Daniel sent us this one — he's been watching the smoking data in Israel, where youth rates are ticking up despite the global trend heading down, and he's asking whether decades of hard-won public health knowledge have actually translated into lower rates everywhere, or if there are countries and demographics that are bucking the trend. It's a sharper question than it sounds.
It really is, because the headline number looks like a public health victory lap. The WHO's latest data shows global smoking prevalence dropped from twenty-two point seven percent in two thousand seven to seventeen percent in twenty twenty-three. That's roughly one point three billion smokers worldwide, down from one point four billion in two thousand, even with population growth.
Fewer smokers in absolute terms, not just proportionally. That's genuinely impressive.
It is, and it's driven mostly by high-income countries. The UK is down to twelve point nine percent as of twenty twenty-four. Australia hit ten point one percent. Canada's in the same neighborhood. These are places that threw the full toolkit at it — plain packaging, tax hikes, indoor smoking bans, graphic warnings, cessation programs.
Yet Daniel's looking around Israel and seeing something that doesn't match that victory narrative. What's the actual number here?
Israel's overall smoking rate is twenty point three percent as of twenty twenty-four, which is well above the OECD average of sixteen point five. But the really concerning piece is youth. The Israel Ministry of Health published data in twenty twenty-five showing that smoking among sixteen to eighteen year olds rose from eight point two percent in twenty twenty to nine point two percent in twenty twenty-five. That's about a twelve percent increase over five years, while the adult rate was flat to slightly declining.
You've got the global trend heading down, the adult trend in Israel heading down or flat, and youth heading up. That's the paradox Daniel's pointing at.
And it's not just Israel. Parts of Eastern Europe, several Middle Eastern countries, and specific demographics within otherwise declining countries are showing the same pattern. The global average hides enormous variation.
Let's start with the big picture then. What's actually driving the global decline, and why isn't it reaching everyone equally?
The decline is really a story of three mechanisms working together. The first is price — excise taxes make smoking economically punishing. The second is denormalization — when you can't smoke in bars, restaurants, workplaces, or public transport, the social convenience collapses. And the third is cessation support — nicotine replacement therapy, counseling, quitlines.
Those three things have been deployed very unevenly globally.
The WHO's Framework Convention on Tobacco Control, the FCTC, just had its twentieth anniversary last year, and while a hundred and eighty two countries are parties to it, implementation varies wildly. The WHO recommends that excise taxes account for at least seventy five percent of the retail price of cigarettes. In Israel, as of twenty twenty-four, it was around sixty percent. In some European countries it's above eighty percent. In parts of Southeast Asia and Africa, it's below thirty.
Israel did raise taxes recently, didn't they?
They did — a thirty percent tax hike on cigarettes in twenty twenty-four. And it did produce about a five percent drop in adult cigarette sales. But here's the kicker: it had virtually no effect on youth waterpipe use.
Because waterpipe tobacco is taxed differently?
It's taxed much lower, and more importantly, it's barely regulated in terms of age verification and point-of-sale restrictions. A sixteen year old in Tel Aviv or Jerusalem can walk into a nargila cafe and order a waterpipe with minimal hassle. The enforcement culture around age restrictions is, to put it generously, porous.
Price elasticity works on adults buying packs of cigarettes at the supermarket, but it doesn't touch the social smoking ecosystem that teenagers are actually navigating.
That's exactly the mechanism. And it's not just Israel. Waterpipe use is huge across the Middle East and North Africa. The World Bank's twenty twenty-four data showed that in Egypt, male smoking rates are still above fifty percent. In Lebanon, they're around forty percent. In Jordan, similar. These are countries where waterpipe is deeply culturally embedded, often perceived as less harmful than cigarettes — which is a dangerous misconception — and where the regulatory infrastructure for age enforcement is weak or nonexistent.
The perception gap is interesting. Everyone knows cigarettes are deadly. But waterpipe somehow escaped that branding.
A one-hour waterpipe session exposes the user to the smoke volume of roughly a hundred cigarettes. The World Health Organization has been saying this for years, but the message hasn't penetrated the way cigarette warnings have. And part of that is because waterpipe smoke is cooled through water, which creates the illusion that it's filtered and safer. It's not. It contains the same carcinogens, the same heavy metals, and in many cases higher levels of carbon monoxide.
