Study Reveals Widespread Confusion Over Nicotine and Smoking-Related Diseases
A large international survey has found substantial confusion among doctors in India about the health effects of nicotine, with 88% of surveyed physicians saying they believed nicotine by itself directly causes lung cancer.
The survey was conducted by physician research network Sermo and included 15,335 licensed doctors across 11 countries. In India alone, 2,383 physicians participated.
The India-specific findings showed that 87% of respondents believed nicotine itself directly causes atherosclerosis, while 86% linked it directly to chronic obstructive pulmonary disease, or COPD.
Other results showed that 78% believed nicotine directly causes head, neck or gastric cancers, 75% associated it directly with birth defects and 71% linked it directly to bladder cancer.
However, the figures require an important clarification.
The survey was conducted in 2022, rather than being a newly conducted 2026 study. Its findings have continued to circulate in reports and discussions about tobacco harm and doctors’ knowledge of nicotine.
Nicotine Is Addictive, but Smoking’s Risks Go Far Beyond Nicotine
The findings highlight an important distinction between nicotine itself and cigarette smoking.
Nicotine is the substance primarily responsible for tobacco dependence. It is highly addictive and is not harmless.
It can increase heart rate and blood pressure, constrict blood vessels and pose particular risks to children, adolescents, pregnant women and developing fetuses.
However, the enormous burden of cancer and chronic lung disease caused by smoking cannot simply be attributed to nicotine alone.
Cigarette smoke contains more than 7,000 chemicals, including dozens known to cause cancer. The US Centers for Disease Control and Prevention identifies cigarette smoking as the leading risk factor for lung cancer and a major cause of COPD and cardiovascular disease.
The International Agency for Research on Cancer similarly identifies substances such as tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, aromatic amines and other compounds in tobacco smoke as major carcinogenic agents.
This distinction can also be seen in nicotine-replacement medicines used to help smokers quit.
The CDC says approved nicotine-replacement therapies are substantially safer than continued cigarette smoking and that most of smoking’s deadly effects come from toxic chemicals in cigarette smoke rather than nicotine itself.
That does not mean nicotine products are harmless. WHO continues to warn that nicotine is addictive and harmful and that electronic cigarettes and other nicotine products should not be considered safe, particularly for young people and non-users.
India Among Countries With Highest Misperceptions in Survey
The misunderstanding was not limited to India.
The survey found large differences between countries when physicians were asked whether nicotine itself directly causes lung cancer.
Indonesia recorded the highest figure at 97%, followed by China at 91%.
India and Japan were both at 88%, while South Africa stood at 82% and Germany at 77%.
The figure was 69% in Israel, 67% in Italy and the United States, 65% in Greece and 60% in the United Kingdom.
Across the entire survey, misconceptions also extended beyond cancer.
The findings suggested that many physicians struggled to separate the effects of nicotine dependence from the consequences of inhaling toxic products created by tobacco combustion.
Interestingly, the India report found that 84% of participating physicians also agreed that most smoking-related harm in adults comes from combustion rather than nicotine itself.
That apparently contradictory result suggests many doctors understood that burning tobacco produces major health risks while still attributing individual smoking-related diseases directly to nicotine.
More Than 15,000 Doctors Surveyed Across 11 Countries
Sermo conducted the quantitative research between February and June 2022.
The study covered China, Germany, Greece, India, Indonesia, Israel, Italy, Japan, South Africa, the United Kingdom and the United States.
Participants were required to be licensed, full-time physicians with at least two years of professional experience.
They also had to spend at least half of their working time providing direct patient care and see at least 20 adult patients each month.
Specialties represented in the survey included family and general practice, internal medicine, cardiology, pulmonology, oncology and psychiatry.
Doctors were asked how strongly they agreed with statements saying that “nicotine by itself directly causes” different smoking-related medical conditions.
The reported percentages combined responses ranging from “moderately agree” through “completely agree.”
That wording is relevant because the survey was measuring physicians’ perceptions of nicotine as a direct cause, rather than asking whether nicotine can have any harmful biological or cardiovascular effects.
Survey Funding Also Requires Context
The survey was funded through a grant from what is now called Global Action to End Smoking, formerly the Foundation for a Smoke-Free World.
The organisation states that it no longer accepts money from companies producing tobacco or non-medicinal nicotine products and says its last charitable funding from PMI Global Services was received through September 2023.
However, at the time the Sermo survey was conducted in 2022, the organisation was receiving funding from Philip Morris International.
WHO has publicly criticised the organisation’s historical relationship with the tobacco company and has advised governments and the public-health community against partnering with it.
That funding history is an important consideration when interpreting research focused on tobacco harm reduction and perceptions of nicotine.
At the same time, the basic distinction between nicotine dependence and the carcinogenic chemicals produced by smoking is supported by major public-health authorities.
WHO identifies tobacco as a leading preventable cause of cancer, while the CDC says smoking causes cancer, cardiovascular disease and COPD and stresses that nicotine itself is primarily responsible for addiction rather than all of smoking’s health damage.
The survey therefore raises a broader public-health concern: physicians need accurate information about both the serious risks of nicotine and the substantially different risks associated with combustible tobacco.
Accurate understanding can be particularly important when doctors counsel smokers about quitting, nicotine-replacement therapy and avoiding continued exposure to cigarette smoke.
