The Woolcock Institute of Medical Research

For more than four decades, Professor Renee Bittoun has treated people addicted to nicotine. And she has a simple message for health professionals: the problem is nicotine, not simply the product that delivers it.

That was the message Bittoun took to two medical conferences last weekend.

On Friday, 7 August, she addressed the DANA (Drug and Alcohol Nurses Association) National Conference in Wollongong, where she urged nurses to always ask about all forms of nicotine use because no form of nicotine is safe.

On Saturday, she was an invited speaker at the Cardiac Conference of Australasia, held in Darling Harbour, Sydney. Her presentation again focused on the distinction between nicotine and vaping, with the message that nicotine itself is not benign.

It is a distinction reflected in the work Bittoun does with patients in the Woolcock’s Smoking and Vaping Cessation Clinic — starting with objective testing of carbon monoxide and plasma nicotine levels to establish each patient’s true exposure and treating nicotine dependence with pharmacotherapy alongside behavioural strategies to break addiction.

That difference is increasingly important as the world grapples with a rapidly expanding range of products designed to deliver nicotine.

For decades, nicotine has largely been regulated indirectly — through the products that deliver it. Cigarettes have been regulated as tobacco products; vaping products have developed their own regulatory frameworks; nicotine replacement products such as patches and gum are treated as therapeutic products; and newer products such as nicotine pouches are regulated differently again, depending on where you live.

The result is a patchwork of rules around a single addictive drug.

Different countries impose different age limits, health warnings, marketing restrictions and product controls. Some classify vapes as tobacco products, others as consumer or medicinal products. Nicotine pouches sit in yet another regulatory space.

The question now being raised internationally is whether that approach has put too much emphasis on the delivery system — and not enough on nicotine itself.

It’s a question which has been given unexpected momentum by the Republic of Palau, a small Pacific nation that has asked the United Nations to consider adding nicotine to the international schedule of controlled psychotropic substances.

As Nature News reported in July, Palau argues that existing international efforts to reduce the harms associated with nicotine addiction focus primarily on tobacco, leaving loopholes for newer products such as vapes and nicotine pouches.

Palau’s proposal is significant because it turns the usual regulatory question on its head. Rather than asking how cigarettes, vapes or pouches should each be regulated, it asks whether the common ingredient — nicotine — should be subject to a consistent international framework.

The World Health Organization estimates that around 1.2 billion people use tobacco globally, while at least 100 million people use electronic cigarettes. Nicotine is highly addictive, and addiction is what drives continued use of products that deliver it.

Palau has already banned the import, sale and use of vapes, and is now seeking a broader international response.

The proposal does not mean nicotine is about to become illegal. It will first undergo a scientific and medical assessment by the WHO Expert Committee on Drug Dependence, which will consider its potential for abuse, harmful effects and medical usefulness. The UN’s 53 member states are then expected to vote on whether nicotine should be added to the schedule in March 2028.

Any international controls would also need to preserve legitimate medical uses of nicotine, including nicotine-replacement therapy used to help people quit.

Professor Bittoun told Nature News that she believes it is unlikely nicotine will ultimately be added to the UN schedule, given the strength of opposition that could be expected from the tobacco industry.

But the significance of Palau’s proposal is not necessarily whether it succeeds.

It is that the world is being asked to reconsider a question that has long been obscured by the products themselves: are we regulating cigarettes, vapes and nicotine pouches — or are we regulating nicotine?

For Professor Bittoun, the answer has always been clear.

Nicotine is the problem.

Find out more

• Our Smoking and Vaping Cessation Clinic
• Cessation Clinic patient information
• Professor Renee Bittoun