Part of the Israel paradox is a product-specific knowledge gap. But you mentioned other demographics bucking the trend globally. What's happening with women in lower-income countries?
This is one of the most underreported stories in global health. Historically, smoking was overwhelmingly male in low and middle income countries — cultural norms discouraged women from smoking. That's changing rapidly as those norms shift and as the tobacco industry aggressively targets women with marketing. In Indonesia, female smoking prevalence rose from four point two percent in twenty ten to six point eight percent in twenty twenty-three. That's a sixty percent relative increase.
That's in a country with a huge population.
Indonesia has roughly two hundred and eighty million people. A two point six percentage point increase among women translates to millions of new smokers. The tobacco industry markets to women there with images of modernity, independence, weight control. The same playbook they used in the United States in the nineteen thirties and forties.
Virginia Slims and the whole "you've come a long way, baby" thing.
Just repackaged for Jakarta and Surabaya. And the policy environment is very different. Indonesia is one of the few countries that hasn't ratified the FCTC. Tobacco advertising is still widespread. Cigarettes are cheap. And there's very little public health infrastructure for cessation.
The two big counter-trends are youth in countries like Israel where specific products evade regulation, and women in countries where the industry is still in growth mode. What about the hardcore smoker problem in countries that have otherwise succeeded?
This is the third piece of the paradox, and it's the one that's most relevant to high-income countries like Canada, Australia, New Zealand, and increasingly the UK. When you've done everything right — high taxes, advertising bans, plain packaging, smoke-free laws — the smokers who remain are a different population than the smokers of thirty years ago.
More addicted, lower income, more likely to have co-occurring mental health conditions.
In Canada, smoking prevalence is around eleven percent nationally, but among people with serious mental illness it's above forty percent. Among Indigenous populations it's above thirty percent. Among people in the lowest income quintile it's more than double the national average. These are people for whom "just quit" advice is laughably inadequate.
Because the smoking isn't just a bad habit — it's self-medication, or it's embedded in a life with chronic stress and few alternatives for relief.
And the cessation tools we've developed were largely tested on middle-class, mentally healthy populations. Nicotine replacement therapy works, but it works better when you have stable housing, disposable income, and access to healthcare. The hardcore smoker population doesn't reliably have those things. So the policy challenge shifts from awareness — they know it's killing them — to addiction treatment and social support.
Which is much harder and more expensive than putting warning labels on packages.
New Zealand tried to solve this with their smokefree generation law — banning cigarette sales to anyone born after two thousand eight. It was world-leading legislation when it passed.
Then they walked it back.
Partially repealed in twenty twenty-six. The black market grew faster than anyone anticipated. Organized crime moved in. The government lost tax revenue. And there was a genuine political backlash from people who saw it as nanny-state overreach, even though the public health rationale was sound.
The black market problem is the unspoken variable in a lot of tobacco policy. Raise taxes high enough, and you create an incentive for smuggling that can completely undermine the public health goal.
It's not theoretical. In some Canadian provinces, contraband cigarettes are estimated to be thirty to forty percent of the market. In the UK, illicit tobacco is about fifteen percent. Once that infrastructure exists — the supply chains, the distribution networks — it doesn't just go away when you adjust policy. It becomes a parallel economy.
To recap the counter-trends so far: youth smoking in Israel driven by waterpipe and weak enforcement, rising female smoking in countries like Indonesia driven by industry marketing, and a hardcore smoker population in high-income countries that's resistant to conventional cessation tools. That's three distinct mechanisms, all hidden by the global headline number.
There's a fourth one that's even more complicated: novel nicotine products. E-cigarettes, heated tobacco, nicotine pouches. These are reshaping the landscape faster than regulators can keep up.
Let's dig into that. Are these products a solution or a new problem?
Both, depending on who you ask and which data you trust. Let's start with the case for them as a solution. Sweden has the lowest smoking rate in the European Union at five point six percent. The main reason is snus — oral tobacco pouches that have been used there for generations. Swedish men switched from cigarettes to snus in large numbers, and the result is the lowest rate of lung cancer and smoking-related mortality in Europe.
