacco sales to anyone born on or after 1 January 2007 became illegal, including for tourists.

The Maldives NCD Alliance has linked 84 percent of deaths in the country to non-communicable diseases. The 2019 Global Youth Tobacco Survey found that 23.1 percent of Maldivian boys and 10.7 percent of girls aged 13 to 15 had used e-cigarettes, a finding cited by health authorities in support of the ban.

Open questions

The Nature Health commentary draws attention to New Zealand's 2022 smoke-free generation law, similar in concept to the Maldives' generational ban, which was repealed by a subsequent government before implementation. The authors say the New Zealand experience suggests that well-regulated smoke-free alternatives can reduce the need for more coercive measures while controlling illicit trade.

The Maldivian government has not indicated any intent to revisit its prohibition. The Ministry of Health continues to frame the country's tobacco strategy as a public health commitment.

The harm-reduction debate, supported by the Nature Health commentary and reflected in Bangladesh's recent decision to lift its vape ban, remains unresolved internationally. The Maldives' position remains aligned with the WHO's stated position.

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