MALAYSIA spends billions of ringgit each year managing diseases linked to smoking, including lung cancer and cardiovascular diseases.
Beyond the human toll on families, the burden on the healthcare system and economy is substantial.
Health experts estimate that the government spends an average of RM16bil annually treating smoking-related diseases.
Meanwhile, broader non-communicable diseases (NCDs), many of which are linked to smoking, incur an even heavier impact: a World Health Organization report found that Malaysia incurs RM64.2bil in economic losses annually, including on healthcare spending and lost productivity.
Reducing this burden is therefore not only a medical challenge but an economic priority.
Thus, understanding the root cause of smoking-related harm is crucial to identify ways forward.
Smoking: a habit defined by combustion
When a cigarette is lit, the tobacco burns at temperatures approaching 800°C. This combustion process produces smoke containing more than 6,000 chemicals, of which at least 100 have been identified by global health authorities as known or potential contributors to smoking-related disease.
These combustion by-products, known as harmful and potentially harmful constituents (HPHC) form the root cause of the overwhelming majority of smoking related harm, according to PMI Science.
PMI Science's research shows that while nicotine is addictive and not without risks, it is not the primary cause of smoking-related diseases.
The overwhelming harmful impact comes from the HPHCs generated when tobacco is burned. In other words, it is the smoke, not the nicotine, that carries the largest health risk.
Nicotine and disease: separating perception from science
Public perception widely views nicotine as being inextricable from smoking related diseases. Yet, scientific evidence shows humans already ingest nicotine daily through common foods.
Vegetables in the nightshade family, including tomatoes, potatoes, eggplants and peppers naturally contain trace nicotine as part of plant defence mechanisms. Studies indicate an average person consumes roughly 1,400 nanograms daily from diet alone, without any smoking-related health effects.
While this is negligible and does not produce the effects associated with smoking, the data underscores an important point for regulators and the public – nicotine itself is not unique to tobacco products, nor is it the main driver of smoking-related disease.
This does not mean nicotine is harmless. It is addictive and not risk-free.
However, scientific consensus increasingly distinguishes addiction from disease causation. Understanding this distinction is central to global public-health discussions.
Reducing harm: the role of smoke-free alternatives
Public-health experts are unequivocal in their conclusion that completely quitting smoking cigarettes remains the best choice for health.
However, for adults who would otherwise continue smoking, harm-reduction strategies are increasingly part of policy discourse worldwide.
Smoke-free products are designed to deliver nicotine without burning tobacco.
These include heated tobacco products and other non-combustible alternatives that avoid combustion and therefore significantly reduce the formation of harmful chemicals associated with smoke.
Recent peer-reviewed research is adding weight to the harm-reduction discussion.
A 2025 cross-sectional study of nearly 1,000 healthy adults compared three groups: current cigarette smokers, people who had switched completely to a heated tobacco product for at least two years and former smokers who had quit all tobacco and nicotine products.
Researchers measured nine biomarkers of potential harm linked to major smoking-related diseases, including indicators of oxygen delivery, carcinogenic exposure, inflammation, oxidative stress, lipid metabolism, endothelial function, platelet activation and lung function.
The findings were striking. Across all nine biomarkers, long-term heated tobacco users showed significantly more favourable levels than current smokers, and in many cases results were similar to those of former smokers.
Notably, nicotine exposure in heated tobacco users was similar to that of smokers, which suggests that the observed differences were driven by the absence of combustion, not by changes in nicotine intake.
The findings support the view that removing combustion, rather than nicotine, is key to reducing exposure to harmful substances.
A public health and economic opportunity
Malaysia’s challenge is clear: smoking-related diseases place heavy strain on healthcare capacity, workforce productivity and national expenditure.
Reducing this burden requires a multi-pronged approach, which includes:
- Preventing new uptake
- Supporting cessation
- Regulating products effectively
- Providing accurate scientific information
Within this framework, smoke-free alternatives may play a role for adult smokers unable or unwilling to quit immediately.
By lowering exposure to toxic combustion chemicals, they could help reduce disease risk and the long-term public health burden.
Science continues to evolve, but one principle is becoming clearer: the greatest harm from smoking comes from burning tobacco, not the nicotine.
Understanding that distinction and using it as a guiding framework may be key to improving long-term public health outcomes while easing Malaysia’s economic burden from smoking-related disease.