There's a tradeoff.
Oral cancer rates in Sweden are higher than the EU average. Not catastrophically higher, but measurably so. So you're trading lung cancer deaths for oral cancer cases. On net, public health experts generally agree that snus is far less harmful than smoking — Public Health England's twenty twenty-five estimate is that e-cigarettes are ninety five percent less harmful than combustible cigarettes — but "less harmful" isn't the same as "harmless.
The WHO is skeptical of the whole harm reduction framework.
The WHO's position is that novel nicotine products should be regulated as strictly as cigarettes, that the precautionary principle should apply, and that the industry can't be trusted — which, to be fair, has historical justification. The tobacco industry has a century-long track record of lying about health effects.
The counterargument is that if you regulate e-cigarettes as strictly as cigarettes, you remove the incentive for smokers to switch. If the packaging is equally ugly, the taxes equally high, and the marketing equally restricted, then why would a smoker bother?
That's the tension in a nutshell. And the evidence for e-cigarettes as cessation tools has been getting stronger. The twenty twenty-five Cochrane Review — which is the gold standard for evidence synthesis — found that e-cigarettes are about one point five times more effective for smoking cessation than nicotine replacement therapy. People who use e-cigarettes to quit are more likely to succeed than people who use patches or gum.
The long-term health effects are unknown because they haven't been around long enough.
We have about fifteen to twenty years of data on e-cigarettes versus sixty-plus years on cigarettes. We know cigarettes kill. We suspect e-cigarettes are much safer, but we can't quantify the residual risk with confidence. And that uncertainty is being exploited by both sides — the industry says "they're safe," the prohibitionists say "they're just as bad." Neither claim is supported by evidence.
What about the youth gateway effect? That's the big fear, right? That e-cigarettes hook young people who would never have smoked, and then some of them migrate to cigarettes.
The evidence on this is mixed, and it's one of the most polarized debates in public health. There are studies showing that youth who vape are more likely to try cigarettes later. But the question is whether that's causation or correlation — are these kids who would have smoked anyway, and vaping was just their entry point rather than the cause?
What does Japan's experience tell us?
Japan is fascinating and underdiscussed. IQOS — the heated tobacco product from Philip Morris — launched there in twenty fourteen. By twenty twenty-five, cigarette sales in Japan had fallen by fifty percent. Youth smoking rates dropped from four point two percent to two point one percent between twenty twenty and twenty twenty-five. That's a dramatic decline.
Heated tobacco displaced cigarettes among young people, rather than recruiting new users.
That's what the data suggests. But there are concerns about dual use — people who use both IQOS and cigarettes rather than switching completely — and about whether the decline in youth smoking is sustainable or just a temporary substitution effect. We won't really know for another decade.
Japan's regulatory approach was very different from what most Western countries have done.
Japan essentially allowed heated tobacco to be marketed as a lower-risk alternative while maintaining strict controls on combustible cigarettes. It was a de facto harm reduction strategy, even though they didn't frame it that way explicitly. The result was one of the fastest declines in cigarette consumption of any developed country.
Contrast that with Finland, which took a completely different approach and also succeeded.
Finland went the prohibition route — plain packaging, flavor bans, strict advertising restrictions, aggressive public health campaigns. Youth smoking in Finland dropped to six percent in twenty twenty-four. That's down from around fifteen percent a decade earlier. And they achieved it without embracing novel nicotine products as a harm reduction tool.
Both approaches can work. The question for Israel is which one is politically and culturally feasible.
That's where it gets sticky. Israel implemented e-cigarette regulation only in twenty twenty-four — relatively late compared to the EU and North America. Waterpipe remains essentially unregulated in terms of youth access. The tax differential between cigarettes and waterpipe tobacco creates an economic incentive for young people to choose waterpipe. And the social normalization of nargila in Israeli culture — it's what you do when you go out with friends, it's part of the cafe scene — makes it resistant to the kind of denormalization campaigns that worked for cigarettes.
The waterpipe is the musical equivalent of beige wallpaper — it's just there, unremarkable, part of the background of social life.
And that's much harder to disrupt than a product that's already stigmatized. You can't just run a scary ad campaign about waterpipe when every eighteen year old knows five people who use one and seem fine.
