Cross-cutting barriers

Beyond structural and regulatory challenges, several cross-cutting barriers continue to limit the acceptance and implementation of tobacco harm reduction (THR) in low- and middle-income countries (LMICs). Misinformation, stigma, moral framing, and political resistance create an environment in which evidence-based discussion of safer nicotine products (SNPs) is difficult and often polarised [^1].

Misinformation is one of the most pervasive obstacles. In many LMICs, both the public and health professionals encounter conflicting or inaccurate claims about SNPs. Messages that equate vaping or nicotine use with smoking, or that conflate all nicotine products with tobacco, are common. Limited access to independent research and the influence of narratives imported from other settings reinforce confusion about relative risk. This misunderstanding discourages people who smoke from switching to less harmful alternatives and undermines confidence in emerging THR evidence.

Stigma also plays a powerful role. Nicotine use, particularly among women, young people, or health professionals, is often viewed as socially unacceptable. In contexts where smoking is already stigmatised, using alternative nicotine products can attract equal or greater disapproval, even when the aim is harm reduction. This discourages open conversation and prevents individuals from seeking accurate information.

Moral framing compounds these barriers by presenting nicotine abstinence as the only acceptable goal. Under this view, continued nicotine use, regardless of reduced harm, is interpreted as a lack of willpower rather than a legitimate public health strategy. This shifts the focus from health outcomes to moral judgement, narrowing the policy space for more pragmatic approaches.

Political resistance further constrains progress. Policymakers in many LMICs are wary of appearing soft on nicotine or of being perceived as sympathetic to industry interests. This often leads to highly restrictive or symbolic policies intended to demonstrate strong tobacco control, even when they unintentionally preserve cigarette dominance. Without informed political leadership, THR remains sidelined in national agendas.

These cross-cutting barriers, rooted in misinformation, stigma, moralism, and political caution, reinforce one another and sustain the status quo.