Abstract
<title>Abstract</title> <p>Governments have advanced tobacco control through high taxes, advertising bans, and public smoking restrictions. However, smoking rates in many developed economies have plateaued, suggesting that conventional measures may be reaching their limits. At the same time, alternative nicotine delivery systems, including e-cigarettes, heated tobacco products, and nicotine pouches, have emerged as lower-risk substitutes for combustible cigarettes. Although not risk-free, these products generally expose users to fewer toxicants than traditional smoking. Regulatory responses vary considerably: some countries apply risk-proportionate policies that distinguish between products according to relative harm, while others regulate all nicotine products similarly. This paper examines the relationship between these regulatory approaches and smoking prevalence across 42 highly developed countries (Human Development Index [HDI] > 0.83). Using OLS regression models controlling for HDI and taxation levels, we find that countries with differentiated, risk-proportionate regulation report smoking prevalence approximately 7 percentage points lower than countries with non-differentiated regulatory systems. The models explain 72%-85% of the cross-country variance in smoking prevalence, with HDI accounting for roughly 50% of the variance. However, “pro-alternative” regulatory regimes significantly improve model performance: these countries experienced an average 38% decline in smoking rates, compared with 12% in more restrictive environments. Taxation differences did not explain the variation in smoking prevalence within this high-HDI cohort, highlighting the potential importance of lower-risk nicotine substitutes in sustaining progress in tobacco control.</p>