For now, yes. The latency period for waterpipe-related disease is decades. The cancers, the COPD, the cardiovascular damage — all of it takes twenty to thirty years to manifest. So the health system won't see the consequences of today's youth waterpipe use until the twenty forties and twenty fifties.
Let's talk about the knowledge gap. Daniel mentioned that everyone except conspiracy theorists now accepts that smoking is harmful. Is that actually true globally?
It's true in high-income countries, mostly. The IHME's twenty twenty-five data shows that awareness of smoking harms is above ninety percent in Canada, Australia, the UK, and most of Western Europe. But in parts of sub-Saharan Africa and South Asia, awareness is below fifty percent. And even where awareness is high, specific misconceptions persist.
The biggest one right now, especially among young people, is that vaping is just as harmful as smoking. The twenty twenty-five Truth Initiative study found that forty percent of young smokers in the US believe smoking isn't worse than vaping. That misconception actually reduces motivation to quit, because if you think they're equally harmful, why bother switching?
The public health messaging that was designed to scare people away from e-cigarettes may have accidentally convinced smokers that quitting isn't worth it.
That's the unintended consequence, and it's a serious one. When the FDA and CDC were sounding the alarm about the EVALI outbreak in twenty nineteen — which turned out to be caused by vitamin E acetate in black-market THC cartridges, not by nicotine e-cigarettes — the messaging got conflated. A lot of people came away thinking "vaping causes acute lung failure," which is not true for regulated nicotine products.
The EVALI thing was a communication disaster.
It really was. Public health agencies were trying to warn about a specific, localized risk, and the message that reached the public was "vaping will put you in the ICU." By the time the cause was identified, the damage to risk perception was done.
Then there's the conspiracy theory hangover Daniel alluded to. The distrust of public health messaging in certain communities.
This has deep roots. In the United States, the tobacco industry spent decades targeting African American communities with menthol cigarette marketing. Menthol makes the smoke smoother and easier to inhale deeply, which increases addiction potential. By the time public health agencies started pushing back, there was already a well-founded skepticism — "you let them market this to us for forty years, and now you're telling us it's dangerous?
That skepticism generalized.
And it's not irrational, given the history. The same dynamic exists in other communities that have been targeted by the industry — low-income populations, LGBTQ communities, military veterans. When you've been treated as a market to exploit, you're not going to automatically trust the institutions that are now telling you to quit.
Second-hand smoke awareness is another area where the knowledge hasn't fully permeated. Daniel mentioned it in the prompt — what's the global picture?
The IHME data for twenty twenty-five estimates one point two million deaths annually from second-hand smoke exposure. That's down from about one point five million a decade ago, but it's still enormous. And the awareness gap is stark. In high-income countries, awareness of second-hand smoke harms is above ninety percent. In parts of sub-Saharan Africa, it's below forty percent. In South Asia, it's around fifty percent.
Awareness correlates with exposure?
The places where people don't know second-hand smoke is dangerous are the places where they're most exposed to it — at home, in workplaces, in public spaces. Children in these settings are getting the equivalent of pack-a-day exposure just from ambient smoke.
That's a failure of the global public health apparatus. The FCTC has been around for twenty years, and we still have hundreds of millions of people who don't know that the smoke from someone else's cigarette can kill them.
It's a knowledge distribution problem. The science is settled. The communication channels to reach these populations don't exist or are underfunded. And in some countries, the tobacco industry actively works to suppress or muddy the message.
Let's shift to the policy question. If you're an Israeli policymaker looking at this youth smoking data, what should you do?
The evidence points to a few interventions with strong track records. Finland's flavor ban and plain packaging package reduced youth smoking by about forty percent after twenty twenty. That's the strongest evidence we have for product regulation specifically targeting youth.
Finland's intervention was aimed at e-cigarettes and conventional cigarettes. Would it work for waterpipe?
Waterpipe requires a different approach because it's consumed differently. You can't plain-package a nargila session at a cafe. The most effective intervention would probably be a combination of much stricter age verification at waterpipe establishments, higher taxes on waterpipe tobacco specifically, and a public education campaign that directly addresses the misconception that waterpipe is safer than cigarettes.
