The Communication Paradox: Why Telling Smokers the Truth About Relative Risk Is So Hard

In 2015, Public Health England released its landmark review concluding that e-cigarettes are 'around 95% less harmful' than smoking. The 95% figure—derived from a multi-criteria decision analysis that assessed the relative harm of different nicotine products across fourteen dimensions—was intended to be a communication tool: a simple, memorable way to convey the vast difference in risk between smoking and vaping. Seven years later, in 2022, the same agency published an updated review that reaffirmed the central finding while acknowledging that the 95% figure had generated controversy. The controversy was not about the science. It was about the communication—and it revealed a paradox at the heart of public health messaging that no agency has fully resolved.

The paradox is this: for fifty years, public health communication about tobacco has been built on a binary. Smoking is deadly. There is no safe form of tobacco. The only safe choice is to never start and, if you have started, to quit completely. This binary message is simple, powerful, and—at the level of the individual smoker's behavior—almost entirely true. The problem is that it leaves no room for gradations of risk. If 'there is no safe tobacco product,' how do you communicate that vaping is 95% less harmful without undermining the absolute prohibition that has been the foundation of tobacco control messaging? The agencies that have tried—Public Health England, the Royal College of Physicians, the New Zealand Ministry of Health—have faced sustained criticism from advocacy groups that view any comparative risk messaging as a concession to the industry. The agencies that have avoided it—the US CDC, the WHO, much of the EU public health apparatus—have presided over populations where a majority of smokers incorrectly believe that vaping is as harmful as or more harmful than smoking.

The evidence on risk misperception is alarming. In the US, the proportion of adults who believe e-cigarettes are 'less harmful' than cigarettes fell from around 40% in 2012 to below 20% by 2020—exactly the period during which the scientific consensus on relative risk was strengthening. The misperception is not random. It's concentrated among smokers, the very population that would benefit most from accurate risk information. The mechanism is straightforward: the 'there is no safe tobacco product' message, amplified by media coverage that emphasizes the risks of vaping without comparative context, has persuaded smokers that switching from cigarettes to vaping is not a harm reduction measure but a lateral move—trading one dangerous product for another. The public health communication intended to protect never-smokers from initiating nicotine use has, as a side effect, discouraged smokers from switching to dramatically less harmful products.

The ethical framework for resolving this paradox is deceptively simple: smokers have a right to accurate information about the relative risks of the products available to them. This right is grounded in the principle of informed consent—the same principle that requires physicians to disclose treatment alternatives and their associated risks. If a smoker is trying to quit and failing, and a safer nicotine product could reduce their risk of premature death by 95% or more, withholding that information—or communicating it in a way that systematically understates the risk differential—is a violation of the ethical obligations that public health agencies claim to uphold. The fact that this argument is controversial within public health circles says more about the institutional dynamics of tobacco control than about the ethics.

What would honest comparative risk communication look like? It would look like the UK's annual Stoptober campaign, which explicitly features vaping as a quitting option alongside NRT. It would look like the Royal College of Physicians' 'Nicotine Without Smoke' report, which presents the evidence on relative risk in plain language without hedging or equivocation. It would look like the New Zealand Vaping Facts website, which states directly that 'vaping is much less harmful than smoking.' These communications share three features: they acknowledge the remaining uncertainty about long-term effects (we have 15 years of data, not 50); they emphasize that the goal is to eliminate smoking, not to promote nicotine use among never-smokers; and they trust the public to understand nuance. The results, in terms of smoking prevalence declines, speak for themselves.

The communication paradox will not be resolved by better science. The evidence is already sufficient. It will be resolved—or not—by a decision about what public health communication is for. If its purpose is to protect the public from the most dangerous available products, then honest comparative risk communication is an obligation. If its purpose is to maintain the simplicity and political power of the anti-tobacco message, then honest comparative risk communication is a threat. The agencies that have chosen the first path are saving lives faster than the agencies that have chosen the second. The difference is measurable, and it's growing.

Shareable insight: Telling smokers that vaping is 'not safe' is true. Telling them it's 'as dangerous as smoking' is false. The difference between these two statements is the difference between information that saves lives and misinformation that costs them.