For generations, smoking has occupied a peculiar space in society: widely known to be harmful, yet broadly tolerated. Young people grow up seeing family members and friends smoke, making it seem like a normal part of life.
Despite years of government and civil society efforts, more than 15 million adults in Pakistan still smoke, suggesting the current approach has not solved the problem. This is not only a concern for the smoker. Passive smokers – family members, coworkers and children who breathe in secondhand smoke – are exposed to many of the same harms without ever choosing to light a cigarette themselves.
This begs the question: are smokers stubborn or is the approach simply not working? When we ask someone to move away from smoking, we are often asking them to give up a version of themselves. That is a significant ask, and we have not treated it with the seriousness it deserves. If we really want to move towards a smokeless society, we don’t just have to address cigarette dependence; we have to address how smokers themselves view it.
As a cardiologist, I have spent years sitting with people who smoke. What strikes me, consistently, is not a lack of awareness. Everyone knows smoking is harmful. What I see instead is something more uncomfortable to confront: a behaviour that society simultaneously condemns and enables, that medicine labels a disease but often treats like a moral failure, and that public health campaigns address with the blunt instrument of fear while offering very little as a solution.
I will admit that I was, for some years, a stubborn person myself. I refused to perform cardiac procedures on patients who would not stop smoking. It took time for me to mature enough to realise that I was protecting my own ego rather than caring for the patient in front of me, because giving up cigarettes is probably one of the hardest things a person can do. I have become more considerate since, though I have never stopped reminding my patients, every time they come in, about the harm that smoking does.
Smoking persists not because people are reckless, but because it fulfils needs, whether stress relief, social belonging or simply a structured pause in a chaotic day. For many smokers, nicotine offers a quick sense of relief, while smoking itself becomes a familiar routine. It is difficult to expect someone to give all of that up without offering a realistic alternative.
So when we tell smokers to walk away from their next cigarette, without equipping them with adequate resources, we are essentially pushing them further into the habit. Nicotine replacement therapies such as patches and chewing gum have helped some people along the way, but they have failed to help the majority quit altogether. In those who have failed to stop smoking despite these known methods, we owe them a more honest conversation about what actually causes the most harm.
The primary driver is not nicotine alone. It is combustion. Scientific evidence consistently shows that the overwhelming majority of smoking-related disease is linked to the toxic chemicals produced during combustion rather than nicotine itself.
This is not to say nicotine is without risk. While it is not the major driver of smoking-related disease, it still has physiological effects, including on heart rate and blood pressure. Tobacco in any form, whether smoked, chewed or otherwise consumed, carries risk for cardiovascular health. This should not be interpreted as suggesting that smokeless tobacco or other nicotine products are risk-free, or that they should replace quitting altogether. All forms of tobacco use should be condemned.
When tobacco burns, it releases toxic chemicals including carbon monoxide, tar and formaldehyde that are responsible for most smoking-related disease, including lung cancer, COPD and cardiovascular disease. These same chemicals are what passive smokers inhale secondhand, which is why reducing combustion matters not just for the smoker but for everyone around them. The harm comes from combustion.
This distinction changes how we approach smoking. For people who cannot quit immediately, the answer may be a gradual move away from combustible tobacco, supported by nicotine replacement therapies, non-combustible alternatives and behavioural support. These approaches acknowledge where people are, rather than where we wish they were. The response should focus on reducing exposure to combustion while supporting smokers realistically. Every step away from burned tobacco reduces harm, and that progress matters.
The body, after all, begins to recover almost immediately when combustion stops. It means the harm is not fixed, the trajectory can change and progress, even if it’s partial, matters.
Sometimes, when you cannot win outright, you have to settle for the lesser evil. I am not trying to promote tobacco or nicotine use of any kind. I am trying to persuade the smokers who cannot, or will not, give up cigarettes today to move towards options that cause less harm than what they are doing now. That is not surrender. It is meeting people where they are, so that fewer of them pay for this habit with their health.
The writer is a renowned cardiologist with over 40 years of experience. He is currently practising at the National Medical Centre, Karachi.