Which is always the weak link.
Israel has laws on the books about indoor smoking and age restrictions, but enforcement is inconsistent at best. There was a Times of Israel piece recently about a government task force that found eight thousand deaths per year in Israel are tied to tobacco, and they specifically flagged the enforcement gap as a critical failure point.
Eight thousand deaths a year in a country of nine million people. That's not a small number.
It's roughly comparable to the annual death toll from COVID at its peak, but it happens every year, year after year, and it doesn't make headlines.
Because it's slow and predictable. There's no news value in "smoking kills another eight thousand Israelis this year.
It's the normalization of a slow-motion catastrophe.
What about the countries that are doing it right? You mentioned Finland and Japan. Who else should we be watching?
Sweden is the obvious harm reduction case study, with the snus caveat I mentioned. The UK has been aggressive on e-cigarettes as cessation tools — the National Health Service actually recommends them. Australia has gone the other direction, with prescription-only access to nicotine e-cigarettes, and their smoking rate is still declining but more slowly. New Zealand was the boldest experiment, and the partial repeal is a cautionary tale about moving faster than the political consensus can sustain.
There's no single playbook. Each country's approach has to account for its specific cultural context, product mix, and political feasibility.
That's the core insight, and it's why the "just do what Sweden did" or "just do what Finland did" arguments miss the point. Israel has a waterpipe culture that Sweden doesn't have. It has a regulatory enforcement culture that's different from Finland's. It has a geopolitical situation that consumes political attention and makes public health a lower priority.
The war does tend to crowd out everything else.
It does, and understandably so. But the eight thousand deaths a year don't pause because there's a conflict in the north.
Let's talk about the individual level. If someone listening is a smoker, or knows a smoker, what does the evidence say about the best way to quit?
The twenty twenty-five update from the US Preventive Services Task Force recommends combination nicotine replacement therapy as first-line treatment — that's a patch for baseline cravings plus a fast-acting form like gum or lozenge for breakthrough cravings. Combined with behavioral counseling, either in-person or through a quitline. The evidence for cold turkey quitting is not strong — most people need multiple attempts and pharmacological support.
E-cigarettes as a quitting tool?
Under medical guidance, they're a reasonable option for people who've tried NRT and failed. The Cochrane Review evidence is solid. But the key phrase is "under medical guidance." Self-experimenting with whatever vape product is available at the corner store is not the same thing as a structured cessation attempt.
Because the products vary wildly in nicotine delivery, quality control, and safety.
A regulated nicotine e-cigarette from a pharmacy is a very different product from a disposable vape with unknown nicotine concentration and unknown additives. One of the regulatory failures in many countries — including Israel until recently — is treating all of these products as the same category.
The actionable advice for an individual smoker is: use the evidence-based tools, don't try to white-knuckle it, and if you're considering e-cigarettes, do it through a healthcare provider, not a vape shop.
That's the summary, yes. And for parents worried about their teenagers, the evidence suggests that scare tactics backfire. The "vaping will kill you" message loses credibility when the kid's friends have been vaping for two years and seem fine. Better to talk about addiction itself — the loss of control, the financial cost, the way nicotine reshapes the adolescent brain's reward system.
That's a harder conversation to have.
It is, but it's more honest. And teenagers have very sensitive dishonesty detectors.
What should we be watching for in the next year or two on this?
The big one is the twenty twenty-six WHO Global Tobacco Report, due in November. It will include the first comprehensive global data on novel nicotine products — e-cigarettes, heated tobacco, nicotine pouches — broken down by country and demographic. That's going to be a major inflection point for global policy.
Because right now, the data is patchy and everyone is arguing from incomplete evidence.
The WHO report will give us a baseline. We'll be able to see which countries have high e-cigarette use and whether it correlates with lower smoking rates or higher youth initiation. That evidence will shape the next decade of regulation.
The other thing to watch is the long-term health data on heated tobacco. Japan has had IQOS for over a decade now. The epidemiological signal should be starting to emerge.
The first cohort studies of long-term IQOS users are underway. If heated tobacco turns out to be substantially safer than cigarettes — and the toxicological data suggests it is, though not as safe as not using anything — that strengthens the harm reduction case. If unexpected harms show up, the calculus changes.
The answer to Daniel's question — has the knowledge permeated into lower rates everywhere? — is a qualified no. Global rates are down, but the map is lumpy. Youth in Israel are smoking more waterpipe. Women in Indonesia are taking up cigarettes. Hardcore smokers in Canada are being left behind by cessation programs. And novel nicotine products are creating a whole new landscape that the regulatory system is struggling to navigate.
The knowledge has permeated, but knowledge alone doesn't change behavior when addiction, culture, marketing, and policy all push in the other direction. The countries that have succeeded — Finland, Sweden, Japan — didn't just tell people smoking was bad. They changed the environment in which smoking decisions are made.
The countries that are struggling — Israel among them — haven't done that consistently, or have done it for cigarettes while leaving other products largely untouched.
That's the core policy failure. You can't regulate one nicotine product aggressively while ignoring another and expect youth rates to decline. Young people will find the gap in the regulatory wall.
Like water through cracks.
Exactly like that.
Alright, so given all this complexity, what can we actually take away from this? Three things seem worth pulling out.
First, for policymakers: targeted interventions beat blanket approaches. Finland's flavor ban and plain packaging worked because they targeted the products and marketing that were actually driving youth initiation. Israel's cigarette tax hike missed the mark because it didn't touch waterpipe. You have to regulate the products young people are actually using, not the ones you wish they were using.
Second, for individuals: if you or someone you know is trying to quit, use the evidence. Combination NRT with counseling is the first-line recommendation. E-cigarettes under medical guidance are a reasonable second-line option. Cold turkey has a low success rate. There's no virtue in suffering through withdrawal unassisted.
Third, for the informed audience watching this space: the twenty twenty-six WHO report in November is going to be a major moment. It'll give us the first real global picture of how novel nicotine products are interacting with smoking rates. That data will either validate the harm reduction approach or strengthen the case for stricter regulation. Either way, it's going to shape policy for the next decade.
The open question that hangs over all of this: will novel nicotine products accelerate the decline of smoking, or create a new generation of nicotine addicts? The answer probably depends less on the science than on the regulatory choices countries make in the next five years.
The science tells us these products are substantially less harmful than smoking. What it doesn't tell us is whether we can make them available to adult smokers who want to quit without making them attractive to teenagers who would never have smoked. That's not a scientific question — it's a regulatory design question.
The countries that solve it will save millions of lives. The countries that don't will be dealing with the consequences for decades.
One last data point that puts the stakes in perspective. The twenty twenty-five Global Burden of Disease Study projects that smoking will cause eight point five million deaths annually by twenty thirty, up from seven point seven million in twenty twenty. That's despite falling prevalence globally.
Because the health effects lag by decades.
The smokers who quit today won't see the mortality benefit for ten to twenty years. The smokers who die in twenty thirty are mostly people who started in the nineteen nineties and two thousands. The youth smoking rates we're seeing now in Israel and Indonesia and elsewhere — those are the mortality statistics of the twenty forties and twenty fifties.
The urgency is real, even if the consequences feel distant.
That's the tragedy of tobacco control. The payoff for getting it right today won't be visible for a generation. And the cost of getting it wrong is invisible until it's too late.
Check the data in your own country. Are you part of the trend, or bucking it?
And now: Hilbert's daily fun fact.
Hilbert: In nineteen twenty-five, Italian archaeologist Roberto Paribeni discovered a single intact floor tile in the ruins of an Aksumite villa near Adulis, in what is now Eritrea. The tile bears a geometric pattern of interlocking hexagons and equilateral triangles — a rare example of a trihexagonal tiling — and is the only surviving decorative element from the structure, which was otherwise reduced to rubble. Art historians believe the tiling was adapted from Coptic textile designs that reached the Aksumite Kingdom through Red Sea trade routes, making it a lone architectural artifact of a cultural fusion that left almost no other physical trace.
...right.
This has been My Weird Prompts. Our producer is Hilbert Flumingtop. You can find every episode at myweirdprompts dot com.
If you got something out of this, leave us a review wherever you listen — it helps other people find the show. We'll be back next week.
